New Fellow Bootcamp Series: Cord compression
An exciting new academic year is about to begin. We know this can be daunting, especially for our newest hematology/oncology fellows. Over the next two weeks, we re-boot some of our high yield episodes you need to know to prepare for your first days as a new fellow and your nights on call.
Next up: Cord compression! [Originally episode 014]
Be sure to check out our Rotation Guides to get you in tip-top shape for fellowship!
Check out our recent tweetorial on this topic created by TFOC Team Member, Dr. Karam Elsolh.
Cord compression:
If someone has a pathologic fracture, think about the following differential as underlying etiologies:
Females: rule out breast cancer
Males: Prostate cancer
Others: multiple myeloma, lymphoma, lung cancer, renal cell carcinoma, bladder
If cord compression, administer steroids; may require radiation to help with shrinking; also may need involvement of neurosurgery if there is lack of spine stability.
Role of radiation in cord compression:
MRI is beneficial to help with radiation planning
Where is the disease in proximity to the spinal cord? In the bone? In the epidural space? Or pushing against the spinal cord +/- blocking CSF?
Is the spine stable? Use SINS scoring (https://radiopaedia.org/articles/spinal-instability-neoplastic-score-sins-2?lang=us)
If good spine stability (low SINS) or is not surgical candidate or radio-sensitive tumor: radiation up front
If poor spine stability (high SINS) then may need surgery up front
Radiosensitive tumors examples:
Lymphoma
Germ cell tumors
Small cell lung cancer
Radio-resistant tumor examples (resistant does not mean that radiation cannot be used, however):
Melanoma
Colorectal
Renal cell
Continue steroids as they are undergoing radiation to prevent flare up from inflammation and acute worsening from the mass on the spinal cord
Role of neurosurgery:
What is a reasonable time that we can wait before operating for a new cord compression?
As noted above, cord compression has various degrees
Questions to ask: What neurologic symptoms? Over what time period?
Asymptomatic: You have time! Perhaps investigate why mass may be there.
Progressive over a couple of weeks: You have a little bit of time (a few days to get them to surgery)
Acutely having symptoms: You should intervene.
Spinal stability: are the weight-bearing components (ligaments) intact? Assessed via upright X-rays
If the tumor is radio-sensitive, may opt for radiation first (if diagnosis is known)
A HUGE thank you to our special guests:
Ryan Miller, MD, MS: Dr. Miller is now an attending Radiation Oncologist at Kaiser Permanente in Southern California
Joshua Loewenstein, MD, MBA: Neurosurgery Attending, REX Neurosurgery and Spine Specialists, Raleigh, NC
