Spinal Cord Compression: An Obstructive Oncologic Emergency

Maryjo Osowski, RN, MSN, AOCN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2002;2(4) 

In This Article

Treatment

Corticosteroid Therapy

Treatment is palliative in most cases, but goals are relief of pain and maintenance or restoration of neurologic function. Other goals include spinal column stabilization and local tumor control.[2,8] Choice of therapy depends on the tumor type and location, the speed of onset, and the degree of function before onset of symptoms.[13]

The patient is admitted to the hospital, usually by the medical oncologist, who has typically consulted with the radiation oncologist and the neurosurgeon. A course of treatment with the corticosteroid dexamethasone is started to reduce the edema and cord compression caused by the tumor mass and to thereby relieve the pain. Dexamethasone has lympholytic activity against lymphomas involving the epidural space.[14] Some controversy exists regarding the optimal dose of dexamethasone; adult doses ordered range from 4 to 100 mg, given every 6 hours. However, many physicians administer a 4- to 100-mg intravenous (IV) bolus followed by 16-96 mg/d in divided doses over several days.[2,3] The dose of dexamethasone, like any corticosteroid, must be tapered gradually. A common schedule for tapering calls for decreasing the dose by one third every 3-4 days. If tapering is not tolerated and neurologic deterioration occurs, a trial of an escalated dose may be attempted, followed by tapering.[15]

Patients who take dexamethasone must be monitored carefully for side effects of corticosteroids, such as immunosuppression, gastrointestinal irritation, fluid retention, euphoria, depression, and hyperglycemia.[8] Blood glucose levels are a particular concern in diabetic patients and must be monitored closely. The diabetic patient's diet and insulin dose may need to be changed. If the patient has been treated with an oral hypoglycemic drug, insulin may need to be temporarily substituted to manage the higher glucose levels. Bolus injections of dexamethasone must be given slowly to avoid rectal or vaginal burning.[4,16]

Radiation Therapy

Radiation therapy is the standard of care for SCC caused by tumor involvement.[1,2,8] Radiation therapy resolves pain by reducing the tumor mass and relieving the SCC. There are different regimens of radiation therapy for SCC. The commonly prescribed regimen is 2-3 Gy per fraction to a total dose not exceeding 30-40 Gy, directed to the spinal cord over 2-4 weeks.[1]

Indicators of a response to radiation therapy include pain relief and a return to baseline function or improved function. Patients may experience some relief of symptoms within a few days after starting radiation therapy, and pain sometimes is relieved within hours. However, return to baseline function after radiation therapy can be delayed for months.[5]

In a small number of patients, particularly those with spinal instability or a rapidly progressing loss of neurologic function, surgery may be indicated. Often these oncology patients are severely compromised by their underlying cancer and numerous treatment regimens. Wound healing and recovery from surgery can be difficult in this population, so patients must be selected carefully for any surgical procedure. They may have failed to respond to radiation therapy, the site of the primary tumor may be unknown, they may have local tumor that recurs at a previously irradiated site, or they may have pathologic fracture with spinal instability or compression of the cord by bone.[1,2]

Chemotherapy is indicated in adults with chemosensitive tumors such as lymphoma or Hodgkin's disease. Chemotherapy can also be used as an adjuvant therapy with irradiation or surgery in patients with breast cancer, prostate cancer, or multiple myeloma. The choice of chemotherapeutic agents depends on the primary tumor type and the chemotherapy history of the patient. Hormone therapy is another option for patients with prostate or breast cancer.[4]

Patients who have failed to respond to chemotherapy and conventional radiation therapy (external beam radiotherapy) and are not candidates for standard surgical procedures (laminectomy) have few options. Palliative care consisting of analgesic administration, nerve blocks, corticosteroid therapy, and side effect management, best performed by hospice care workers, is indicated in these patients. Optimal nursing management after treatment for SCC is paramount for success.[13]

Palliative care goals include prevention of further injury, good pain control, restoration and maintenance of bowel and bladder function, and provision of emotional support for both the patient and caregivers. The response to treatment depends in general on the level of function at the time of diagnosis. If a patient presents with bladder and bowel symptoms and paresthesias, it is less likely that he or she will recover bladder and bowel function or the ability to walk.

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