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National Collaborating Centre for Cancer (UK). Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2008 Nov. (NICE Clinical Guidelines, No. 75.)

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Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression.

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7Supportive care and rehabilitation

7.1. Introduction

Rehabilitation and supportive care are integral to the promotion of independence and quality of life in people with cancer. Some of these patients will, for oncological and general medical reasons, be unsuitable for active treatment of MSCC. NHS guidance for these patients has been issued1. The NICE guidance on ‘Improving supportive and palliative care for adults with cancer’ recommends the provision of holistic, client centred rehabilitation and care through well organised, multi-professional team working.

People with MSCC often experience significant functional losses coupled with the emotional distress associated with advancing disease. However, published evidence specifically examining the effectiveness of rehabilitation and supportive care for people with MSCC is limited. The following is an amalgamation of best available evidence from MSCC and other conditions.

7.2. Interventions for thromboprophylaxis

Risk factors for venous thromboembolism (VTE) include malignancy, reduced mobility, hospital stay for greater than four days, and major surgery including spinal surgery. All patients with MSCC and especially those undergoing surgery for MSCC are at high risk of VTE.

There is a balance in spinal surgery between the risk of thrombo-embolic complications and the risk of post-operative haemorrhage causing recurrent cord compression. Where heparin is recommended, low molecular weight heparin (LMWH) is preferred because it leads to fewer thrombotic events and fewer bleeding complications compared with unfractionated heparin.

Recommendations

  • Offer all patients who are on bed rest with suspected MSCC thigh-length graduated compression/anti-embolism stockings unless contra-indicated, and/or intermittent pneumatic compression or foot impulse devices.
  • Offer patients with MSCC who are at high risk of venous thromboembolism (including those treated surgically and judged safe for anti-coagulation) subcutaneous thromboprophylactic low molecular weight heparin in addition to mechanical thromboprophylaxis2.
  • For patients with MSCC, individually assess the duration of thromboprophylactic treatment, based on the presence of ongoing risk factors, overall clinical condition and return to mobility.

Qualifying statement: These recommendations are based on existing NICE guidance and extrapolation of evidence from research in surgical patients, patients with malignancy and patients with traumatic spinal cord injury. The optimal duration of therapy is unknown.

2

See 'Venous thromboembolism' (NICE clinical guideline 46) for information on reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing spinal surgery.

Health Economic Evaluation

The GDG did not rate this topic as a health economic priority; therefore the cost-effectiveness literature on this topic has not been reviewed.

7.3. Management of pressure ulcers

Pressure ulcers may affect quality of life and rehabilitation outcomes. They are difficult to treat and potentially life threatening. People with MSCC are at very high risk of developing pressure ulcers because of impaired mobility and sensation, as well as compromised bowel and bladder function. Pressure relieving mattresses or other pressure relieving devices are often not enough to prevent pressure ulcers.

Recommendations

  • Undertake and document a risk assessment for pressure ulcers (using a recognised assessment tool) at the beginning of an episode of care for patients with MSCC. Repeat this assessment every time the patient is turned while on bed rest and at least daily thereafter.
  • While patients with MSCC are on bed rest, turn them using a log rolling technique at least every 2–3 hours. Encourage patients who are not on bed rest to mobilise regularly (every few hours). Encourage and assist those who are unable to stand or walk to perform pressure relieving activities such as forward/sideways leaning at least hourly when they are sitting out.
  • Promptly provide pressure relieving devices to patients with MSCC appropriate to their pressure risk assessment score. Offer patients with restricted mobility or reduced sensation cushions and/or mattresses with very high-grade pressure-relieving properties.
  • When caring for patients with MSCC, adhere to the pressure sore assessment, prevention and healing protocols recommended in ‘The use of pressure-relieving devices for prevention of pressure ulcers’ (NICE clinical guideline 7) and 'The management of pressure ulcers in primary and secondary care' (NICE clinical guideline 29).

Qualifying statement: These recommendations are based on existing NICE guidance relating to the prevention and management of pressure ulcers and GDG consensus.

Health Economic Evaluation

The GDG did not rate this topic as a health economic priority; therefore the cost-effectiveness literature on this topic has not been reviewed.

7.4. Bladder and bowel continence management

Impairment of bladder and bowel sensation and function have major impact on the care and well-being of patients with MSCC, including incontinence, retention, constipation, obstruction, infection, discomfort and occasionally severe ill-health or death.

The management of bladder and bowel disturbance and paraplegia may differ depending on the level of neurological disability (upper motor neuron versus lower motor neuron).

Recommendations

  • Assess bowel and bladder function in all patients with MSCC on initial presentation and start a plan of care.
  • Monitor patients with MSCC who are continent and without urinary retention or disturbed bowel function at least daily for changes in bladder and bowel function.
  • Manage bladder dysfunction in patients with MSCC initially by a urinary catheter on free drainage. If long-term catheterisation is required, consider intermittent catheterisation or suprapubic catheters.
  • Offer a neurological bowel management programme to patients with MSCC and disturbed bowel habit as recommended in ‘Faecal incontinence’ (NICE clinical guideline 49). Take account of patient preferences when offering diet modification, faecal softeners, oral or rectal laxatives and/or constipating agents as required. Digital stimulation, manual evacuation, rectal irrigation and surgical treatment may be offered, as required.

Qualifying statement: These recommendations are based on NICE guidance and GDG consensus.

Clinical Evidence

Bowel management is addressed in the NICE clinical guideline ‘Faecal incontinence: the management of faecal incontinence in adults’ (2007b).

No studies were retrieved that included patients with MSCC specifically. However, several Cochrane systematic reviews provided relevant evidence about bladder management that can be extrapolated to MSCC patients. Jahn et al. (2007) evaluated which type of in-dwelling urinary catheter is best to use for long-term bladder drainage in adults. Overall, the included trials provided insufficient evidence to indicate which types of catheters are best to use in which patients. One trial did suggest, that the use of a hydrogel coated latex catheter rather than a silicone catheter may be better tolerated. Jamison et al. (2004) assessed the effects of using different types of urinary catheters and external (sheath) catheters in managing the neurogenic bladder, compared to alternative management strategies or interventions. Out of 400 studies considered no studies were found that met the inclusion criteria. Niël-Weise et al. (2005a) reviewed catheter policies in order to determine if any were better than others in terms of effectiveness, complications, quality of life and cost-effectiveness in long-term catheterised adults and children. Limited evidence indicated that when antibiotic prophylaxis was compared with antibiotics when clinically indicated, for patients using intermittent catheterisation, there were inconsistent findings about the effect of antibiotic prophylaxis on symptomatic urinary tract infection (UTI). For patients using indwelling urethral catheterisation, one study reported fewer events of symptomatic UTI in the prophylaxis group. When antibiotic prophylaxis was compared with giving antibiotics when microbio-logically indicated, for patients using intermittent catheterisation, there was limited evidence that receiving antibiotics reduced the rate of bacteriuria (asymptomatic and symptomatic). There was also limited evidence that prophylactic antibiotics reduced symptomatic bacteriuria. Niël-Weise et al. (2005b) investigated the outcomes of alternative approaches to catheterisation for short-term bladder drainage in adults. Patients managed with an indwelling catheter had more cases of bacteriuria, more frequent recatheterisation and more suffered discomfort than patients managed with suprapubic catheterisation. There was no evidence of complications during insertion, although not all trials reported this outcome explicitly. Findings from three studies suggested that when indwelling urethral catheterisation was compared to intermittent catheterisation there were fewer cases of bacteriuria in patients with the intermittent catheterisation. Only a proportion of the participants in the studies included in these reviews had spinal cord injury.

Health Economic Evaluation

The GDG did not rate this topic as a health economic priority; therefore the cost-effectiveness literature on this topic has not been reviewed.

7.5. Maintaining circulatory and respiratory functioning

Alterations of sympathetic vascular tone, relative parasympathetic overactivity, and respiratory muscle paralysis may cause complex and sometimes life-threatening vascular and cardio-respiratory changes in people with MSCC. These include hypoventilation, hypotension, bradycardia, and autonomic dysreflexia especially in the acute phase of paralysis or with high spinal cord lesions.

Recommendations

  • Include heart rate and blood pressure measurement, respiratory rate and pulse oximetry in the initial assessment and routine monitoring of all patients with MSCC.
  • Symptomatic postural hypotension in patients with MSCC should be managed initially by patient positioning and devices to improve venous return (such as foot pumps and graduated compression/anti-embolism stockings). Avoid overhydration which can provoke pulmonary oedema.
  • Include clearing of lung secretions by breathing exercises, assisted coughing and suctioning as needed in the prophylactic respiratory management of patients with MSCC. Treat retained secretions and the consequences by deep breathing and positioning supplemented by bi-phasic positive airway pressure and intermittent positive pressure ventilation if necessary.

Qualifying statement: In the absence of definitive research evidence these recommendations have been made with GDG consensus, supported by a moderate quality clinical guideline and poor quality observational studies.

Clinical Evidence

Respiratory management

The evidence-based guideline from the Consortium for Spinal Cord Medicine (2005) provided some of the evidence for respiratory management for MSCC patients. This guideline was appraised using the AGREE Instrument (2003), it was rated as being of moderate quality.

Maintaining circulatory functioning

Two expert reviews reported outcomes from using fludrocortisone (Bloomfield et al. 2002, Claydon et al. 2006), although widely used, there was no high level evidence of effect on hypotension. Clinical consensus as described in these studies recommended that fludrocortisone be used as treatment of vasovagal syncope and orthostatic hypotension. For compression bandages, two studies (one small non-randomised, comparative study (Rimaud et al. 2007) and one expert review (Claydon et al. 2006)) reported outcomes. This very limited evidence suggested the use of compression bandages or support stockings to restrict venous pooling in the visceral area and dependent limbs to manage hypotension. For electrically induced and voluntary activation of physiologic muscle pump, one comparative, non-randomised study evaluated this intervention (Faghri et al. 2002). Limited evidence indicated effectiveness of functional electrical stimulation (FES) during standing and tilting in spinal cord-injured individuals and may prevent orthostatic hypotension and circulatory hypokinesis and improve tolerance to tilting and standing.

The evidence from two very small non-randomised comparative studies (Svensson et al. 1995, Ter et al. 2006) evaluating passive leg movements suggest that passive leg movements do not prevent thrombosis in acute spinal cord injury (SCI) patients or alter the arterial peripheral circulation in patients with SCI or control participants.

Health Economic Evaluation

The GDG did not rate this topic as a health economic priority; therefore the cost-effectiveness literature on this topic has not been reviewed.

7.6. Access to specialist rehabilitation and transition to care at home

The potential benefits of specialist in-patient neurological and functional rehabilitation have to be weighed against the time required to achieve these (often small) gains for patients with MSCC. Additionally the general health and ability and wish to return home of patients with a life-limiting diagnosis and decreasing functional ability needs to be considered.

Survival rates at one year for people with MSCC have been reported as being less than 20%. Because of this, MSCC should be regarded as a life-limiting disease, and considerable attention needs to be paid to ensuring high quality, individualised support for people when they return home. Emphasis is on a coordinated, person-centred discharge planning process which takes into account the individual circumstances of each patient and their carers. The timing of these discussions needs to be sensitive to the emotional adjustments that the patient and carer may be experiencing. Communication between secondary, primary and tertiary care needs to be geared towards smooth transfer and continuity of care for patients.

Recommendations

  • Ensure that all patients admitted to hospital with MSCC have access to a full range of healthcare professional support services for assessment, advice and rehabilitation.
  • Focus the rehabilitation of patients with MSCC on their goals and desired outcomes, which could include promoting functional independence, participation in normal activities of daily life and aspects related to their quality of life.
  • Offer admission to a specialist rehabilitation unit to those patients with MSCC who are most likely to benefit, for example, those with a good prognosis, a high activity tolerance and strong rehabilitation potential.

Qualifying statement: These recommendations are based on GDG consensus.

  • 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. It should involve the patient and their families and carers, their primary oncology site team, rehabilitation team and community support, including primary care and specialist palliative care, as required.

Qualifying statement: This recommendation is based on GDG consensus as well as the NICE guidance 'Improving supportive and palliative care for adults with cancer’ (2004) and ‘West of Scotland Cancer Network Guidelines for Malignant Spinal Cord Compression’ (2007).

  • Ensure that community-based rehabilitation and supportive care services are available to people with MSCC following their return home, in order to maximise their quality of life and continued involvement in activities that they value.
  • Ensure that people with MSCC are provided with the equipment and care they require in a timely fashion to maximise their quality of life at home.

Qualifying statement: These recommendations are based on GDG consensus.

  • Offer the families and carers of patients with MSCC relevant support and training before discharge home.

Qualifying statement: This recommendation is based on GDG consensus as well as the NICE guidance 'Improving supportive and palliative care for adults with cancer’ (2004) and ‘West of Scotland Cancer Network Guidelines for Malignant Spinal Cord Compression’ (2007).

  • Clear pathways should be established between hospitals and community-based healthcare and social services teams to ensure that equipment and support for people with MSCC returning home and their carers and families are arranged in an efficient and coordinated manner.

Qualifying statement: This recommendation is based on GDG consensus.

Clinical Evidence

There is limited evidence of effectiveness of specialised rehabilitation for patients with MSCC. There were no randomised, controlled comparisons available between specialised rehabilitation and no rehabilitation or any other form of rehabilitation. The available evidence comes from case series studies and includes populations of which a very small proportion were MSCC patients. (Eriks 2003; Hacking 1993; McKinley et al. 1999, McKinley et al. 2000 and McKinley et al. 2001 ; New 2005). In general patients with traumatic spinal cord injury had greater improvement in their functional independence than non-traumatic spinal cord injury patients (this group contained a subset of MSCC patients). Spinal epidural metastasis (SEM) treatment plus intensive rehabilitation programme was compared to receiving only SEM treatment in a biased observational study (Ruff et al. 2007). Patients who received intensive rehabilitation survived longer. Median survival for the rehabilitation group was significantly longer compared to the no rehabilitation group. Patients in the rehabilitation group were statistically more likely to be discharged home than the no rehabilitation group. Patients in the no rehabilitation group were statistically more likely to be diagnosed with clinical depression compared to rehabilitation patients. After completing rehabilitation, the rehabilitation group had significantly higher satisfaction with life score than that of the no rehabilitation group patients. After completion of rehabilitation intervention, the rehabilitation group had lower pain levels than the group of patients with no rehabilitation.

Health Economic Evaluation

The GDG did not rate this topic as a health economic priority; therefore the cost-effectiveness literature on this topic has not been reviewed.

References

  • Bloomfield DM. Strategy for the management of vasovagal syncope. Drugs & Aging. 2002;19:179–202. [PubMed: 12027777]
  • Claydon VE. Orthostatic hypotension following spinal cord injury: Understanding clinical pathophysiology. Spinal Cord . 2006:341–351. [PubMed: 16304564]
  • Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury: a clinical practice guideline for health-care providers. 2005. Available from www​.pva.org/site/DocServer/resmgmt​.pdf?docID=703. [PubMed: 16048145]
  • Department of Health/Chief Medical Officer. Report of the independent expert working group on the prevention of venous thromboembolism in hospitalised patients. 2007.
  • Eriks , Angenot , Lankhorst Epidural metastatic spinal cord compression: functional outcome and survival after inpatient rehabilitation. Spinal Cord. 2004;42(4):235–239. [PubMed: 15060521]
  • Faghri PD. Electrically induced and voluntary activation of physiologic muscle pump: A comparison between spinal cord-injured and able-bodied individuals. Clinical Rehabilitation . 2002:878–885. [PubMed: 12501950]
  • Hacking , Van As , Lankhorst Factors related to the outcome of inpatient rehabilitation in patients with neoplastic epidural spinal cord compression. Paraplegia. 1993;31(6):367–374. [PubMed: 8336999]
  • Jahn P, Preuss M, Kernig A, Seifert-Hühmer A, Langer G. Types of indwelling urinary catheters for long-term bladder drainage in adults. Cochrane Database of Systematic Reviews. 2007;(3) Art. No.: CD004997. [PubMed: 17636782] [Cross Ref]
  • Jamison J, Maguire S, McCann J. Catheter policies for management of long term voiding problems in adults with neurogenic bladder disorders. Cochrane Database of Systematic Reviews CD004375. 2004 [PubMed: 15106248]
  • McKinley , Huang , Brunsvold Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation . Archives.of Physical.Medicine & Rehabilitation. 1999;80(10):1253–1257. [PubMed: 10527083]
  • McKinley , Huang , Tewksbury Neoplastic vs. traumatic spinal cord injury: an inpatient rehabilitation comparison . American. Journal of Physical.Medicine & Rehabilitation. 2000;79(2):138–144. [PubMed: 10744187]
  • McKinley WO, Seel RT, Gadi RK, Tewksbury MA. Nontraumatic vs. traumatic spinal cord injury: a rehabilitation outcome comparison. Am J Phys Med Rehabilitattion. 2001;80:693–699. [PubMed: 11523972]
  • New PW. Functional Outcomes and Disability After Nontraumatic Spinal Cord Injury Rehabilitation: Results From a Retrospective Study. Arch Phys Med Rehabilitation. 2005;86(2):250–261. [PubMed: 15706551]
  • National Institute for Health and Clinical Excellence. Pressure relieving devices: the use of pressure relieving devices for the prevention of pressure ulcers in primary and secondary care, NICE clinical guideline 7. London: NICE; 2003.
  • National Institute for Health and Clinical Excellence. Improving supportive and palliative care for adults with cancer, NICE cancer service guidance. London: NICE; 2004.
  • National Institute for Health and Clinical Excellence. Pressure ulcers: The management of pressure ulcers in primary and secondary care, NICE clinical guideline 29. London: NICE; 2005.
  • National Institute for Health and Clinical Excellence. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery, NICE clinical guideline 46. London: NICE; 2007.
  • National Institute for Health and Clinical Excellence. Faecal incontinence: the management of faecal incontinence in adults, NICE clinical guideline 49. London: NICE; 2007.
  • Niël-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database of Systematic Reviews. 2005;(3) Art. No.: CD004203. [PubMed: 16034924] [Cross Ref]
  • Niël-Weise BS, van den Broek PJ. Urinary catheter policies for long-term bladder drainage. Cochrane Database of Systematic Reviews. 2005;(1) Art. No.: CD004201. [PubMed: 15674931] [Cross Ref]
  • Rimaud D, Calmels P, Roche F, Mongold JJ, Trudeau F, Devillard X. Effects of graduated compression stockings on cardiovascular and metabolic responses to exercise and exercise recovery in persons with spinal cord injury. Archives of Physical Medicine & Rehabilitation. 2007;88:703–709. [PubMed: 17532890]
  • Ruff R. L., Adamson V. W., Ruff S. S., Wang X. Directed rehabilitation reduces pain and depression while increasing independence and satisfaction with life for patients with paraplegia due to epidural metastatic spinal cord compression. Journal of Rehabilitation Research & Development. 2007;44:1–10. [PubMed: 17551853]
  • Scottish Intercollegiate Guidelines Network. Antithrombotic therapy, SIGN publication no 36. Edinburgh: SIGN; 1999. Available from www​.sign.ac.uk/pdf/sign36.pdf.
  • Scottish Intercollegiate Guidelines Network. Prophylaxis of venous thromboembolism, SIGN publication no 36. Edinburgh: SIGN; 2002. Available from www​.sign.ac.uk/pdf/sign62.pdf.
  • Svensson M, Siosteen A, Wetterqvist H, Sullivan L. Influence of physiotherapy on leg blood flow in patients with complete spinal cord injury lesions. Physiotherapy Theory and Practice. 1995;11:97–107.
  • Ter WW, De Groot PC, van Kuppevelt DH, Hopman MT. Passive leg movements and passive cycling do not alter arterial leg blood flow in participants with spinal cord injury. Physical Therapy. 2006;86:636–645. [PubMed: 16649888]
  • West of Scotland Malignant Spinal Cord Compression Guidelines. Development Working Group on behalf of the West of Scotland Cancer Network. 2007.
Copyright © 2008, National Collaborating Centre for Cancer.

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Bookshelf ID: NBK55015

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