Granulocyte colony-stimulating factor (G-CSF) mobilizes bone marrow-derived cells into injured spinal cord and promotes functional recovery after compression-induced spinal cord injury in mice

The aim of the present study was to elucidate the effects of granulocyte colony-stimulating factor (G-CSF)-mediated mobilization of bone marrow-derived stem cells on the injured spinal cord. Bone marrow cells of green fluorescent protein (GFP) transgenic mice were transplanted into lethally irradiated C57BL/6 mice. Four weeks after bone marrow transplantation, spinal cord injury was produced by a static load (20 g, 5 min) at T8 level. G-CSF (200 microg/kg/day) was injected subcutaneously for 5 days. Immunohistochemistry for GFP and cell lineage markers was performed to evaluate G-CSF-mediated mobilization of bone marrow-derived cells into injured spinal cord. Hind limb locomotor recovery was assessed for 6 weeks. Immunohistochemistry revealed that G-CSF increased the number of GFP-positive cells in injured spinal cord, indicating that bone marrow-derived cells were mobilized and migrated into injured spinal cord. The numbers of double positive cells for GFP and glial markers were larger in the G-CSF treated mice than in the control mice. Luxol Fast Blue staining revealed that G-CSF promoted white matter sparing. G-CSF treated mice showed significant recovery of hind limb function compared to that of the control mice. In conclusion, G-CSF showed efficacy for spinal cord injury treatment through mobilization of bone marrow-derived cells.

What Happens to People after Malignant Cord Compression? Survival, Function, Quality of Life, Emotional Well-being and Place of Care 1 Month after Diagnosis

AIMS

To present further findings from the Scottish Cord Compression Study, in which the diagnosis, management and outcome of 319 patients with a definitive diagnosis of malignant cord compression (MCC) were examined.

MATERIALS AND METHODS

In total, 256 (80%) patients in the study consented to be interviewed shortly after diagnosis and at follow-up interviews. One hundred and twenty-eight patients were interviewed 1 month after diagnosis (40% of the total; 57% [128/224] of patients alive 1 month after diagnosis; 68% [128/188] of patients who also consented to follow-up). Survival data of the whole MCC population and data from interviewing 128 patients 1 month after diagnosis are presented.

RESULTS

The median survival of all patients was 59 days (95% confidence interval [CI] 43-75 days). The median Karnofsky performance status was 50 (interquartile range 40-60), indicating a need for considerable nursing and medical care, and was poorest for patients with lung cancer (median 40; interquartile range 30-60). The place of care was dependent on mobility at diagnosis; patients walking at diagnosis were more likely to be at home, whereas patient requiring assistance or who were unable to walk were more likely to be in institutional care (P = 0.019). Mobility and bladder function were determined by mobility and bladder function at diagnosis (P < 0.001). Of those unable to walk at diagnosis, 7% regained full mobility. Of those catheterised at presentation, 28% regained full bladder function. Forty-seven per cent (56/120, 95% CI 40-54) of patients interviewed were in pain despite oncological treatment and 18% (22/ 120; 95% CI 8-19) reported the pain as severe (visual analogue scale > 7). The median quality-of-life (Schedule for Evaluation of Individualised Quality of Life) score was 72/100, and was higher in patients with a better performance status (P = 0.026). A minority of patients (8%) screened positive for anxiety and depression using the Hospital Anxiety and Depression scale.

CONCLUSIONS

Notwithstanding the difficulties in following up this group of patients, this paper reports valuable findings detailing the experience of patients with MCC 1 month after diagnosis and treatment.

Paraplegia as the presenting manifestation of extramedullary megakaryoblastic transformation of previously undiagnosed chronic myelogenous leukemia

Extramedullary tumors, also known as granulocytic sarcomas (GS), occur most frequently in acute myelogenous leukemia (AML). They may signal the onset of the accelerated phase of chronic myelogenous leukemia (CML) or the blastic transformation of a myeloproliferative disorder. Occasionally, a GS may be the presenting sign of undiagnosed AML, and rarely the presenting sign of undiagnosed CML or aleukemic leukemia. Paraplegia due to a spinal cord GS is an extremely rare presentation of undiagnosed leukemia. This is the first case report of paraplegia as the presenting manifestation of extramedullary megakaryoblastic transformation of previously undiagnosed CML. A 53-year-old woman reported back pain for 6 days, rapidly progressing to paraplegia. Physical examination noted a large abdominal mass and flaccid paralysis in both lower extremities. Spinal MRI revealed a T4-T6 vertebral mass causing spinal stenosis and cord compression. Tumor debulking and laminectomy were performed emergently. The tumor consisted of noncohesive blast cells. The CBC revealed a leukocyte count of 238,300/microl and a differential consistent with CML. Reexamination of the patient found that the abdominal mass was a giant spleen. Further immunohistochemical studies of the tumor were consistent with extramedullary acute megakaryoblastic blast transformation of CML. Although extramedullary blast crises herald the accelerated phases in approximately 10% of CML cases, megakaryoblastic blast transformation of CML accounts for less than 3% of these cases. The combination of acute paraplegia and megakaryoblastic transformation in a previously undiagnosed patient with CML is extremely rare and may pose a diagnostic dilemma.

Treatment of oncologic emergencies

Most oncologic emergencies can be classified as metabolic, hematologic, structural, or side effects from chemotherapy agents. Tumor lysis syndrome is a metabolic emergency that presents as severe electrolyte abnormalities. The condition is treated with allopurinol or urate oxidase to lower uric acid levels. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. Syndrome of inappropriate antidiuretic hormone should be suspected if a patient with cancer presents with normovolemic hyponatremia. This metabolic condition usually is treated with fluid restriction and furosemide. Febrile neutropenia is a hematologic emergency that usually requires inpatient therapy with broad-spectrum antibiotics, although outpatient therapy may be appropriate for low-risk patients. Hyperviscosity syndrome usually is associated with Waldenström's macroglobulinemia, which is treated with plasmapheresis and chemotherapy. Structural oncologic emergencies are caused by direct compression of nontumor structures or by metastatic disease. Superior vena cava syndrome presents as neck or facial swelling and development of collateral venous circulation. Treatment options include chemotherapy, radiation, and intravenous stenting. Epidural spinal cord compression can be treated with dexamethasone, radiation, or surgery. Malignant pericardial effusion, which often is undiagnosed in cancer patients, can be treated with pericardiocentesis or a pericardial window procedure.

Clinical Approach to Metastatic Epidural Spinal Cord Compression

Metastatic epidural spinal cord compression (MESCC) is a devastating complication of cancer that occurs when cancer metastasizes to the spine and then secondarily compresses the spinal cord. It is a relatively common complication of cancer and. in the United States, more than 20,000 cases of MESCC are diagnosed annually. If left untreated, virtually 100% of these patients would become paraplegic; therefore, it is considered a true medical emergency and immediate intervention is required. Even with aggressive therapy, results can often be unsatisfactory. Although most patients with MESCC have limited survival, up to one third will survive beyond one year. Thus. it is essential to consider aggressive therapy to preserve or improve the quality of life and prevent paraplegia.

[Vertebroplasty in the treatment of back pain]

BACKGROUND

Percutaneous vertebroplasty (PVP) represents a minimally invasive option which is gaining in importance for the treatment of vertebral compression fractures (VCF) and osteolysis of the spine. This article describes the indications for its use, peri-interventional imaging, technique, and results of PVP.

MATERIAL AND METHODS

The current guidelines for performance of PVP are explained in accordance with the "Interdisciplinary Consensus Paper on Vertebroplasty and Kyphoplasty" of the German Professional Associations and the 2005 CIRSE Guidelines. The results of our own study carried out in 2002 are compared to the complication rates and clinical outcomes reported in the literature.

RESULTS

Painful osteoporotic VCF and osteolysis within the vertebral body due to metastases and multiple myeloma are indications for PVP. Absolute contraindications are, in particular, asymptomatic VCF, alleviation of pain by drug treatment, therapy-refractory coagulopathies, allergies to cement components, and active infections. MRI or CT is indicated before undertaking PVP to assess the fracture age, to exclude other causes of pain, and to evaluate the posterior edge of the vertebral body. High-quality mono- or biplanar fluoroscopy--preferably in combination with CT (fluoroscopy)--is necessary for PVP to minimize the risk of cement leakage. A clear reduction in pain [mean reduction of 6.1 points (VAS)] is achieved in 86-92% of the patients with PVP. Our own study treating 58 patients (mean follow-up 323+/-99 days) revealed a clear alleviation of pain in 77% [-5.7 points (VAS)].

CONCLUSION

PVP constitutes a safe and effective minimally invasive treatment approach to stabilize and reduce acute and chronic back pain due to osteoporotic VCF and tumor-associated osteolysis.

Cost-effectiveness of surgery plus radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression

PURPOSE

A recent randomized clinical trial has demonstrated that direct decompressive surgery plus radiotherapy was superior to radiotherapy alone for the treatment of metastatic epidural spinal cord compression. The current study compared the cost-effectiveness of the two approaches.

METHODS AND MATERIALS

In the original clinical trial, clinical effectiveness was measured by ambulation and survival time until death. In this study, an incremental cost-effectiveness analysis was performed from a societal perspective. Costs related to treatment and posttreatment care were estimated and extended to the lifetime of the cohort. Weibull regression was applied to extrapolate outcomes in the presence of censored clinical effectiveness data.

RESULTS

From a societal perspective, the baseline incremental cost-effectiveness ratio (ICER) was found to be $60 per additional day of ambulation (all costs in 2003 Canadian dollars). Using probabilistic sensitivity analysis, 50% of all generated ICERs were lower than $57, and 95% were lower than $242 per additional day of ambulation. This analysis had a 95% CI of -$72.74 to 309.44, meaning that this intervention ranged from a financial savings of $72.74 to a cost of $309.44 per additional day of ambulation. Using survival as the measure of effectiveness resulted in an ICER of $30,940 per life-year gained.

CONCLUSIONS

We found strong evidence that treatment of metastatic epidural spinal cord compression with surgery in addition to radiotherapy is cost-effective both in terms of cost per additional day of ambulation, and cost per life-year gained.

Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy?

BACKGROUND CONTEXT

Cervical spondylotic myelopathy has traditionally been managed through surgical decompression with or without reconstruction. Currently, a multicenter, blinded clinical trial that has supported such a therapeutic recommendation does not exist. There have been case-control studies that have and have not shown long-standing benefit to surgical decompression and reconstruction.

PURPOSE

The purpose of this review is to examine the efficacy of nonoperative therapy for cervical spondylotic myelopathy.

CONCLUSIONS

It appears that both static and dynamic factors play a role in the pathophysiology of cervical spondylotic myelopathy. Furthermore, once clinical cervical spondylotic myelopathy is evident, progression may occur despite the best of treatments, both surgical and nonsurgical.

Spinal cord compression: an oncologic emergency associated with metastatic cancer: evaluation and management for the home health clinician

Spinal cord compression is an oncologic emergency that needs to be identified, evaluated, and treated promptly for favorable patient outcomes. Although there are nonmalignant types of spinal cord compression, this article focuses on patients presenting with metastatic cancer. Home care clinicians should be knowledgeable with current assessment strategies aimed at recognizing this potentially debilitating condition. Using an assessment tool could assist clinicians with early detection of spinal cord compression, which could improve the overall quality of life.

Bone marrow stem cells and polymer hydrogels--two strategies for spinal cord injury repair

1. Emerging clinical studies of treating brain and spinal cord injury (SCI) led us to examine the effect of autologous adult stem cell transplantation as well as the use of polymer scaffolds in spinal cord regeneration. We compared an intravenous injection of mesenchymal stem cells (MSCs) or the injection of a freshly prepared mononuclear fraction of bone marrow cells (BMCs) on the treatment of an acute or chronic balloon-induced spinal cord compression lesion in rats. Based on our experimental studies, autologous BMC implantation has been used in a Phase I/II clinical trial in patients (n=20) with a transversal spinal cord lesion. 2. MSCs were isolated from rat bone marrow by their adherence to plastic, labeled with iron-oxide nanoparticles and expanded in vitro. Macroporous hydrogels based on derivatives of 2-hydroxyethyl methacrylate (HEMA) or 2-hydroxypropyl methacrylamide (HPMA) were prepared, then modified by their copolymerization with a hydrolytically degradable crosslinker, N,O-dimethacryloylhydroxylamine, or by different surface electric charges. Hydrogels or hydrogels seeded with MSCs were implanted into rats with hemisected spinal cords. 3. Lesioned animals grafted with MSCs or BMCs had smaller lesions 35 days postgrafting and higher scores in BBB testing than did control animals and also showed a faster recovery of sensitivity in their hind limbs using the plantar test. The functional improvement was more pronounced in MSC-treated rats. In MR images, the lesion populated by grafted cells appeared as a dark hypointense area and was considerably smaller than in control animals. Morphometric measurements showed an increase in the volume of spared white matter in cell-treated animals. In the clinical trial, we compared intraarterial (via a. vertebralis, n=6) versus intravenous administration of BMCs (n=14) in a group of subacute (10-33 days post-SCI, n=8) and chronic patients (2-18 months, n=12). For patient follow-up we used MEP, SEP, MRI, and the ASIA score. Our clinical study revealed that the implantation of BMCs into patients is safe, as there were no complications following cell administration. Partial improvement in the ASIA score and partial recovery of MEP or SEP have been observed in all subacute patients who received cells via a. vertebralis (n=4) and in one out of four subacute patients who received cells intravenously. Improvement was also found in one chronic patient who received cells via a. vertebralis. A much larger population of patients is needed before any conclusions can be drawn. The implantation of hydrogels into hemisected rat spinal cords showed that cellular ingrowth was most pronounced in copolymers of HEMA with a positive surface electric charge. Although most of the cells had the morphological properties of connective tissue elements, we found NF-160-positive axons invading all the implanted hydrogels from both the proximal and distal stumps. The biodegradable hydrogels degraded from the border that was in direct contact with the spinal cord tissue. They were resorbed by macrophages and replaced by newly formed tissue containing connective tissue elements, blood vessels, GFAP-positive astrocytic processes, and NF-160-positive neurofilaments. Additionally, we implanted hydrogels seeded with nanoparticle-labeled MSCs into hemisected rat spinal cords. Hydrogels seeded with MSCs were visible on MR images as hypointense areas, and subsequent Prussian blue histological staining confirmed positively stained cells within the hydrogels. 4. We conclude that treatment with different bone marrow cell populations had a positive effect on behavioral outcome and histopathological assessment after SCI in rats; this positive effect was most pronounced following MSC treatment. Our clinical study suggests a possible positive effect in patients with SCI. Bridging the lesion cavity can be an approach for further improving regeneration. Our preclinical studies showed that macroporous polymer hydrogels based on derivatives of HEMA or HPMA are suitable materials for bridging cavities after SCI; their chemical and physical properties can be modified to a specific use, and 3D implants seeded with different cell types may facilitate the ingrowth of axons.

Spinal cord compression from traumatic anterior cervical pseudomeningoceles

✓Pseudomeningoceles rarely develop after cervical trauma; in all reported cases the lesions have extended outside the spinal canal.

The authors report the first known cases of anterior cervical pseudomeningoceles contained entirely within the spinal canal and causing cord compression and neurological injury. The authors retrospectively reviewed the cases of three patients with traumatic cervical spine injuries and concomitant compressive anterior pseudomeningoceles. The lesion was recognized in the first case when the patient’s neurological status declined after he sustained a severe atlantoaxial injury; the pseudomeningocele was identified intraoperatively and decompressed. After the decompressive surgery, the patient’s severe tetraparesis partially resolved. In the other two patients diagnoses of similar pseudomeningoceles were established by magnetic resonance imaging. Both patients were treated conservatively, and their mild to moderate hemiparesis due to the pseudomeningocele-induced compression abated.

The high incidence of anterior cervical pseudomeningoceles seen at the authors’ institution within a relatively brief period suggests that this lesion is not rare. The authors believe that it is important to recognize the compressive nature of these lesions and their potential to cause devastating neurological injury.

[Metastatic spinal cord compression syndrome. A retrospective analysis of 297 patients]

INTRODUCTION

The purpose of this study was to look at the prognostic factors and the effects (regression of symptoms and survival rate) of the treatment given to patients with metastatic spinal cord compression syndrome (MSCCS).

MATERIALS AND METHODS

Data from 297 patients who were treated at Odense University Hospital from 1989 to 2003 were collected through a retrospective evaluation of medical records.

RESULTS

The patients' median age was 67 years. The most common primary diagnoses were prostate cancer, breast cancer and lung cancer. The patients' motor function at the time of diagnosis, the primary cancer diagnosis, the time from primary diagnosis to development of MSCCS and the treatment given were all significant prognostic factors. The patients receiving surgery (whether or not also receiving radiotherapy) had a significantly higher survival rate (4.8 months) than those who received only radiotherapy (3.3 months).

CONCLUSION

Primary diagnosis, the degree of symptoms and the time from primary diagnosis to development of MSCCS are important prognostic factors that should be considered when choosing the treatment for a given patient. With an active attitude, it is possible to retain walking skills during the remaining and often short lifetime. Patients whose general condition allows for it should receive acute surgery followed by radiotherapy.

Efficacy of postural reduction in osteoporotic vertebral compression fractures followed by percutaneous vertebroplasty

OBJECTIVE

Vertebroplasty in the symptomatic osteoporotic vertebral fracture has become increasingly popular. However, there have been some limitations in restoring the height of the collapsed vertebrae and in preventing the leaking of cement. In the severely collapsed vertebrae of more than two thirds of their original height, vertebroplasty is regarded as a contraindication. We tried postural reduction using a soft pillow under the compressed level. This study was undertaken to investigate the effectiveness of the combination of postural reduction and vertebroplasty for re-expansion and stabilization of the osteoporotic vertebral fractures.

METHODS

A total of 75 patients with single level vertebral compression fracture were treated with postural reduction followed by vertebroplasty. In 30 patients, the vertebral body was severely collapsed more than two-thirds of its original height. We calculated the compression ratio (anterior height/posterior height) and measured the Cobb angle. We analyzed the degree of re-expansion according to the onset duration.

RESULTS

The mean compression ratio was 0.60 +/- 0.15 initially and increased to 0.75 +/- 0.17 after vertebroplasty. The mean Cobb angle was 16.14 +/- 11.29 degrees and corrected to 10.71 +/- 12.08 degrees. The degree of re-expansion showed significant relation with the onset duration. Twenty-eight of 30 (93%) severely collapsed vertebrae re-expanded after postural reduction, which made vertebroplasty possible.

CONCLUSION

This new method of vertebroplasty leads to significant restoration of height and correction of kyphosis. The re-expansion was closely related with onset duration. In cases of severely collapsed vertebrae which is able to be re-expanded by postural reduction, vertebroplasty could be applied safely.

Metastatic spinal cord compression: the hidden danger

BACKGROUND

A 47-year-old male underwent resection of a left-shoulder melanoma in 1997. In November 2004 he was found to have multiple brain lesions and adrenal, lung, and bone metastases, and in January 2005 underwent resection of his symptomatic right parietal lobe lesion and subsequent whole-brain radiation. In February 2005 he experienced headaches and word-finding difficulty and was found to have four progressive brain lesions on MRI. These were resistant to conventional radiotherapy and were treated with stereotactic radiosurgery. The patient later developed an obstruction of the jejunum and underwent resection of multiple abdominal masses. In April 2005, the patient commenced temozolomide and underwent radiation therapy to the left arm for pain thought to be caused by an increase in size of his melanoma metastasis. In August 2005 the patient reported persistent and worsening arm pain, despite a further course of radiotherapy in June 2005.

INVESTIGATIONS

Physical examination including a thorough neurological examination, radiography, X-ray, CT scan, and MRI.

DIAGNOSIS

Metastatic melanoma to the cervical spine (C7 vertebra) with spinal cord compression.

MANAGEMENT

Involved field radiotherapy, temozolomide, opioids, gabapentin, corticosteroids, and Cyberknife therapy.

Regression of an atlantoaxial degenerative articular cyst associated with subluxation during conservative treatment

✓ The presence of an atlantoaxial degenerative articular cyst is rare; when present this lesion extends posteriorly to the dens, causing cervicomedullary compressive myelopathy. The authors describe a symptomatic case of this lesion associated with atlantoaxial subluxation in a 76-year-old man. The patient’s neurological symptoms resolved and corresponded to a reduction in the size of the cyst. After 8 months of continued conservative treatment, in which the patient wore a Philadelphia collar, the cyst spontaneously regressed. Subsequently, a C1–2 posterior fusion was performed to treat the atlantoaxial subluxation.

Mouse spinal cord compression injury is reduced by either activation of the adenosine A2A receptor on bone marrow-derived cells or deletion of the A2A receptor on non-bone marrow-derived cells

Activation of the adenosine A(2A) receptor (A(2A)R) at the time of reperfusion has been shown to reduce ischemia-reperfusion injury in peripheral tissues and spinal cord. In this study we show that treating mice with the A(2A)R agonist, 4-{3-[6-amino-9-(5-cyclopropylcarbamoyl-3,4-dihydroxy-tetrahydro-furan-2-yl)-9H-purin-2-yl]-prop-2-ynyl}-piperidine-1-carboxylic acid methyl ester for four days beginning before or just after the onset of reperfusion after compression-induced spinal cord injury rapidly (within 1 day) and persistently (>42 days) reduces locomotor dysfunction and spinal cord demyelination. Protection is abolished in knockout/wild type bone marrow chimera mice selectively lacking the A(2A)R only on bone marrow-derived cells but retaining receptors on other tissues including blood vessels. Paradoxically, reduced spinal cord injury is also noted in A(2A)R -/- mice, and in wild type/knockout bone marrow chimera mice selectively lacking the A(2A)R on non-bone marrow-derived cells, or in mice treated with the A(2A) antagonist, 4-(2-[7-amino-2-[2-furyl][1,2,4]triazolo[2,3-a][1,3,5]triazin-5-yl-amino]ethyl)phenol. The greatest protection is seen in knockout/wild type bone marrow chimera mice treated with 4-{3-[6-amino-9-(5-cyclopropylcarbamoyl-3,4-dihydroxy-tetrahydro-furan-2-yl)-9H-purin-2-yl]-prop-2-ynyl}-piperidine-1-carboxylic acid methyl ester, i.e. by activating the A(2A)R in mice expressing the receptor only in bone marrow-derived cells. The data suggest that inflammatory bone marrow-derived cells are the primary targets of A(2A) agonist-mediated protection. We conclude that A(2A) agonists or other interventions that inhibit inflammation during and after spinal cord ischemia may be effective in reducing spinal cord injury in patients, but excessive or prolonged stimulation of the A(2A)R may be counterproductive. It may be possible to devise strategies to produce optimal spinal cord protection by exploiting temporal differences in A(2A)R-mediated responses.

Successful treatment of spinal cord compression secondary to extramedullary hematopoietic mass by hypertransfusion in a patient with thalassemia major

A 15-year-old girl with thalassemia major who suffered from paraparesis with a history of progressive lower limb weakness for 2 years immigrated from mainland China to Hong Kong. She had not received regular blood transfusion since the age of 6 years after splenectomy. MRI of the spine showed thoracic spinal cord compression secondary to extramedullary hematopoietic mass. She made significant recovery with hypertransfusion therapy alone. MRI of the spine repeated 3 months later showed nearly complete resolution of the extramedullary hematopoietic mass.

Diagnosis and management of juxtafacet cysts

Juxtafacet cysts are lesions that are associated with spinal facet joints. Although these lesions are frequently noted as incidental findings on imaging studies of the spine, they may produce symptoms in some patients. Juxtafacet cysts can mimic herniated discs, resulting in symptoms from focal nerve root and/or spinal cord compression. Some of these lesions are associated with spinal instability, and patients may require spinal fusion to address this underlying disorder. Conservative therapy for symptomatic lesions is often unsuccessful, although there are reports of spontaneous resolution of these cysts as well as the symptoms associated with them. Surgical therapy should be focused on decompression of the lesions causing nerve root compression and the accompanying symptoms, while recognizing that instability requiring fusion may be present in some but not all cases.

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.

Metastatic spinal cord compression

Approximately 70% of cancer patients have metastatic disease at death. The spine is involved in up to 40% of those patients. Spinal cord compression may develop in 5% to 10% of cancer patients and up to 40% of patients with preexisting nonspinal bone metastasis (>25,000 cases/y). Given the increasing survival times of patients with cancer, greater numbers of patients are likely to develop this complication. The role of surgery in the management of metastatic spinal cord compression is expanding. The management of metastatic spine disease can consist of a combination of surgery, radiation treatment, and chemotherapy. Treatment modalities are not mutually exclusive and must be individualized for patients evaluated in a multidisciplinary setting.