Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre

Malignant Spinal Cord Compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multiprofessional care and rehabilitation, are paramount in optimising quality of life. This audit reports data collected retrospectively over a period of 12 months on patients with MSCC referred to the West of Scotland Cancer Centre (n=174). It was carried out to build on the work of the Clinical Resource and Audit Group (CRAG) and to examine current practice for symptom assessment, multiprofessional care and rehabilitation of patients with MSCC admitted to the cancer centre. Areas of concern include poor assessment of pain, the poor ambulatory status of patients on admission and the lack of clear plans for mobilisation and rehabilitation for the majority of patients. Recommendations include the development of regional guidelines for referral, treatment and rehabilitation, and the development of a pathway of care for use in all care settings across the region, together with improvements for use in patient information, staff education, audit and research. These are now being taken forward through the West of Scotland Cancer Network with dedicated funding from Macmillan Cancer Relief

The Dosimetric Impact of Implants on the Spinal Cord Dose During Stereotactic Body Radiotherapy

Background The effects of spinal implants on dose distribution have been studied for conformal treatment plans. However, the dosimetric impact of spinal implants in stereotactic body radiotherapy (SBRT) treatments has not been studied in spatial orientation. In this study we evaluated the effect of spinal implants placed in sawbone vertebra models implanted as in vivo instrumentations. Methods Four different spinal implant reconstruction techniques were performed using the standard sawbone lumbar vertebrae model; 1. L2-L4 posterior instrumentation without anterior column reconstruction (PI); 2. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (AIAC); 3. L2-L4 posterior instrumentation, L3 corpectomy, and anterior column reconstruction with a titanium cage (PIAC); 4. L2-L4 anterior instrumentation, L3 corpectomy, and anterior column reconstruction with chest tubes filled with bone cement (AIABc). The target was defined as the spinous process and lamina of the lumbar (L) 3 vertebra. A thermoluminescent dosimeter (TLD, LiF:Mg,Ti) was located on the measurement point anterior to the spinal cord. The prescription dose was 8 Gy and the treatment was administered in a single fraction using a CyberKnife® (Accuray Inc., Sunnyvale, CA, USA). We performed two different treatment plans. In Plan A beam interaction with the rod was not limited. In plan B the rod was considered a structure of avoidance, and interaction between the rod and beam was prevented. TLD measurements were compared with the point dose calculated by the treatment planning system (TPS). Results and discussion In plan A, the difference between TLD measurement and the dose calculated by the TPS was 1.7 %, 2.8 %, and 2.7 % for the sawbone with no implant, PI, and PIAC models, respectively. For the AIAC model the TLD dose was 13.8 % higher than the TPS dose; the difference was 18.6 % for the AIABc model. In plan B for the AIAC and AIABc models, TLD measurement was 2.5 % and 0.9 % higher than the dose calculated by the TPS, respectively. Conclusions Spinal implants may be present in the treatment field in patients scheduled to undergo SBRT. For the types of implants studied herein anterior rod instrumentation resulted in an increase in the spinal cord dose, whereas use of a titanium cage had a minimal effect on dose distribution. While planning SBRT in patients with spinal reconstructions, avoidance of the rod and preventing interaction between the rod and beam might be the optimal solution for preventing unexpectedly high spinal cord doses.PubMedWoSScopu