MANAGEMENT OF A PATIENT WITH A SPINAL

CORD MASS AND LYMPHOMA (ACUTE CARE)

Becca Shonsey

DPT 774

Put yourself in his shoes

Imagine feeling weak Imagine being told nothing is wrong Imagine a month goes by and you start

to get leg numbness 1 week passes and you can’t walk Each step of the way something

changes

PURPOSE

Our prime purpose in this life is to help others. And if you can't help them, at least don't hurt them. ~Dalai Lama

Help you help your patient with a spinal compression and lymphoma in acute care

Objectives The student will be able to identify the signs

and symptoms of spinal tumor compression The student will be able to differentiate

between spinal tumor signs and lymphoma signs

The student will be able to develop a treatment plan for a patient with cancer in an acute care setting

The student will be able to determine the prognosis of a patient with both a spinal tumor and lymphoma

Patient History 42 year old white male Homeless 12 pack of beer each week 25 packs of cigarettes a year Mid thoracic and abdominal pain, decreased

renal function (April) CT on chest, abdomen and pelvis (April)-no

significant findings Pt reports: 1 week ago LE numbness, 48

hours ago LE weakness

Examination PIP: Progressive weakness and inability to

walk HR: 82 Oxygen Saturation: 94% BP: 140/77

Negative: hypotension, fever, chills, sweat, weight loss, nausea, vomiting, headache, facial paresis, spinal tenderness with palpation

Examination

Positive: Renal function decreaseNumbness below nipples to saddleReflexes 3+UE strength 5/5LE Strength :

○ Bilateral hip flexion 2/5 ○ Bilateral knee extension 3/5 ○ R dorsiflexion and plantarflexion 2/5 ○ L dorsiflexion and plantarflexion 4/5

Knowing spinal compression 15% of all CNS tumors are primary

spinal tumors3

Spinal cord tumorsPrimary are rare?Compress the cord and surrounding nervesSx: pain or numbness in back, arms or

legsXDecreased ms strengthXLoss of bowel or bladder control

(sometimes)X

Physiotherapy Functional Mobile Profile (PFMP): 26/63

The intra-rater reliability ICC=.99 and inter-rater reliability ICC= .97 in acute care setting1

Quick and easy to perform Has been used on patients following

surgery of the spine2

Higher score means higher function/ independence

Evaluation

Weakness, numbness, renal decrease = possible spinal tumor

Decreased independence with bed mobility, sit to stand and walking according to PFMP

Further examination: MRI thoracic and lumbar

○ Mid thoracic dorsal and right lateral mass○ At T7

Treatments

Medically: Immediate surgery performed followed by radiation

○ Review of patients with spinal cord compression. 46% after surgery were able to walk and 49% after radiation4

Treatments Physical Therapy (Day 2)

Increase mobility○ At an oncology unit the policy was changed to have PTs see

pts within the 1st 48 hours. Pts were getting up sooner and ambulating. The results were a 14% decrease in patient length of stay within 1 year5

Increase ambulation○ Increase strength○ Gait training

Case series of 79 patients with spinal cord compression treated by radiation with 9 receiving an operation. Median age of 60 years. The collaborative team determined that walking was the most important factor. 90% of patients who walked before radiation walked after radiation6

Changes

Day 4: medication decreased and patient has increased R LE numbness, patient returned to max A for all activities, another MRI

Day 5: Oncology reports no MRI changes

Day 6: PET/CT = lymphoma axillary, groin and behind the heartRefused PT

Lymphoma7

56,000 people in the US each year Signs and symptoms

Painless/swollen lymph nodesUnexplained weight lossFeverNight sweatsChest painWeakness and FatigueXAbdominal or back painX

Re-examination and evaluation

Pt feels pins and needles Decreased proprioception/ foot slap Min A with most ADLs and mobility (PFMP

46/63) Strength

L Hip flexion and knee extension 3/5L dorsiflexion and plantaflexion 3+/5R Hip flexion and knee extension 3-/5R dorsiflexion and plantarflexion 3/5

Possible discharge

New treatment (Day 7-9) Gait training/ walking

A systematic review of cancer patients reported that studies have found a decrease in symptoms and increase in function with patients participating in a walking program8

Wheelchair training A retrospective cohort study looking at 83 patients post spinal

surgery. Therapy included respiratory exercises, bed mobility, sit to stand, walking in the room and hall, stairs and wheelchair ambulation. Those patients in their 40s and had operations at one level had the most significant increase in PFMP scores (P<0.05) with wheelchair locomotion, bed mobility and walking2

Day 10: Discharge to transitional care unit and then to Washington with father to begin chemotherapy PFMP 52/63

Prognosis

PoorIn a case series all three patients had spinal

tumors removed surgically followed by radiation. A 61 year old died after 6 months, a 23 year old after 1 year and a 51 year old after 11 months9

A retrospective cohort study reported on 60 patients whose mean survival was 3-4 months10

Drinker, smoker, lymphoma, uninsured

Summary

Important to recognize signs of spinal tumor compression and cancer

In acute care focus on patient function More research needs to be done on the

best treatment in acute care In the future a quality of life outcome

measure may be useful

Your understanding Your patient with back pain comes in and

reports progressive weakness in their UE, having difficulty urinating, and having numbness

Refer them to get tested (MRI, PET, CT)

A patient is in the hospital with cancer and is going through radiation. Do you walk them or let them rest in bed all day?

Walk them while monitoring symptoms

References 1. Brosseau L, Laferriere L, Couroux N, Marion M, Theriault J. Intra- and inter-rater

reliability and facorial validity studies of the physiotherapy functional mobility profile (PFMP) in acute care patients. Physiotherapy Theory and Practice. 1998;15:147-154.

2. Yildirim Y, Kara B, Arda M. Evaluation of patients with spinal operation according to functional mobility. Neuro Rehabil. 2009;24: 341-347.

3. Class notes and expert opinions of Julia Osbourne, PT, CLT-LANA. 4. Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol.

2005;6:15-24. 5. Crannell C, Stone E. Bedside physical therapy project to prevent deconditioning

in hospitalized patients with cancer. Oncol Nurs Forum. 2008;35(3):343-345. 6. Kovner F, et al. Radiation therapy of metastatic spinal compression:

Multidisciplinary team diagnosis and treatment. J Neuro Oncol. 1999; 42:85-92. 7. Non-Hodgkins Lymphomas Page. Available at: http://www.medicinenet.com/non-

hodgkins_lymphomas/page3.htm. Accessed July 3, 2010. 8. Visovsky C. Exercise and cancer recovery. J Issues in Nursing. 2005;10(2):1-8. 9. Arnold P. Floyd H, Anderson K, Newell K. Surgical management of carcinoid

tumors metastatic to the spine: resort of three cases. Clin Nuerol Neurosurg. 2010;112:443-445.

10. Guo Y, Young B, Palmer J, Mun Y, Bruera E. Prognostic factors for survival in metastatic spinal cord compression: a retrospective study in a rehabilitation setting. Am J Phys Med Rehabil. 2003;82:665-668.

QUESTIONS

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