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The National Institute for Health and Clinical Excellence (NICE) has today (26 November 2008) published a clinical guideline on the diagnosis and management of adults at risk of and with metastatic spinal cord compression.

Metastatic spinal cord compression is a rare complication of cancer. People who have cancer are at risk of it spreading (metastasising) to other parts of their body including the liver, lungs or bones. Spinal metastases can be painful and, if not treated, can lead to metastatic spinal cord compression (MSCC). This is when the metastases press on the spinal cord. If it isn’t treated quickly, metastatic spinal cord compression can lead to serious disability, including permanent paralysis, and early death.

The true incidence of MSCC in England and Wales is unknown because cases are not systematically recorded. However, evidence from an audit carried out in Scotland between 1997 and 19991 and from a published study from Canada2, suggests that the incidence may be up to 80 cases per million people every year.

This equates to approximately 4000 cases each year in England and Wales, or more than 100 cases per cancer network each year.

The guideline, which was produced by NICE’s National Collaborating Centre for Cancer, recommends that every cancer network should ensure that appropriate services are commissioned and in place for the efficient and effective diagnosis, treatment, rehabilitation and ongoing care of patients with MSCC. These services should include the establishment of an MSCC coordinator to provide 24 hour cover to guide the care of patients with suspected MSCC. Other key recommendations from the guideline include:

• Patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain should be informed about the symptoms of MSCC.

• The MSCC coordinator should be contacted urgently (within 24 hours) to discuss the care of patients with cancer and any symptoms suggestive of spinal metastases.

• The MSCC coordinator should also be contacted immediately to discuss the care of patients with cancer and symptoms suggestive of spinal metastases who have any of the neurological symptoms or signs suggestive of MSCC, and view them as an oncological emergency.

• An MRI of the whole spine should be performed in patients with suspected MSCC, unless there is a specific contraindication.

• Patients with severe mechanical pain suggestive of spinal instability, or any neurological symptoms or signs suggestive of MSCC, should be nursed flat with neutral spine alignment.

• Definitive treatment should be started, if appropriate, ideally within 24 hours of the confirmed diagnosis of MSCC.

• Discharge planning and ongoing care, including rehabilitation for patients with MSCC, should start on admission and be led by a named individual from within the responsible clinical team.

Mr Barrie White, Neurosurgeon at the Queen’s Medical Centre in Nottingham and Guideline Development Group Chair said: “Less than one in a thousand patients with back pain have metastatic spinal cord compression, but it is vital that the condition is suspected, investigated and treated as early as possible. Recommendations such as those to ensure that information is given to patients at risk, that facilities for investigation and treatment are readily available, and that timely treatment is co-ordinated and delivered by recognised experts should in most cases, prevent paralysis from adversely affecting the quality of life for people with metastatic cancer.”

Dr R Euan Paterson, General Practioner & Macmillan GP Facilitator in Glasgow said: “This guideline will help to ensure that patients, carers and clinicians consider the possibility of MSCC in cancer patients with back pain. Critically, this guideline recommends that clinicians who are familiar with MSCC are involved in the diagnostic pathway as soon as suspicion exists, appropriate investigations are carried out in a timely fashion and senior doctors participate in what are extremely complex treatment decisions. Furthermore, it also clearly states the high level of care that patients with this condition should receive.”

Christine Ward, Nurse Consultant for Adult Palliative Care at North Yorkshire and York Primary Care Trust said: “The recommendations made in this guideline are based on the best available evidence and will help to ensure that patients receive the most appropriate care according to their particular circumstances. In particular, the recommendation that each cancer network has a designated MSCC coordinator to offer advice on the initial management of patients with suspected MSCC including moving and handling, and drug treatment, will help to improve outcomes for patients by making sure that they get the right treatment, as quickly as possible.”

Michael Scanes, User Involvement Facilitator at the Essex Cancer Network and Patient Representative on the Guideline Development Group said: “Patients who develop metastatic spinal cord compression often do so at one of the most distressing periods of their lives. The recommendations made in this guideline, such as those outlining how the patient’s family and friends should be involved in consultations over the patient’s ongoing care and rehabilitation, will help to ensure that the patient knows they are receiving the necessary support and best available care throughout the course of their treatment.”

1. The guidance is available at http://www.nice.org.uk/Guidance/SpinalCordCompression.

About Cancer Networks

2. Cancer Networks bring together a range of organisations; those who provide services, as well as those who fund them, and are the vehicle for ensuring that all patients within their population area have equal access to the highest quality of cancer services available. Currently, there are around thirty Cancer Networks across the Country. The Cancer Networks were established following the recommendations of the Calman-Hine report (1995) and the more recent NHS Cancer Plan (September 2000) and the Manual of Cancer Standards (April 2001). Its core objectives are to

• Develop all aspects of local cancer services: prevention, screening, diagnosis, treatment, supportive and specialist palliative care.
• Develop multi-disciplinary teams and make arrangements to ensure that all patients are reviewed by them prior to treatment.
• Agree common protocols and service patterns to tackle variations and make best use of resources available.
• Develop workforce education, training and facility strategies.

The network structures enable the PCT's to make collective decisions about services provided for populations larger than an individual PCT and together with the provider trusts monitors their performance.

About NICE

3. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

4. NICE produces guidance in three areas of health:

• public health – guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies – guidance on the use of new and existing medicines, treatments and procedures within the NHS
• clinical practice – guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.