Patients presenting with back pain and history of cancer

Purpose

Metastatic spinal cord compression (MSCC) is a well-recognised complication of cancer. The National Institute of Clinical Excellence (NICE) provided clinical guidelines regarding assessment and management of patients with back pain and cancer history with suspected spinal cord compression; NICE CG-75. This study aims to determine if patients are managed appropriately and in a timely manner, according to these guidelines.

Approach

Between January-December 2016, data was collected and recorded from Musculoskeletal Clinical Assessment Service (MCAS) and spinal consultant referrals. 5260 patients were referred to spinal MCAS; 150 with back pain and a cancer history were identified for retrospective review. 154 patients were identified from orthopaedic consultant's data who had been investigated for MSCC; 32 patients had confirmed MSCC.

Outcomes

From MCAS, 38% of patients were referred for MRI for possible spinal metastases. Mean waiting time for investigation and obtaining results was 29 days. 73% of inpatients with suspected MSCC and neurological symptoms had MRI within 24-hours. 93% of inpatients with clinically suspected spinal metastases and no neurological symptoms had MRI performed within one week. 16% of patients investigated in outpatients with back pain, a cancer history and no neurological symptoms had MRI completed within one week.

Cost and savings

Patients with MSCC or spinal metastases were appropriately and timely investigated as inpatients in accordance with NICE CG-75. Patients in outpatient services did not meet recommendations. Improvements in access for clinicians to MRI investigations for suspected spinal metastases or MSCC from outpatient services with a cancer history in accordance with NICE CG-75 is required.

Implications

By considering the number of patients assessed within the MCAS service and the number of patients referred for further investigation (or not), and correlating this with the number of patients with positive metastatic findings, it can be concluded that spinal MCAS is an appropriate means of managing this cohort of patients.

Patients presenting to orthopaedic spinal consultants with suspected MSCC and spinal metastases were also effectively and timely managed as inpatients.

It is difficult and not always possible to adhere to the recommended timeliness of investigation guidelines stated within NICE CG-75. Patients presenting with a history of cancer, back pain and neurological symptoms should always be investigated within 24 hours and those patients without neurological symptoms within one week. However, those patients presenting to outpatient services without suspected MSCC or spinal metastases could be investigated as urgent OPD referral of within two weeks.

Clinically diagnosing the presence or absence of spinal metastases or MSCC, and identifying the correct spinal level of pathology using clinical signs and symptoms only, is both challenging and often inaccurate. Patients presenting to healthcare services with a known history of cancer, or clinical features implying spinal metastases or MSCC, necessitate urgent investigation as described in the CG-75. These guidelines are appropriate at managing this specific cohort of patient. However, CG-75 does not effectively manage patients with a history of cancer and back pain of none-sinister cause.

Top three learning points

  1. As a service we are meeting the recommended CG-75 guidelines for in-patients with back pain, a history of cancer and possible MSCC.
  2. We are not meeting the recommended CG-75 guidelines for patients with back pain and a history of cancer.
  3. It is not possible from a time and financial point of view to meet some of the CG-75 guidelines.

Fund acknowledgements

RLBUHT - Charitable funding donation. RLBUHT Therapies department - funding donation

Additional notes

Presented at Physiotherapy UK 2018.