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PRACTICE: B D White, A J Stirling, E Paterson, K Asquith-Coe, A Melder on behalf of the Guideline Development Group Diagnosis and management of patients at risk of or with metastatic spinal cord compression: summary of NICE guidance BMJ 2008; 337: a2538 [Full text]

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Co-ordinated approach to the diagnosis of malignant cord compression improves outcomes

Pamela Levack, Lynsay Allan, Lee Baker, John Dewar, Sam Eljamel, Robert Grant, Graeme Houston, Trudy Mcleay and Alastair Munro   (11 December 2008)

Co-ordinated approach to the diagnosis of malignant cord compression improves outcomes 11 December 2008
Pamela Levack, Consultant in Palliative Medicine Ninewells Hospital, Dundee DD19SY, Lynsay Allan, Lee Baker, John Dewar, Sam Eljamel, Robert Grant, Graeme Houston, Trudy Mcleay and Alastair Munro Send response to journal: Re: Co-ordinated approach to the diagnosis of malignant cord compression improves outcomes	We welcome the NICE guidance on the diagnosis and management of patients at risk or with malignant cord compression [MCC]1 and agree that a committed and co-ordinated approach is needed to improve the current situation. Following the Scottish [CRAG] Audit in 2001 2 all Health Boards in Scotland were advised to implement rapid referral systems in order to co-ordinate the process of early diagnosis. This national initiative supported by Macmillan has, through the three Scottish regional cancer networks, made good progress. The networks have each appointed MCC project leads, fast track referral is being implemented across Scotland, a national minimum dataset has been agreed with the Information and Statistics Division [ISD] Scottish Government Health Department, and a national education toolkit is being developed in collaboration with Macmillan and NHS Scotland. In Tayside for example, we have a rapid referral hotline with a cord compression co-ordinator working closely with a senior clinician. The results of the first 100 patients referred through the hotline are now available and compare very favourably with the original Scottish [CRAG] audit. The median time from the general practitioner or consultant referring to the hotline and a diagnosis of MCC was one day. This compares with a median of 66 days in the CRAG audit. The number of patients unable to walk at all at the time of diagnosis was 23% - compared to 46% [Table 1]. The median duration of symptoms the patient experienced before a diagnosis of MCC was made was reduced from 89 to 32 days. Furthermore as the education programme in the community and in the acute setting has progressed, the percentage of referrals from primary care is increasing - currently 36% of all referrals to the hotline are from primary care – compared with 16% at the outset of the project. As more patients are mobile and more comfortable at the time of MRI, imaging is of a better quality and it takes less time. Table 1—Mobility at the time of diagnosis of MCC. A comparison between the Tayside hotline, and the CRAG audit 52% of patients scanned though the hotline had either MCC [46%] or malignant nerve root compression [6%]. In Tayside, this compares with 23% identified through a retrospective audit of 104 patients referred for MRI with a diagnosis of “query cord compression?” before the hotline was in place [Table 2]. Table 2—A comparison of the first 100 patients referred to the Tayside hotline and those referred over the preceding 2 years for “query cord compression” [ n=104]. The overall statistic is statistically significant at =44.47, df=5, p<0.001. ** 104 MRI reports of all patients with suspected cord compression between 01/01/2002 – 31/12/2003 were retrieved from the computerised Radiology Information System® of Ninewells Hospital, Dundee, UK. MRI reports were re-classified according to the definitions agreed by the cord compression group to use when reporting scans from the hotline. Our experience with the hotline demonstrates that not only are outcomes improved for patients but also better use is made of hard-pressed resources. 1. White BD, Stirling AJ, Paterson E et al. on behalf of the Guideline development Group. Diagnosis and management of patients at risk of or with metastatic spinal cord compression: Summary of NICE guidance. BMJ 2008 337 1349-51 2. Levack P, Collie D, Gibson A et al. and members of the Scottish Cord Compression Audit Group. A prospective audit of the diagnosis, management and outcome of malignant cord compression. Report No CRAG 97/08 2001. www.crag.scot.nhs.uk/Committees/ceps/reports Competing interests: None declared