01Approach to the Critical Patient/attcp62

Recognition and time critical priorities

›Malignant spinal cord compression overview

›New objective motor weakness

›New bowel or bladder dysfunction

›Saddle anesthesia

›Progressive severe back pain

›Known cancer with back pain

›No known cancer with red flag back pain

›Thoracic pain or band like radicular pain

›Pain worse at night or supine

›Rapid progression over hours to days

›Immediate stabilization priorities

›Airway risk with high cervical involvement

›Respiratory weakness

›Weak cough

›Hemodynamic instability

›Sepsis physiology with alternative diagnosis

›Hemorrhage physiology with alternative diagnosis

›Spinal motion restriction when unstable spine suspected

›Severe mechanical pain with movement

›Deformity or step off

›Early activation and parallel actions

›Immediate MRI access pathway

›Whole spine MRI preferred

›Targeted MRI plus screening sequences when resource limited

›Early neurosurgery or spine surgery consultation

›Motor deficit present

›Suspected mechanical instability

02History/hx57

Presenting symptoms and timeline

›Symptom pattern

›Back pain characteristics

›Mechanical pain with movement

›Night pain

›Midline tenderness

›Radicular pain

›Band like thoracic pain

›Limb shooting pain

›Motor symptoms

›Weakness onset time

›Falls

›Sensory symptoms

›Numbness distribution

›Paresthesias

›Autonomic symptoms

›Urinary retention

›New incontinence

›Constipation with overflow

›Time course

›Hours to days progression

›Higher likelihood of surgical emergency

›Weeks progression

›Higher likelihood of gradual tumor growth

Malignancy context and risk factors

›Cancer history

›Known malignancy type

›Breast

03Physical Exam/exam36

Neurologic examination

›Cord level localization

›Motor strength by myotome

›Hip flexion

›Knee extension

›Ankle dorsiflexion

›Great toe extension

›Ankle plantarflexion

›Sensory testing by dermatome

›Light touch

›Pinprick

›Reflexes and upper motor neuron signs

›Hyperreflexia

›Clonus

›Babinski sign

›Gait assessment when safe

›Spastic gait

›Foot drop

›Cauda equina focused findings

›Perineal sensation

›Anal wink

›Rectal tone

›Bulbocavernosus reflex when appropriate

Spine and systemic examination

›Spine examination

›Midline tenderness

›Deformity

›Percussion pain

04Differential Diagnosis/ddx26

Life threatening and time sensitive causes

›Compressive myelopathy differentials

›Malignant epidural spinal cord compression

›ICD 10 G95.20 spinal cord compression unspecified

›ICD 10 C79.51 secondary malignant neoplasm of bone

›Spinal epidural abscess

›Fever or bacteremia association

›Spinal epidural hematoma

›Anticoagulant use

›Recent procedure

›Vertebral burst fracture with retropulsion

›Trauma history

›Disc herniation with myelopathy

›Acute radicular onset

›Non compressive myelopathy differentials

›Transverse myelitis

›Spinal cord infarction

›Demyelinating disease relapse

Mimics and related syndromes

›Radiculopathy and plexopathy

›Metastatic plexopathy

›Herpes zoster radiculitis

›Peripheral neuromuscular causes

›Guillain Barre syndrome

›Critical illness neuropathy

›Musculoskeletal pain without neurologic compromise

›Vertebral compression fracture

›Degenerative spondylosis

05Laboratory Tests/lt26

Core labs and treatment readiness

›Baseline labs

›Complete blood count for anemia and cytopenias

›Leukocytosis supporting infection alternative

›Thrombocytopenia affecting procedures

›Electrolytes and renal function for contrast and medication planning

›Creatinine for CT contrast suitability

›Potassium for perioperative planning

›Liver panel for medication metabolism and malignancy burden

›Elevated alkaline phosphatase supporting bony metastases

›Coagulation studies for procedure planning

›INR for anticoagulant effect

›aPTT for heparin effect

Targeted tests based on presentation

›Infection evaluation when indicated

›Blood cultures with fever or sepsis physiology

›Antibiotics timing coordination with imaging when unstable

›C reactive protein or erythrocyte sedimentation rate for inflammatory signal

›Non specific elevation in malignancy and infection

›Malignancy evaluation when new diagnosis suspected

›PSA in older male with bony pain

›Serum protein electrophoresis with lytic lesions suspicion

›Serum free light chains with myeloma suspicion

›Steroid safety monitoring

›Glucose monitoring after corticosteroids

›Hyperglycemia risk

›Electrolytes monitoring with prolonged corticosteroids

›Sodium retention risk

06Diagnostic Tests/dt45

Scoring Systems

›Scoring and classification tools

›Epidural spinal cord compression grading

›Bilsky ESCC grade for degree of thecal sac and cord compression

›Higher grade associated with greater neurologic risk

›Mechanical instability assessment

›Spinal Instability Neoplastic Score for instability risk

›Pain component emphasizing mechanical pain

›Prognostic stratification for treatment selection

›Tokuhashi score for survival prediction in spinal metastases

›Tomita score for surgical strategy selection

›Functional status measures

›ECOG performance status

›Karnofsky performance status

MRI

›MRI preferred diagnostic modality

›Whole spine MRI with and without contrast

›Multilevel disease frequency

›Surgical and radiation planning benefit

›Urgency targets

›Same day imaging for neurologic deficit progression

›Within 24 hours for suspected compression with symptoms

›MRI findings supporting malignant compression

›Epidural mass

›Vertebral body metastasis

›Pathologic fracture

›Spinal cord edema

›MRI contraindications and alternatives

07Disposition/dispo26

Level of care and pathway decisions

›Admission requirements

›Suspected or confirmed malignant spinal cord compression

›Neurologic monitoring

›Definitive therapy coordination

›Motor deficit or sphincter dysfunction

›High risk of irreversible injury

›Uncontrolled pain requiring parenteral therapy

›Frequent reassessment need

›Higher acuity placement criteria

›High cervical lesion suspicion

›Respiratory monitoring

›Rapidly progressing deficits

›Frequent neuro checks

›Post operative status

›Hemodynamic monitoring

›Transfer criteria

›No urgent MRI capability

›No spine surgery capability

›No urgent radiotherapy capability

Consultant confirmation and timing

›Definitive management coordination

›Neurosurgery or spine surgery treatment decision

›Decompression and stabilization candidacy

›Radiation oncology treatment plan

›Emergency radiotherapy for non surgical candidates

›Oncology hematology systemic therapy planning

›Radiosensitive tumor systemic control

08Treatment/t68

Corticosteroids

›Steroid strategy

›Dexamethasone for suspected malignant spinal cord compression with neurologic symptoms

›Initial dosing typical regimen

›16 mg per day total dose

›Divide into 8 mg twice daily or equivalent schedule

›Parenteral equivalent when oral not feasible

›IV dosing matching oral total daily dose

›Transition to oral when able

›Taper principles after definitive therapy

›Gradual taper over days to weeks

›Faster taper if rapid neurologic stability and short course

›Adverse effect prevention

›Gastric protection when high risk

›Proton pump inhibitor or H2 blocker selection per local practice

›Glucose monitoring and management

›Insulin strategy when needed

›Avoidance considerations

›Strong infection concern requiring balancing risk

›Severe uncontrolled diabetes requiring close monitoring

Definitive local control

›Surgery and radiotherapy selection

›Surgical decompression plus postoperative radiotherapy for selected patients

›Single area of compression

›Good performance status

›Expected survival sufficient for recovery

›Spinal instability needing fixation

›Radioresistant tumor histology

09Special Populations/sp32

Pregnancy

›Pregnancy specific considerations

›Imaging approach

›MRI without ionizing radiation preferred

›Gadolinium risk benefit discussion when contrast considered

›Steroid considerations

›Dexamethasone maternal effects monitoring

›Obstetric consultation for fetal monitoring when viable gestation

›Radiotherapy considerations

›Urgent maternal indication with fetal shielding planning

›Multidisciplinary decision making

Geriatric

›Older adult considerations

›Baseline frailty and mobility

›Higher fall risk during weakness

›Rehab planning early

›Steroid adverse effects risk

›Delirium risk

›Hyperglycemia risk

›Myopathy risk

›Surgical candidacy nuance

›Bone quality affecting fixation

›Higher perioperative risk assessment

Pediatrics

›Pediatric considerations

›Etiology differences

›Neuroblastoma

›Sarcoma

10Background/b37

Epidemiology

›Epidemiologic features

›Common oncologic emergency

›Occurs in a minority of cancer patients

›Often first presentation of malignancy in some cases

›Most frequent primary tumors

›Breast

›Prostate

›Lung

›Myeloma

›Typical anatomic distribution

›Thoracic most common

›Lumbar next most common

›Cervical least common

Pathophysiology

›Mechanisms of cord compromise

›Epidural tumor extension from vertebral metastasis

›Posterior vertebral body involvement

›Epidural space invasion

›Pathologic fracture with retropulsion

›Bony fragment compression

›Venous plexus spread

›Multilevel seeding risk

›Secondary edema and ischemia

›Neurologic deficits partially steroid responsive

Therapeutic Considerations

›Time dependence of neurologic recovery

›Ambulatory status at treatment start predicts outcome

11Patient Discharge Instructions/pdi18

Copy discharge instructions

›Discharge instructions for patients not admitted

›This condition can threaten walking and bladder or bowel control

›Return immediately for new weakness in arms or legs

›Return immediately for numbness in groin or inner thighs

›Return immediately for trouble starting urination or inability to urinate

›Return immediately for new loss of bladder or bowel control

›Return immediately for worsening back pain especially at night

›Avoid heavy lifting and high risk activities until cleared

›Follow up plan

›Oncology or hematology appointment date and time

›Radiation oncology appointment date and time

›Medication instructions

›Steroid dosing schedule if prescribed

›Do not stop steroids abruptly without guidance

›Glucose checks if diabetic or prediabetic

›Safety planning

›Use assistive device if unsteady

›Do not drive if leg weakness or sedating medications

12References/r19

Clinical Guidelines and consensus statements

›Guideline sources

›NICE guidance on spinal metastases and metastatic spinal cord compression

›Imaging urgency and pathway recommendations

›Steroid use recommendations

›Oncology and radiation practice guidelines for metastatic spinal cord compression

›Radiotherapy fractionation selection principles

›Spine oncology surgical decision frameworks

›SINS for instability risk

›ESCC grading for epidural compression

Evidence Based Sources

›Key trials and reviews

›Randomized trial evidence supporting surgery plus radiotherapy in selected patients

›Ambulation outcomes

›Continence outcomes

›Systematic reviews on corticosteroids in malignant spinal cord compression

›Dose related toxicity considerations

›Benefit in pain and neurologic symptoms

›Reviews on radiotherapy approaches for metastatic spinal cord compression

›Prognosis guided fractionation

›Re irradiation and SBRT considerations

Evidence & Review

Evidence & Review