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Course: Oncology Nursing

Topic: Nursing Management of

Oncological Emergency - Spinal Cord Compression

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Module Goals

Learners will be able to:

Explain the underlying pathophysiology of Spinal Cord Compression.
Describe the scope of the problem including the incidence, etiology and risk factors for this oncologic emergency.
List the clinical manifestations that are associated with this emergency situation.
Explain the nursing assessment for spinal cord compression including relevant diagnostic tests.
Characterize the nursing interventions and supportive care important to address this problem in a timely and effective manner.

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Spinal Cord Compression

Spinal cord compression occurs when there is pressure on the spinal cord. The pressure from a tumor or other factor causes the nerves in the spinal cord to swell and slows down or blocks the blood supply to the nerves and the nerves stop working normally.

Causes:

Metastatic tumors in the epidural space (breast, lung, prostrate, kidney tumors are common)
Abnormal spinal alignment (scoliosis)
Injury to the spine (trauma)
Spinal tumors (lymphomas)
Certain bone diseases
Rheumatoid arthritis
Infection

Johns Hopkins Medicine, 2021

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Spinal Cord Compression

Symptoms:

Back pain that is intense, localized and persistent in cancer patient
Loss of sensation to the feet
Numbness or cramping, or weakness in the hands, arms, or legs
Trouble walking or with coordination
Burning or tingling in the arms, buttocks, or down the legs
Weakness in the foot that causes a limp
Pain and stiffness to the back and neck
Any change in bladder or bowel function
Decrease in reflexes

Johns Hopkins Medicine, 2021

Kaplow & Iyere, 2016

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Nursing Assessments

Assess for pain or tenderness in spinal column
Assess motor function (gait, posture, and balance).
Assess deep tendon reflexes included Babinski reflexes.
Assess sensory on the body by touching the feet, hands, arms, and legs and assessing if there is a feeling of difference in sensation, also, on the torso and if there is a difference from each side.
Assess bilateral hand grasps and foot strength and determine if they are equal or different.
Assess urinary and stool incontinence.

Kaplow & Lyere, 2016

Contact info: info@nursesinternational.org

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Review Question

A client presents to the emergency department with left leg weakness and ataxia. You need to perform a neurological assessment on the patient. Please review your cranial nerve assessment.

Cranial Nerve I-Olfactory Cranial Nerve VII-Facial

Cranial Nerve II-Optic Cranial Nerve VIII-Vestibulocochlear

Cranial Nerve III-Oculomotor Cranial Nerve IX-Glossopharyngeal

Cranial Nerve IV-Trochlear Cranial Nerve X-Vagus

Cranial Nerve V-Trigeminal Cranial Nerve XI-Accessory

Cranial Nerve VI-Abducens Cranial Nerve XII-Hypoglossal

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Diagnostics for Spinal Cord Compression

Cancer Research UK, 2021

Johns Hopkins Medicine, 2021

CT scan-(computed tomography)- This is a test that uses x-rays and a computer to create detailed images of the inside of your body. These images are taken at different angles and the computer puts them all together to create a 3-dimensional image for the radiologist and healthcare professionals to view.
MRI- (magnetic resonance imaging)-This is a type of scan that uses magnetic fields and radio waves to take pictures of the inside of the body. The scan can take between 15-90 minutes depending on which part of the body is being imaged. This test can be done to determine if a patient has cancer or other disease processes and how big it may be. This exam is used to look for tumors and to see how far tumors have spread.

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Treatment for Spinal Cord Compression

Corticosteroids such as dexamethasone- These help to decrease the swelling and relieve the pressure on the spinal cord.
Lying flat-This helps to reduce movement in the patient’s spine and prevent further damage to the spinal cord.
Wear a brace-A physiotherapist will help the patient sit up and move and help with a brace when it is appropriate
Pain medication-This condition is painful, so make sure the patient have pain medication so they can perform ADL’s. (NSAIDS or Opioids)
Radiotherapy-This is high energy x-rays to target and destroy the cancer cells and to help to shrink the tumor that is damaging the nerves around the spinal cord

(Copy and paste this slide to prepare other slides)

Cancer Research UK, 2021

Johns Hopkins Medicine, 2021

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Treatments continued….

Surgery-The tumor may be removed to help relieve the pressure from the spinal cord
Bisphosphonates such as alendronate help by slowing the bone loss in the spinal cord
Chemotherapy Medication-Helps to shrink the tumor decreasing the pressure on the spinal cord
Vertebroplasty or kyphoplasty-the doctor injects cement into the area where the swelling is pressing on the spinal cord and helps to strengthen that area.

Cancer Research UK, 2021

Johns Hopkins Medicine, 2021

Kaplow & Lyere, 2016

Contact info: info@nursesinternational.org

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Case Study

A 68 year old male presents to the emergency department for evaluation of a gradual onset of lower extremity weakness over one month, resulting in falls and bladder incontinence over the past few days. He also states that he has noticed some weakness and tingling in his arms and hands. He reports about 10 pounds of weight loss over the last six months and just not feeling well. He has chronic back pain from working in a factory, but the back pain has been getting worse. His past medical history confirms he has hypertension, diabetes, and multiple back surgeries. He is not allergic to anything. He only takes his blood pressure and diabetic medication. On exam, the nurse notes that his bilateral grasps are weak, he is weak when standing, and he has difficulty lifting his legs. The physician orders and MRI and the results return with a tumor on his L3.

What do you notice about his symptoms and his diagnosis? How do they relate?

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Nursing Management

Spinal Cord Compression is a medical EMERGENCY!
The nurse must monitor the patient for worsening symptoms.
Tumors that are located in the cervical spine could potentially cause breathing issues, so the nurse needs to be aware of watching for breathing problems.
Perform a thorough neurological physical examination.
You must explain to the patient what is going on and the treatment plans as prescribed by the healthcare provider.
Remember to include the interdisciplinary team members such as physical therapy to help with mobility

Kaplow & Lyere, 2016

Contact info: info@nursesinternational.org

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Nursing Management Continued...

Appropriate management of pain
If urinary retention or incontinence may need to insert a urinary catheter and monitor for urinary tract infection
Initiate deep vein thrombosis prophylaxis orders for increase in bedrest
Bowel management in patient with loss of bowel control, may need softeners, and help with ADLs
Monitor for adverse effects of administered medications
Help maintain their dignity and encourage independence for what they can do
Involve case management and social workers to help with home management and discharge planning

Kaplow & Lyere, 2016

Contact info: info@nursesinternational.org

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Critical Thinking Question

A client is receiving high dose dexamethasone due to a Non-Hodgkin’s lymphoma on T10. Which finding would the nurse interpret as a potential complication of this treatment?

Positive nitrites in the urine
Positive blood in the stool
Increase in blood glucose
Itching to the skin

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Critical Thinking Question

A nurse is caring for a patient who has a large neurofibroma surrounding the spinal cord at T2. Which would the nurse expect to see as the tumor increases in size?

Urinary incontinence
Constipation
Arrhythmias
Headaches

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Red Flags

Any cancer patient with intense back pain or tenderness
Urinary retention. then weakness in extremities, then unilateral weakness
Know where the tumor is located and what are potential things that can happen in that area
Weakness in extremities
Unilateral weakness
This is something that has to be treated
Also, pay attention to complications from the treatments

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Cultural Considerations

Occurs in all race, nationalities.
Occurs in 5-10% of patients with advanced cancers.
Median survival rate is 2-3 after diagnosis with 17% alive after 1 year.
Pain is expressed differently in different cultures.
Patient may be reluctant to admit to pain, so be observant when feeling along their spinal cord and watch for visual clues of pain.

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References:

Campillo-Recio, D., Aritzia, M., Benitez, G., Martinez, J., Martin, C., & Catelli, S. (2019). Metastatic spinal cord compression: incidence, epidemiology, and prognostic factors. Rev Clin Esp (Barc), 219(7):386-389.

Cancer Research UK. (2021). About Cancer: Spinal cord compression. Retrieved from https://www.cancerresearchuk.org/about-cancer/coping/physically/spinal-cord-compression/about

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References:

Johns Hopkins Medicine (2021). Health Home: Spinal cord compression. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-cord-compression

Kaplow, R. and Iyere, K. (2016). Oncology emergency series: understanding spinal cord compressions. Nursing 46 (9). Retrieved from https://nursing.ceconnection.com/ovidfiles/00152193-201609000-00010.pdf

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