Spinal Cord Compression: A Case Study

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Spinal Cord Compression A Case Study

• Angie Angeles-Lo, SN,
• Kathy Berliner, SN
• Anthony Bodestyne, SN
• Lisa Warren, SN

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Spinal Cord CompressionPatient History

• Pt Demographics 55 year old female, diagnosed 1
  year prior with metastatic colon cancer. This
  patient had a section of colon removed in 11/02
  she now has a permanent transverse colostomy.
  She was admitted to Kaiser South San Francisco on
  11/20/03 for Spinal Cord Compression with
  paralysis of the lower extremities.

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Spinal Cord CompressionPatient History

• History of Present Hospitalization In 9/03,
  multiple retroperitoneal nodes were discovered on
  CT. On the advice of the physician, the pt flew
  to El Salvador to visit family. On 11/19, pt
  awoke with severe 10/10 back pain accompanied by
  b/l weakness of the lower extremities. She was
  seen in the ER in El Salvador where she received
  epidural analgesia in order to sit through the
  flight back to the U.S. By the end of the
  flight, the pt had no sensation or movement of
  the lower extremities.

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Spinal Cord CompressionDiagnostic Tests

• CT Scan A scan of the thoracic spine done on
  11/20. The impression showed probable metastatic
  disease to the thoracic spine. Air was seen
  within the epidural space at the lower thoracic
  level. Exact etiology is unknown.
• MRI A follow up MRI was done of the thoracic and
  lower spine that same day. The impression showed
  extensive metastatic tumor involving the
  cervical, thoracic, lumbar and sacral vertebrae,
  with evidence or spinal cord compression at T2
  and T9.

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Spinal Cord CompressionPathophysiology

• Definition Spinal cord compression damage occur
  when a tumor directly enters the spinal cord or
  when the vertebral column collapses from tumor
  entry. Tumors may begin in the spinal cord but
  more commonly spread from other areas of the body
  such as the lung, prostate, breast, colon.

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Spinal Cord CompressionPathophysiology

• Direct compression or distortion of the spinal
  cord may result from neoplastic infiltration of
  the vertebral bodies or paravertebral spaces.
• Rarely, cancerous growths may originate from
  structures within the epidural space.
• Nerve tracts most vulnerable to mechanical
  pressure include the corticospinal and
  spinocerebellar tracts and the posterior spinal
  columns.

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Spinal Cord Compression Pathophysiology

• Spinal cord compression usually follows
  hematogenous dissemination of a malignancy to the
  vertebral bodies, with subsequent expansion of an
  epidural mass. Generally, metastatic seeding
  appears in the thoracic spine 70 of with the
  lumbar spine being the next most involved
  site.The cervical spine is affected in
  approximately 10 of cases.Multiple spinal levels
  are affected in about 30 of patients.
• Systemic cancers with a tendency for spinal cord
  metastasis include the following breast,
  prostate, renal, or lung neoplasms lymphoma
  sarcoma and multiple myeloma.

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Spinal Cord CompressionPathophysiology

• Spread into the epidural space may occur by means
  of tumor extension through the intervertebral
  foramina or hematogenous spread by way of the
  Batson venous plexus. Additionally,
  gastrointestinal and pelvic malignancies tend to
  affect the lumbosacral spine lung and breast
  cancers are more likely to affect the thoracic
  spine.

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Spinal Cord CompressionPathophysiology

• Leptomeningeal metastases spread by means of
  diffuse or multifocal seeding of the meninges
  from systemic cancer (eg, lung or breast cancer,
  melanoma, lymphoma). Consequent signs and
  symptoms are referable to the brain, cranial
  nerves, or spine. Evidence of spinal compromise
  includes lower extremity weakness, paresthesias,
  reflex asymmetry, and spinal pain.

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Spinal Cord CompressionSigns and Symptoms

• Signs and Symptoms Spinal cord compression
  causes back pain, usually before neurologic
  deficits occur. Neurologic deficits are related
  to the spinal level of compression and include
  the following
• 1. Numbness
• 2. Tingling
• 3. Loss of urethral, vaginal and rectal
  sensation
• 4. Muscle weakness
• 5. If paralysis occurs, it is usually permanent.
• 6. Valsalva maneuvers, such as coughing,
  sneezing, or straining, may exacerbate radicular
  back pain.

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Spinal Cord CompressionTreatment

• Nurses caring for clients with spinal cord
  compression must recognize the condition early.
  The nurses assesses the client for neurologic
  changes consistent with spinal cord compression.
  The nurse also teaches clients and families to
  recognize the symptoms of early spinal cord
  compression and to seek medical assistance as
  soon as possible.
• Treatment is largely palliative. High-doses
  radiation is usually administered to reduce the
  size of the tumor in the area and relieve
  compression. Radiation may be given in
  conjunction with chemotherapy to treat the total
  disease. Surgery is occasionally performed to
  remove the tumor from the area and rearrange the
  bony tissue so less pressure is placed on the
  spinal cord. External back or neck braces may be
  prescribed to reduce the weight borne by the
  spinal column and to reduce pressure on the
  spinal cord or spinal nerves.

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Spinal Cord CompressionPatient Medications

• Dexamethasone- Management of cerebral edema and
  spianal compression .Potent, locally acting
  anti-inflammatory and immune modifier.Action-suppr
  esses inflammation and the normal immune
  response. Dosage-0.75-9mg PO/IV/IM daily IM, IV
  (Adults) Dexamethasone phosphate10 mg initially
  IV, 4 mg q 6 hr, may be decreased to 2 mg q 812
  hr, then change to PO. Adverse reaction- nausea,
  dizziness, HA Serious reaction -anapyhaxis.
  Implication- Assess patient for changes in level
  of consciousness and headache throughout therapy.
  
• Protonix- For hypersecretory condition, GERD
• Dosage 40-120mg PO BID Max240 mg/d. Infodo not
  crush, cut chew ActionInhibits gastric parietal
  cell hydrogen-potassium ATPase (proton pump
  inhibitr) Adverse RXN HA, diarrhea Serious side
  effect Anaphylaxis Implicationmonitor for and
  immediately report SS of angioedma or severe
  skin reaction

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Spinal Cord CompressionPatient Medications

• Fentanyl Patch For Chronic Pain
• Dosage 25-100 mcg/hr patch q72h Action Binds
  to various opiate receptors, producing analgesia
  and sedation. Adverse reaction dry mouth,
  euphoria. Serious side effect respiratory
  depression, severe HTN. Implicationevaluate
  pain relief. Monitor VS, O2 Sat, bladder
  function.
• Heparin-DVT Tx/prophylaxis
• Dosage 5000 U SC q8-12h Action with antithrobin
  III and heparin cofactor, inhibits thrombin and
  Factor Xa and inhibits conversion of fibrinogen
  to fibrin Adverse reaction Prolonged clotting
  time, bleeding Serious reaction hemorrhage
  ImplicationMonitor patient for hypersensitivity
  reactions (chills, fever, urticaria). Report
  signs to physician.Monitor platelet count every
  23 days throughout therapy.

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Spinal Cord CompressionPatient Medications

• InsulinDue to glucocorticoid administration.
• Dosage Sliding Scale before meals and bedtime
  Action Lower blood glucose by increasing
  transport into cells and promoting the conversion
  of glucose to glycogen Adverse reaction rebound
  hyperglycemia (Somogyi effect), hypoglycemia
  Serious reaction-anaphylaxis Implications Check
  type, species source, dose, and expiration date
  with another licensed nurse. Do not interchange
  insulins without consulting physician or other
  health care professional.

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Spinal Cord CompressionRadiation Therapy

• Radiation treatment to areas of tumor compression
  should be pursued after appropriate imaging and
  consultation.
• Cord compression from an epidural tumor is
  considered one of the few emergencies in
  radiation oncology.
• Spinal cord tolerance to radiation depends on the
  fraction size and cumulative dose.

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Spinal Cord CompressionRadiation Therapy

• Radiation treatment affects normal cells while
  damaging cancer cells. Sometimes this effect on
  normal cells and tissues can cause pain and
  discomfort.
• Skin dryness, difficulty in swallowing or skin
  sores may occur. The radiation therapy specialist
  can recommend a program to care for the skin to
  alleviate these side effects.
• Fatigue can be a disabling side effect of cancer,
  cancer treatments and dealing with pain. It
  restricts a person's ability to manage their
  usual activities.
• This patient was receiving external beam
  radiation for 8 days as palliative treatment to
  shrink the tumor that invaded the spinal column.

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Spinal Cord CompressionNursing Assessments and
Interventions

• Monitor and document vital signs.Rationale
  Obtain info on patients overall condition
• Assess neurological status including limb
  strength, sensation, bladder and bowel
  functionRationale Establish patients level of
  consciousness. Ascertain any evidence of
  increasing spinal cord compression as indicated
  by motor dysfunction, weakness, ataxia, sensory
  loss, numbness, tingling, loss of sensation to
  pain and temperature, constipation and urinary
  retention.

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Spinal Cord CompressionNursing Assessment

• Monitor blood chemistry and patient for signs of
  hypercalcemia, such as confusion, drowsiness and
  lethargy. Rationale Elevated calcium levels may
  be associated with bone mets causing spinal cord
  compression
• Assess alterations in elimination of urine and
  feces in terns of urgency, frequency, level of
  control over function, retention, constipation
  and incontinence. Rationale Early autonomic
  and nervous system involvement results in
  constipation and urinary retention. Bowel and
  bladder incontinence develop with advanced
  autonomic nervous system involvement.

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Spinal Cord CompressionNursing Assessment

• Assess patients pain level. Assess for
  duration, location, type, intensity and quality.
  Assess pain interventions. Consider
  non-pharmacological interventions such as
  relaxation, therapeutic massage and adjustment of
  patients position.
• Assess patients skin as there are at risk for
  impaired skin integrity. Rationale Maintain
  good body alignment at all times to decrease the
  risk of further injury to spine.

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Spinal Cord CompressionNursing Assessment

• Assess for signs and symptoms of deep venous
  thrombosis due to activity. This can lead to
  pulmonary embolism, which can be a lethal
  complication. Many die within one hour of onset
  of symptoms or before it has been suspected.
• For a DVT assess for calf and groin tenderness,
  pain, sudden onset of unilateral swelling of leg
  and positive Homans sign. Symptoms of pulmonary
  embolism include dyspnea, chest pain,
  restlessness, cough and hemoptysis. Signs
  include tachypnea, crackles, pleural friction
  rub, tachycardia, diaphoresis, fever and
  petechiae over chest and axilla.

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Spinal Cord CompressionNursing Assessment

• Assess and monitor patient and familys
  psychological status and adaptation to diagnosis
  and implication on lifestyle. Feelings of
  helplessness, hopelessness and depression are
  common. Bed bound patients become withdrawn and
  lose motivation.

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Spinal Cord CompressionNursing Diagnoses and
Interventions

• Impaired physical mobility related to
  neuromuscular impairment. Interventions include
  maintain proper body alignment, ROM exercises,
  adequate nutrition, teach patient how to move in
  bed, monitor skin area over pressure areas.
• Risk for falls related to decreased or absent
  lower extremity sensation and strength.
  Interventions include bed in low position, side
  rails up, keep frequently used items within
  patients reach, provide assistance with
  ambulation.

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Spinal Cord CompressionNursing Diagnoses and
Interventions

• Risk for impaired skin integrity related to
  physical immobilization and loss of bladder and
  bowel control. Interventions include Active or
  passive range of motions, ambulate to the extend
  possible, change positions every 2 hours, reduce
  pressure using things like pillows, air
  mattresses and bed cradles, maintain good body
  hygiene, encourage adequate fluid and nutritional
  intake.
• Bowel incontinence related to loss of rectal
  sphincter control. Interventions include Keep
  area clean and dry. Monitor anal and genital
  skin integrity. Record each episode including
  when it occurs, amount, color and consistency.
  Provide emotional support for patient.

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Spinal Cord CompressionNursing Diagnoses and
Interventions

• Ineffective Individual Coping related to
  inadequate level of confidence in ability to
  cope. Interventions include maintain
  consistency in approach and teaching whenever
  interacting with patient, monitor for and
  reinforce behavior suggesting effective coping
  continuously, assist patient to identify and use
  available support systems before discharge from
  hospital and help patient evaluate which methods
  he or she have used that have not been successful
  or have been only partially successful.