Spinal metastases and metastatic spinal cord compression

Service commissioners, working with their cancer alliance, should:

• ensure clear care pathways for referral, diagnosis, treatment, rehabilitation and ongoing care of people with suspected or confirmed spinal metastases or MSCC

• ensure appropriate services are commissioned and in place for efficient and effective implementation of the care pathways

• monitor services regularly through prospective audit of the care pathways (for example, collecting outcome data for treatments). [2023]

The cancer alliance should appoint a lead for MSCC whose responsibilities include:

• advising the cancer alliance, commissioners and providers about the provision and organisation of clinical services

• ensuring that the local care pathways are documented, agreed and implemented consistently across the alliance

• maintaining an alliance-wide audit of incidence, timeliness of management and outcomes using nationally agreed measures

• arranging and chairing regular meetings of the MSCC steering group (at least twice a year), at which treatment outcomes will be reported and the local care pathways reviewed and amended if necessary (see also recommendation 1.1.4 for details of the steering group). [2023]

Services within the cancer alliance (including those in primary, community, secondary and tertiary care) should have an identified lead healthcare professional for MSCC whose responsibilities include:

• representing their service at alliance level in the development of care pathways

• implementing and disseminating information about the care pathways

• ensuring timely and effective communication between all relevant healthcare professionals involved in the care pathways, including those in palliative care

• raising and maintaining awareness and understanding of treatments among all clinical staff across the locality

• contributing to regular alliance MSCC audits of care

• attending and contributing to regular alliance MSCC steering group meetings. [2023]

Every cancer alliance should have a steering group for MSCC that:

• includes people with lived experience and representatives from primary, community, secondary and tertiary care

• includes an MSCC service representative, for example, the MSCC coordinator

• has strong links to cancer alliance groups for primary tumours. [2023]

Ensure that there is a designated local MSCC service with clear processes and referral pathways so that all people with suspected or confirmed spinal metastases or MSCC are referred to an MSCC service with an appropriate level of urgency (see recommendations 1.3.2 and 1.3.3 about when to contact the MSCC coordinator, and recommendations 1.5.2 and 1.5.3 about when to offer an MRI scan). [2023]

MSCC services should ensure that the first point of contact for people referred to the service is the MSCC coordinator. When the MSCC coordinator is not working, the role should be carried out by a designated clinician with appropriate expertise (for example, an on-call oncology registrar). [2023]

MSCC services should ensure that the role of MSCC coordinator is covered at all times (24 hours a day, 7 days a week) and is based in an oncology service. [2023]

MSCC services should have arrangements in place to coordinate care between different specialties and services, for example, by having:

• clear referral criteria and processes

• processes for information sharing

• effective channels for communication between specialties. [2023]

MSCC services should operate through a multidisciplinary approach, with key members from relevant specialties, including:

• acute oncology

• haematology

• histopathology

• oncology

• palliative care

• physiotherapy

• radiology

• spinal surgery. [2023]

Specialties providing treatment within the MSCC service (for example, spinal surgery and radiotherapy) should designate a single point of contact to liaise with other services, provide advice and contribute to the coordination of care. [2023]

MSCC services should establish links and communication pathways with primary and community care and other relevant services (for example, palliative care and social services) so that information about the person's care and support needs is shared effectively to ensure safe discharge from hospital, continuity of care and appropriate follow up (see also the section on providing support and rehabilitation services). [2023]

MSCC services should have systems and processes in place for recording data, audit evaluation, and investigating and reporting incidents. [2023]

Be aware of the impact of health inequalities (for example, deprivation) on outcomes for people with spinal metastases or MSCC. Ensure that:

• information is collected and analysed by local services to identify any health inequalities

• education is provided within services on reducing local health inequalities

• reasonable adjustments are made by local services to address any health inequalities, in line with the Equality Act 2010. [2023]

Hospital and community services should establish coordinated care pathways with each other, and with social services, to ensure that people with spinal metastases or MSCC:

• are discharged in a safe and timely manner and

• receive the support they need for themselves and their families and carers once home. [2023]

The person in the role of MSCC coordinator should ensure that:

• key information about each person is recorded; this includes information on:

  • clinical presentation

  • neurological assessment

  • performance status

  • frailty assessment

  • investigations, including imaging reports

  • oncology assessment and disease staging

  • individual needs, preferences and circumstances (for example, language and communication needs)

• initial triage of information about the person's care is performed

• appropriate information is shared with primary care and with the multidisciplinary team

• discharge planning is coordinated. [2023]

The person in the role of MSCC coordinator should provide initial advice to referring healthcare professionals on:

• pain management (see the section on pain management)

• spinal stability (see the sections on imaging investigations and tools for assessing spinal stability and prognosis)

• immobilisation (see the section on immobilisation)

• use of dexamethasone (see the section on corticosteroid therapy)

• referral and transfer for specialist treatment. [2023]

A senior clinician from the multidisciplinary team with expertise in diagnosing and managing spinal metastases and MSCC should develop a personalised care plan with the person. This should take into account the person's needs and preferences, and advice from the multidisciplinary team (see recommendation 1.1.9) and other clinicians, if relevant, such as:

• allied health professionals

• pharmacists

• the referring health professional. [2023]

Centres treating spinal metastases or MSCC should ensure that a senior clinician is available at all times to give advice and support to the MSCC service. [2023]

MSCC services should ensure that there is local access to urgent MRI scans (within 24 hours) for all people with suspected MSCC who have neurological signs and symptoms. MRI scans should be available outside normal working hours if needed to start immediate treatment (see recommendation 1.5.4). [2023]

Imaging departments should make provision for short-notice spinal scans, taking into account the relative urgency of scans investigating suspected spinal metastases or MSCC (see recommendations 1.5.2 and 1.5.4). [2023]

MSCC services should ensure that radiotherapy and simulator facilities are available for urgent (within 24 hours) daytime sessions, 7 days a week for people with MSCC so that radiotherapy can be given within 24 hours of a decision to treat (see recommendation 1.10.4). [2023]

Ensure access to community-based nursing and rehabilitation services, and equipment and support to meet the needs of people with suspected or confirmed spinal metastases or MSCC, and their families and carers. [2023]

Ensure access for people with MSCC to appropriate specialist rehabilitation services (including to specialist rehabilitation units) if they are likely to benefit from it, based on an assessment of their circumstances, their level of function and the type of treatment they received. [2023]

Discharge planning should be led by a named individual from within the responsible clinical team and involve:

• the person and their family and carers, if appropriate

• the primary oncology site team

• the rehabilitation team

• a pharmacist

• community support, including primary care and specialist palliative care, if needed. [2023]

MSCC services should establish clear pathways of care, linking hospital and community-based healthcare and social services to ensure that equipment and support for people with MSCC returning home, and their families and carers, are available and coordinated. [2023]

MSCC and rehabilitation services should provide support and training to the families and carers of people with MSCC before discharge from hospital (see the section on support and training for carers in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs). [2023]

MSCC and rehabilitation services should take account of the section on discharge from hospital in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs for hospital discharge planning. [2023]

MSCC and rehabilitation services should take account of the principles of rehabilitation in the NICE guideline on rehabilitation after critical illness in adults. [2023]

Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers are given information and support that is tailored to their needs and preferences so that they are fully informed and supported to be involved in all decisions about their care. Follow the principles in NICE's guidelines on shared decision making and patient experience in adult NHS services. [2023]

Discuss with the person and their family or carers the reasons why investigations and treatments are being offered by the multidisciplinary team, and the risks and benefits of these, so that they fully understand their options and are involved in decisions about their care. [2023]

Give opportunities to the person and their family or carers to discuss their concerns and ask questions about issues such as:

• their diagnosis and what it might mean for them

• initial treatment options

• risks and benefits of treatment options

• how the condition could affect them in the future, including the possibility of worsening symptoms and functional decline

• ways to manage pain

• when further treatment options could be considered. [2023]

Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers know who to contact if they develop new symptoms or signs (see box 1) or if their existing symptoms worsen. [2023]

Carry out a holistic needs assessment with the person, and their family or carers if appropriate, as soon as possible after initial diagnosis, once the person is physically and emotionally able to be involved in the assessment, and revisit this when needs or preferences change. [2023]

Give advice on how to access support based on the holistic needs assessment, including help with psychological, emotional, spiritual and financial needs. [2023]

Discuss with the person their needs and preferences and the support they receive, and aim to help them:

• maintain their independence and quality of life

• deal with uncertainty

• adapt to potential changes in their level of function. [2023]

Discuss with the person and their family or carers their experience of the service and explore whether changes can be made to better meet their needs. Ask about any concerns they may have, such as:

• accessing the service and attending appointments

• undergoing investigations

• adhering to treatment

• their social and practical circumstances

• disabilities that may be relevant to their care. [2023]

Offer the person opportunities to discuss advance care planning (with support from family and carers if appropriate). For principles of advance care planning, see the section on advance care planning in the NICE guideline on decision making and mental capacity and the NICE quick guide on advance care planning. [2023]

Offer the person end-of-life care, when appropriate, following NICE's guidelines on end of life care for adults and care of dying adults in the last days of life. [2023]

When the person is approaching the end of their life, discuss the bereavement support available with their family or carers and provide written information. Give advice on how to access bereavement support according to their wishes and preferences. [2023]

Ensure that all people with spinal metastases or MSCC, and their families or carers, if appropriate:

• have access to support and advice from the full range of healthcare services needed

• are supported by healthcare services to adapt to changes and to maintain their independence and quality of life. [2023]

Ensure that people with spinal metastases or MSCC and their families or carers have ongoing access to support and training on appropriate care techniques and use of equipment both in hospital and after they are discharged home. This may include:

• manual handling

• use of spinal braces

• use of equipment (such as wheelchairs)

• managing bladder and bowel problems. [2023]

Radiological imaging of the spine in people with suspected spinal metastases or MSCC should be overseen by a radiologist to ensure:

• appropriate and complete imaging is performed and

• they report the results urgently. [2023]

Offer an MRI scan to people with suspected MSCC (see recommendation 1.3.2), to be performed:

• as soon as possible (and always within 24 hours)

• at the local hospital or appropriate centre with direct access to imaging facilities.
  
  Transfer to a tertiary centre for MRI should only be undertaken if local MRI is not possible. [2023]

Offer an MRI scan to guide treatment options for people with clinical suspicion of spinal metastases but without suspicion of MSCC (see recommendation 1.3.3), to be performed:

• within 1 week

• at the local hospital. [2023]

Offer overnight MRI only in clinical circumstances in which urgent diagnosis is needed to enable treatment to start immediately. [2023]

MRI of the spine should include:

• sagittal T1 and/or short TI inversion recovery (STIR) sequences of the whole spine, to identify spinal metastases

• sagittal T2-weighted sequences, to show the level and degree of compression of the cord or cauda equina by a soft tissue mass and to assess possible MSCC and detect lesions within the cord itself

• supplementary axial imaging through any significant abnormality noted on the sagittal scan. [2023]

In people with an existing diagnosis of spinal metastases without symptoms or signs of cord compression, do not perform MRI of the spine solely for the early radiological detection of cord compression. [2023]

If MRI is contraindicated, carry out a CT scan for people with suspected spinal metastases or MSCC. Rarely, if more information is needed for diagnosis and to guide management, carry out myelography after CT scanning. [2023]

If myelography is indicated, only perform it at a neuroscience or spinal surgical centre. [2023]

Do not perform plain X-ray of the spine to diagnose or rule out spinal metastases or MSCC. [2023]

Consider multiplanar viewing or 3-plane reconstruction of recent or new CT images for people with spinal metastases or MSCC to:

• assess spinal stability and

• plan vertebroplasty, kyphoplasty or spinal surgery. [2023]

Seek advice from a specialist (for example, a physiotherapist) on the use of orthoses to promote mobility and to prevent loss of range of limb movement. [2023]

Ensure adequate pain relief is provided promptly for people with suspected or confirmed spinal metastases or MSCC, including while the person is waiting for investigations or treatment. [2023]

Carry out an individualised pain assessment for people presenting with pain related to suspected or confirmed spinal metastases or MSCC. This should include assessing:

• the severity, location and characteristics of the pain

• the underlying cause of the pain and whether this has deteriorated

• the impact of pain on lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

Discuss and agree a pain management plan with the person based on their individualised pain assessment and taking into account any previous strategies tried, as well as their concerns and expectations. Discussions may include:

• why a particular management plan is being suggested

• the psychological impact of pain, including the effect on emotional wellbeing

• pharmacological analgesic treatment options, with individualised information and advice, including possible risks and benefits, and dosage titration

• individualised coping strategies for pain

• other treatment options, if suitable, for example:

  • physical therapy

  • immobilisation (for example, bracing)

  • psychological therapies

  • systemic anticancer treatments

  • bisphosphonates (see the section on bisphosphonates)

  • denosumab (see the section on denosumab)

  • corticosteroids (see the section on corticosteroid therapy)

  • radiotherapy (see the section on radiotherapy)

  • surgery (see the section on invasive interventions)

• when and how to seek further advice if pain persists, progresses or changes in character.
  
  For more information about involving people in decisions and supporting adherence, see the NICE guidelines on shared decision making and medicines adherence. [2023]

After starting or changing a pain management plan, carry out a clinical review to assess the effectiveness of the chosen treatment. [2023]

Consider referring the person to a specialist pain service (or, if appropriate, a palliative care service) if pain is difficult to manage at any stage, including at initial presentation, and if:

• they have severe pain or

• their pain significantly limits their lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

When deciding on analgesic medication, discuss with the person and take into account:

• the possible side effects

• the possible effects on existing comorbidities and new comorbidities that could arise from treatment

• concurrent medications (including over-the-counter medicines) and possible drug interactions. [2023]

Offer non-opioid or opioid analgesic medication, individually or in combination, to people with pain associated with suspected or confirmed spinal metastases or MSCC. The choice of medicine should be based on the ongoing individualised pain assessment and agreed in the pain management plan. [2023]

At each review, discuss analgesic drug dosage, titration, tolerability and adverse effects, and agree to continue or update the pain management plan where necessary. [2023]

For people with pain that has neuropathic features or is unresponsive to opioid analgesia, consider managing pain according to the NICE guideline on neuropathic pain in adults. [2023]

For people having strong opioids in palliative care, follow the recommendations on starting and titrating opioid analgesia and managing side effects in the NICE guideline on palliative care for adults. [2023]

When using strong opioids, follow the processes for their safe use and management in the NICE guideline on controlled drugs. [2023]

For people with spinal involvement from myeloma or breast cancer, offer bisphosphonates to reduce pain and the risk of vertebral fracture or collapse. [2008]

For people with spinal metastases from prostate cancer, offer bisphosphonates to reduce pain only if conventional analgesia fails to control pain. [2008]

Do not use bisphosphonates to treat spinal pain in people:

• with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer (if conventional analgesia fails) or

• with the intention of preventing MSCC, except as part of a randomised controlled trial. [2008]

For people with bone metastases from breast cancer and from solid tumours other than prostate, follow the NICE technology appraisal guidance on denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. [2023]

When considering radiotherapy as a treatment option, explain the impact of the cancer and its treatment on future fertility. Explore the person's priorities for fertility and offer referral to a fertility specialist if suitable, but do not delay urgent treatment for spinal metastases or MSCC. See also the section on people with cancer who wish to preserve fertility in the NICE guideline on fertility problems. [2023]

For people with spinal metastases without MSCC who have non-mechanical spinal pain:

• offer 8 Gy single fraction radiotherapy, even if they are paralysed or

• consider stereotactic ablative body radiotherapy for people with a good overall prognosis (see the section on tools for assessing spinal stability and prognosis) or oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement. [2023]

Be aware that radiotherapy for haematological malignancy with spinal metastases may reduce the success of stem cell harvest. If stem cell harvest is being considered, discuss the use of radiotherapy with the relevant haematology multidisciplinary team. [2023]

Offer urgent radiotherapy (to be given as soon as possible and within 24 hours) to people with MSCC that is not suitable for spinal surgery, unless:

• they have had complete tetraplegia or paraplegia for 2 weeks or longer and their pain is well controlled or

• their overall prognosis is considered to be poor (see also the section on tools for assessing spinal stability and prognosis). [2023]

Use 8 Gy single fraction radiotherapy for people with MSCC having radiotherapy unless they are at high risk of side effects. [2023]

Consider multiple fraction radiotherapy for people at high risk of side effects from radiation, for example, if they have:

• disease requiring a large treatment field or fields

• had previous radiotherapy treatments. [2023]

For people with asymptomatic spinal metastases, consider radiotherapy only:

• as part of a randomised controlled trial with the intention of preventing MSCC or

• as part of a treatment strategy for oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement or

• if there are radiological signs of impending cord compression by an epidural or intradural tumour. [2023]

Offer postoperative radiotherapy after the person has recovered from surgery for spinal metastases or MSCC. For information on surgery, see the section on invasive interventions. [2023]

Consider further radiotherapy for people with spinal metastases or MSCC who have:

• had a good response to previous radiotherapy and

• developed recurrent symptoms at least 3 months after initial radiotherapy. [2023]

If further radiotherapy is being considered, discuss the possible benefits and risks with the person and take into account the following factors before agreeing a treatment plan:

• total biological equivalent dose

• the time since the previous treatment

• volume of tissue to be irradiated. [2023]

Before an invasive intervention is offered, make a treatment plan in discussion with the appropriate specialists (such as an oncologist and spinal surgeon) within the MSCC service multidisciplinary team. [2023]

If the primary cancer has not been identified, carry out a radiologically guided biopsy if:

• identifying the primary cancer may affect treatment decisions and

• there is no need for immediate treatment. [2023]

Offer surgical intervention intended to halt or reverse neurological decline as soon as possible after the onset of neurological symptoms or signs indicating MSCC. [2023]

Take into account the speed of onset and rate of progression of neurological symptoms and signs when determining the urgency of surgical intervention. [2023]

Do not use a time limit after complete tetraplegia or paraplegia as the only factor to decide whether to offer surgical intervention to restore neurological function. [2023]