Metastatic spinal cord compression: a poster and mnemonic supporting acute hospital staff to deliver optimal patient care
Intended for healthcare professionals
Evidence and practice    

Metastatic spinal cord compression: a poster and mnemonic supporting acute hospital staff to deliver optimal patient care

Sophie Needham Acute oncology clinical nurse specialist, Southport and Ormskirk Hospital NHS Trust, Southport, England
Julie Marshall Acute oncology clinical nurse specialist, Southport and Ormskirk Hospital NHS Trust, Southport, England

Why you should read this article:
  • To enhance your understanding of metastatic spinal cord compression diagnosis and management

  • To learn about a resource developed to support acute hospital staff to recognise and manage metastatic spinal cord compression

  • To be aware of the results of an audit evaluating the effects of the resource on patient care and staff adherence to guidance

Metastatic spinal cord compression (MSCC) occurs when metastatic disease causes vertebral collapse or compression of the spinal cord or when a tumour extends into the epidural space. It is an oncological emergency which will cause paralysis if left untreated. It is crucial that acute hospital staff recognise ‘red flag’ signs and symptoms of MSCC and adhere to the National Institute for Health and Care Excellence (NICE) guideline on MSCC recognition and management.

In 2019, a serious untoward incident involving a patient with confirmed MSCC was reported at an acute trust in England. This prompted the acute oncology team to examine the management of patients with MSCC at the hospital. A poster and mnemonic highlighting the main NICE recommendations were developed and distributed to all acute wards and areas. This article describes how that resource was developed and how the acute oncology team assessed its effects by conducting a two-phase retrospective and prospective audit.

Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1823

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

@sophiemac432

Correspondence

s.needham1@nhs.net

Conflict of interest

None declared

Needham S, Marshall J (2022) Metastatic spinal cord compression: a poster and mnemonic supporting acute hospital staff to deliver optimal patient care. Cancer Nursing Practice. doi: 10.7748/cnp.2022.e1823

Acknowledgements

The authors would like to thank Michelle Roberts, acute oncology team secretary, Dale Ankers, senior audit and effectiveness officer, and the audit team at Southport and Ormskirk Hospital NHS Trust for supporting data collection and analysis

Published online: 08 August 2022

Metastatic spinal cord compression (MSCC) is an oncological emergency and early detection and prompt treatment are essential to avoid spinal cord injury causing paralysis. The National Institute for Health and Care Excellence (NICE) (2008) has published a clinical guideline on risk assessment, diagnosis and management in adults with MSCC which is under review and expected to be updated by August 2023.

In 2019, a serious untoward incident was reported regarding the care of a patient with confirmed MSCC in a district general hospital in England. One major issue identified in the subsequent case review was suboptimal patient positioning. This prompted the local acute oncology team to examine how patients with suspected or confirmed MSCC were managed. Anecdotally, the team had noted issues on wards such as incorrect corticosteroid dosing and partial spinal imaging in the first instance. Regional guidelines regarding the care of patients with suspected or confirmed MSCC were available on the hospital’s intranet in the form of a lengthy and detailed document. Concerns were raised that staff did not know how to access these guidelines and did not have time to search for them or study them.

The hospital’s acute oncology team wanted to increase staff adherence to the NICE (2008) guideline and enhance patient care. This article describes how the team developed, disseminated and evaluated a resource designed to support acute hospital staff to deliver optimal care to patients with suspected or confirmed MSCC.

Metastatic spinal cord compression

MSCC occurs when metastatic disease causes vertebral collapse or compression of the spinal cord or when a tumour extends into the epidural space (Twycross and Wilcock 2016). Almost any cancer can spread to the spine, which has a rich blood supply, but this is more common in breast cancer, prostate cancer, lung cancer, lymphoma and myeloma (Macmillan Cancer Support 2020).

Prevalence, prognosis and diagnosis

MSCC occurs in approximately 3-5% of patients diagnosed with cancer and indicates that their disease is progressing. Around 75% of patients diagnosed with MSCC already have a cancer diagnosis, but for nearly a quarter of patients, an MSCC diagnosis is the first indication of malignancy (Levack et al 2002). Historically, life expectancy in people diagnosed with MSCC is approximately six months (Macdonald et al 2019). Prognosis in patients with MSCC depends on the primary tumour site, treatment options and comorbidities. The incidence of MSCC is likely to increase due to improvements in anticancer treatments, survival rates and patient outcomes (Boussios et al 2018).

Common ‘red flag’ signs and symptoms of MSCC include pain, heavy legs and abnormal gait (Turnpenney et al 2015). Table 1 lists signs and symptoms of MSCC, which are varied and often non-specific and insidious.

Table 1.

Signs and symptoms of metastatic spinal cord compression

Sign or symptomCharacteristics
Progressive, unrelenting back pain
  • Worse at night, preventing sleep

  • ‘Band like’

  • Worsened by coughing and straining

  • Spinal tenderness

Neurological
  • Radicular pain, burning, sharp or shooting sensation

  • Heavy legs, limb weakness

  • Abnormal gait and falls

  • Altered sensation, pins and needles in the limbs

Deterioration of bladder and/or bowel function
  • Patient unable to empty bladder

  • Urinary incontinence

  • Constipation, reduced bowel motility

  • Decreased anal tone causing faecal incontinence

Recognition of the signs and symptoms of MSCC by non-cancer clinicians is suboptimal (Brooks et al 2014). Distinguishing between back pain due to MSCC and back pain due to other causes is challenging. Age is a risk factor in cancer; age-specific incidence rates rise steeply from around the ages of 55 years to 59 years and a third of new cancer diagnoses are in people aged over 75 years (Cancer Research UK 2021). This means that patients with MSCC may have frailty, which compounds the complexities of diagnosing the condition (Al-Qurainy and Collis 2016).

Early recognition and diagnosis, prompt investigation and urgent referral to the cancer centre have been recognised as challenges in the management of MSCC since Husband’s (1998) influential prospective study. Shah et al (2021) acknowledged that these challenges remain despite the NICE (2008) guideline and the presence of acute oncology teams in hospitals and MSCC coordinators in tertiary centres.

Management

Active treatment options for patients with MSCC include surgery, radiotherapy and chemotherapy. NICE (2008) recommends that treatment is started within 24 hours of diagnosis before further neurological deterioration. If treatment is started within 48 hours of diagnosis, morbidity and length of hospital stay decrease in ambulatory patients, with consequent benefits for the overall health economy (Guddati et al 2017). Open and honest conversations with patients and their family and/or carers are crucial to establish patients’ wishes and preferences for treatment.

The palliative intent of all treatment for patients with MSCC is to reduce pain and preserve or restore neurological function to maintain quality of life (Boussios 2018). The decision whether or not to offer active treatment is informed by several factors, including the primary cancer site, the presence of visceral metastases, the number of bone metastases and the patient’s overall fitness (Macdonald et al 2019, Gandham et al 2021). Best supportive care is offered if the patient is not fit enough to receive, or does not want, active treatment.

All patients with suspected MSCC should receive a one-off dose of 16mg dexamethasone followed by a maintenance dose of 8mg dexamethasone twice a day, alongside a proton pump inhibitor (PPI) (Macdonald et al 2019). If MSCC is confirmed, NICE (2008) recommends:

  • For patients receiving active treatment, continuing the regimen described above until active treatment is completed. Once active treatment is completed, the dose of dexamethasone should be reduced gradually over five to seven days and then stopped. If neurological function deteriorates and/or pain increases at any time, the dose should be temporarily increased.

  • For patients receiving best supportive care, gradually reducing and then stopping the dose of dexamethasone as symptoms allow.

Dexamethasone is a corticosteroid and reduces inflammation and pain, but it can also elevate blood glucose levels, which therefore need to be monitored (NICE 2008). With corticosteroids there also is a risk of psychiatric reactions, so patients with mental health issues should be monitored. Maintenance doses of corticosteroids should be given before midday to prevent insomnia (Joint Formulary Committee 2022).

For patients with MSCC whose cancer has just been discovered, further investigations are required to determine the primary tumour site. If computed tomography (CT) does not reveal an obvious primary tumour site, a bone biopsy will be required. Adequate histological samples are essential for the prompt diagnosis and treatment of the primary cancer, but high-grade lymphomas are extremely sensitive to corticosteroids and tissue necrosis may occur, which may affect biopsy results and delay diagnosis (Ali et al 2019, Bloxham et al 2022). Specialist advice should be sought before administering corticosteroids to patients with no obvious biopsy site or in whom there is a significant suspicion of lymphoma (Gandham et al 2021), and treatment for MSCC should be discussed between MSCC coordinators, oncologists and if applicable spinal surgeons (NICE 2008).

Ensuring patients are lying supine with a neutral spine position is recommended to protect the spinal cord until bone and neurological stability is ensured (NICE 2008). In MSCC, often more than one area of the spine requires intervention. Partial spinal imaging can lead to delays, therefore whole spine magnetic resonance imaging (MRI) is considered the gold standard (NICE 2008). Regular neurological assessments, including daily monitoring of bowel and bladder function, should be undertaken on presentation when MSCC is suspected and then daily to evaluate the extent and location of possible spinal cord injury (NICE 2008).

Acute oncology teams are pivotal in the management of patients with suspected or confirmed MSCC. Their role has evolved from providing patient support and advice to expertly guiding patients and healthcare professionals through oncology-related admissions. They also provide education to staff and patients (UK Acute Oncology Society 2022).

Acute oncology teams were developed in the UK in response to findings and recommendations relating to the safety of patients receiving systemic anticancer treatment (SACT) published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2008). The focus of the NCEPOD (2008) review of the care of patients who had died within 30 days of receiving SACT was to ensure that robust patient safety mechanisms were in place. One of NCEPOD’s (2008) recommendations was that every hospital with an emergency department (ED) should have an acute oncology team.

Key points

  • Metastatic spinal cord compression (MSCC) is an oncological emergency requiring prompt diagnose and treatment

  • Early recognition, prompt investigation and urgent referral are recognised challenges in MSCC management

  • Treatment options in MSCC are surgery, radiotherapy and chemotherapy (active treatment options) and best supportive care

  • All patients with suspected MSCC should receive dexamethasone and a proton pump inhibitor

  • An acute oncology team has developed a poster and mnemonic supporting hospital staff to deliver optimal care to patients with suspected or confirmed MSCC

Supporting staff to deliver optimal patient care

The acute oncology team at the hospital decided to develop a resource that would support ward staff to deliver optimal care to patients with suspected or confirmed MSCC. This resource was developed, disseminated and evaluated using Plan, Do, Study, Act (PDSA) cycles (NHS England and NHS Improvement 2022a).

Plan – developing the resource

The aim was to develop a quick reference guide on how to manage patients with MSCC that would be readily available on the wards. This took the form of a poster based on the NICE (2008) guideline and featuring the mnemonic SPINE – for Steroids, Position, Imaging, Neurology and Elimination. Mnemonics are recognised as valuable tools for recalling important information (Putnam 2015, Radović and Manzey 2019).

Alongside a short and simple explanation for each letter of the mnemonic, the poster featured the image of a spine that enhanced its visual appeal. It also featured contact numbers for the acute oncology team and for the tertiary cancer centre as well as details of where to access the full MSCC guidelines on the hospital’s intranet. In September 2021, the poster was updated to include instructions regarding patients newly diagnosed with cancer and emphasise the need for early specialist involvement. The need to monitor patients’ blood glucose level, which had featured on the initial version, was removed due to lack of space.

Figure 1 shows the second version of the SPINE mnemonic poster (without the local contact details).

Figure 1.

SPINE mnemonic poster

cnp.2022.e1823_0001.jpg

A stakeholder analysis performed at planning stage showed that the successful implementation of the resource required involvement of the communications, radiology, clinical audit and education teams. The ED team was identified as a major stakeholder and the medical and nursing teams were identified as the stakeholders with the most influence over the success of implementation. Involving stakeholders in PDSA cycles increases the likelihood of sustaining the proposed change (NHS England and NHS Improvement 2022b). However, engagement with the various stakeholders proved a challenge, since the resource was developed at the start of the coronavirus disease 2019 (COVID-19) pandemic when face-to-face meetings and education were not considered a priority for acute staff.

To engage with stakeholders, the resource, its dissemination and evaluation were discussed at the quarterly acute oncology steering group meetings that took place between January 2020 and January 2021. Although involvement of the stakeholders in the PDSA cycles was limited, they were aware of the project and what had led to it.

Do – disseminating the resource

In February 2020, the poster was distributed to all acute wards and all areas of the ED, since patients with suspected MSCC may be cared for on any acute ward at the hospital. The acute oncology team recommended that the posters should be displayed in any area used by medical and nursing teams. Disseminating the resource included visiting wards and departments to introduce the poster, which gave the team an opportunity to deliver educational sessions on MSCC. However, staffing constraints led to a suboptimal uptake and the delivery of educational sessions was restricted by redeployments within the acute oncology team due to the COVID-19 pandemic.

Study – evaluating the effects of the resource

Audit method

An audit was performed to evaluate the effects of the resource on the care of patients with MSCC and on staff’s adherence to guidance. The audit comprised two phases:

  • A retrospective audit performed before the introduction of the poster.

  • A prospective audit performed after the introduction of the poster.

The two audit phases were performed over the same six-month period one year apart, in June-December 2019 and June-December 2020, respectively. All radiology requests and reports of spinal MRI scans performed within the two audit periods were reviewed. MRI scan requests and reports were screened for the words ‘cancer’, ‘metastases’ and ‘cord compression’. Additionally, for both audit phases, the electronic case notes of patients with suspected or confirmed MSCC – including medical and nursing notes, prescriptions and bedside charts – were retrieved and examined.

The standards measured in the audit, which were based on the NICE (2008) guideline, are shown in Box 1.

Box 1.

Standards measured in the audit

  • Did the patient receive dexamethasone on suspicion of malignant spinal cord compression (MSCC)?

  • Did they receive the correct dose of dexamethasone?

  • Did they receive a proton pump inhibitor (PPI)?

  • Was it documented that the patient had to lay supine with a neutral spine position?

  • Did the patient have a whole spine magnetic resonance imaging (MRI) scan requested and/or performed in the first instance?

  • Did the patient have their bowel and bladder function monitored?

  • Was the patient known to have cancer?

  • What were the timings of the MRI scans requested, performed and reported?

  • Were the patient’s blood glucose levels monitored while they received dexamethasone?

  • Was a pain assessment carried out and did the patient subsequently receive analgesics?

  • Was MSCC confirmed or excluded?

  • If MSCC was confirmed, did the patient receive treatment for MSCC within 24 hours, as recommended by the National Institute for Health and Care Excellence (2008)?

  • Did the ward receive a discharge summary from the tertiary cancer centre?

Audit findings

In the first audit phase, 482 MRI scan requests and reports were screened; 22 patients (5%) were identified as having suspected MSCC and their electronic notes were reviewed; of these 22 patients, eight (36%) were confirmed to have MSCC. In the second audit phase, 1,330 MRI scan requests and reports were screened; 65 patients (5%) were identified as having suspected MSCC and their electronic notes were reviewed; of these 65 patients, 29 (45%) were confirmed to have MSCC. In all but one audit standard, the second audit phase showed an improvement compared with the first audit phase. Figure 2 shows a summary of audit findings.

Figure 2.

Summary of audit findings

cnp.2022.e1823_0002.jpg

In the first and second audit phase, 86% and 85% of patients (n=19/22 and n=55/65), respectively, received dexamethasone. In the first audit phase, 55% of patients (n=12/22) had received the correct dose of dexamethasone and this had increased to 92% of patients (n=60/65) in the second audit phase.

Regarding positioning, the proportion of patients for whom it was documented that they had to lay supine with a neutral spine position had increased from 59% (n=13/22) in the first audit phase to 77% (n=50/65) in the second audit phase. Monitoring of bladder function had increased to 98% (n=64/65) in the second audit phase from 86% (n=19/22) in the first audit phase. The proportion of patients who had their blood glucose level monitored had increased from 23% (n=5/22) to 40% (n=26/65) in the first and second audit phase, respectively. In the second audit phase, the number of patients referred to the acute oncology team had increased to 92% (n=60/65) from 68% (n=15/22) in the first audit phase.

There were no significant differences between audit phases in the proportions of patients who received a PPI, who had a whole spine MRI scan performed in the first instance and who had their bowel function monitored.

Collecting staff feedback

Staff feedback was collected in January 2022, after publication of the findings from the second audit phase. A short electronic questionnaire was devised to assess staff’s awareness of the SPINE mnemonic poster in acute areas, evaluate whether they considered the poster helpful and identify areas for improvement. The questionnaire was emailed to 375 medical and nursing staff at the trust. Medical staff were selected using the email distribution list of the clinical education team and nursing staff received the email via acute ward nurse managers. Of the 375 recipients, 28 responded, giving a suboptimal response rate of 7%. In retrospect, the response rate could have been improved by circulating the questionnaire specifically to staff in acute care teams. Medical staff who received the email may have included staff working in non-acute areas.

Among the 28 respondents, 79% (n=22) were aware of the poster, 71% (n=20) found it ‘extremely useful’ and 4% (n=1) found it ‘not useful’. Negative feedback was related to information fatigue in clinical areas. Some respondents noted that posters can get damaged and are outdated in the digital age. Some suggested using the clinical section of the hospital’s intranet instead, but that would fail to address the original concerns about staff not knowing how to access the existing regional guidelines on the intranet and lack of time to search for or study them.

Discussion

The audit showed that, in most cases, patient care followed the NICE (2008) guideline and that adherence to the guideline improved after dissemination of the poster. The audit did, however, reveal areas for improvement. For example, some patients had received 8mg dexamethasone instead of the recommended 16mg and some had not received any dexamethasone. Neurological symptoms are a recognised late sign of MSCC and a clear indication of the need to administer corticosteroids, but the audit did not measure the presence of neurological symptoms against the administration of dexamethasone.

Monitoring of blood glucose levels had improved in the second audit phase (n=26/65, 40%) compared with the first audit phase (n=5/22, 23%) but remained suboptimal. In the second audit phase, patients’ possible diagnosis of diabetes mellitus was included to determine whether blood glucose levels were monitored because patients were taking high-dose corticosteroids or because they had diabetes. Among the 26 patients whose blood glucose level was monitored (40% of 65), nine had diabetes (14% of 65) so 17 were monitored specifically because they were taking high-dose corticosteroids (26% of 65). Further research and guidance on the initiation and frequency of blood glucose level monitoring in patients taking high-dose corticosteroids are required.

A lack of patient adherence to staff’s advice to lay supine with a neutral spine position was noted. It is difficult to establish whether this was due to the lack of a clear explanation by staff of the importance of maintaining a neutral spine position or to patients choosing not to follow the advice. The acute oncology team had verbally emphasised the need to lay supine with a neutral spine position to several patients who nonetheless had chosen to mobilise. Verbal advice may need to be followed by written information explaining the risks of MSCC and the rationale for this aspect of management.

After the first audit phase, it was recommended to investigate whether a known cancer diagnosis affected whether a whole spine MRI was performed in the first instance. Of the 65 patients in the second audit phase, 51 (78% of 65) had a known cancer diagnosis. Of these 51 patients, 41 (63% of 65) had a whole spine MRI scan performed in the first instance, so ten patients (15% of 65) with a known cancer diagnosis only had a partial spine MRI scan initially.

Some patients in the audit had been newly diagnosed with widespread visceral and bone metastases and presented with MSCC. These patients were either being investigated for a new cancer or undergoing non-cancer investigations in another specialty and a whole spine MRI scan undertaken before any other imaging modality would not have been clinically appropriate. In the second audit phase, 5% (n=3/65) of patients had an incidental finding of MSCC detected by CT but were too unwell for further imaging and subsequent treatment, so a whole spine MRI scan was not requested. This means that the audit standard of all patients having a whole spine MRI scan in the first instance was actually unattainable.

The radiology department sends an email alert to the acute oncology team when a spinal MRI scan has confirmed the presence of MSCC. Before the audit, radiology only alerted the team if the MRI reports were local – that is, written by radiologists at the trust. In the first and second audit phase, 91% (n=440/482) and 92% (n=1,225/1,330) of spinal MRI reports were local, respectively. This has been addressed and email alerts are now also issued when outside reporting agencies are used. However, it remains imperative that ward staff recognise MSCC as an emergency that requires prompt action.

The acute oncology team is available weekdays between 9am and 5pm. Patients presenting out of hours are not always referred to the team and the SPINE mnemonic poster was designed as a safety net. The care of patients admitted with complications of cancer, including those with suspected or confirmed MSCC, can be improved by the early involvement of the acute oncology team (Neville-Webbe et al 2013). Overall, 86% (n=75/87) of patients in the audit were referred to the acute oncology team and seen by an acute oncology clinical nurse specialist within 24 hours.

The number of patients with suspected MSCC was almost three times higher in the second audit phase than in the first (n=65 versus n=22). The authors are unsure why. One potential reason is that patients who presented between June 2020 and December 2020 – a few months after the start of the COVID-19 pandemic – had more advanced disease than those who presented between June 2019 and December 2019 – before the pandemic. In the UK, in the acute phase of the pandemic, some non-curative SACT was paused as a precaution (NICE 2020), which meant that some patients with metastatic disease had their treatment paused; routine cancer screening was deferred; many people were reluctant to seek medical attention because of fears around COVID-19; and patients experienced delays in diagnosis and treatment (Cancer Research UK 2022).

Future steps

The acute oncology team has noted, from the audit findings and anecdotally from clinical practice, that the nursing and medical teams appear more familiar with recognising ‘red flag’ signs and symptoms of MSCC and tend to initiate the recommended management as soon as the suspicion of MSCC is raised, as opposed to waiting for MSCC to be confirmed. However, even in the second audit phase, the rates of fulfilment of some of the audit standards remained below 90% (Figure 2), so improvements are still needed.

To ensure the poster is sustainable and futureproof, QR codes are being developed and could be inserted, for example, in new starter handbooks, on screensavers and on the homepage of the hospital’s intranet. The idea behind the SPINE mnemonic poster was to embed learning so that eventually the poster would no longer be needed. However, because of staff turnover, there is a need to continue to display the poster and provide ongoing education. The acute oncology team now routinely delivers education on MSCC and its management to hospital staff working on acute wards.

The audit will be performed every year with the aim of continuously monitoring improvement and amending the poster as needed. The audit can be time consuming and requires a team approach. The findings of the initial audit have shown the need to record and consider additional factors including neurological symptoms; how quickly corticosteroids are stopped in patients in whom MSCC has been excluded; and how quickly patients mobilise after active treatment. Maintaining mobility not only improves patients’ function and quality of life but is also a prognostic factor for the consideration of further anticancer treatments (NICE 2008, O’Sullivan et al 2013). Incorporating these factors into the audit would allow the acute oncology team to assess the entire episode of care for patients with suspected or confirmed MSCC.

Conclusion

MSCC is an oncological emergency and must be diagnosed and treated promptly, which can be challenging. It is crucial that staff working on acute hospital wards adhere to the NICE guideline on the recognition and management of MSCC. Following a serious untoward incident at a district general hospital in England, the hospital’s acute oncology team developed a quick reference guide that would be readily available on the wards. This took the form of a poster featuring the mnemonic SPINE – for Steroids, Position, Imaging, Neurology and Elimination – that was introduced on all acute wards and areas.

A two-phase audit demonstrated some improvements in patient care and in staff’s adherence to NICE’s recommendations. The acute oncology team provides ongoing education to staff on MSCC management and conducts an annual audit into the care of patients with suspected or confirmed MSCC.

References

  1. Ali M, Pervez M, Mounter P et al (2019) The double edge sword steroid facilitated diagnosis of primary thyroid lymphoma. Endocrine Abstracts. 62, CB5. doi: 10.1530/endoabs.62.CB5
  2. Al-Qurainy R, Collis E (2016) Metastatic spinal cord compression: diagnosis and management. BMJ. 353, i2539. doi: 10.1136/bmj.i2539
  3. Bloxham N, Cross J, Garnett M et al (2022) Hodgkin lymphoma presenting with spinal cord compression: challenges for diagnosis and initial management. Pediatric and Developmental Pathology. 25, 2, 168-173. doi: 10.1177/10935266211033269
  4. Boussios S, Cooke D, Hayward C et al (2018) Metastatic spinal cord compression: unraveling the diagnostic and therapeutic challenges. Anticancer Research. 38, 9, 4987-4997. doi: 10.21873/anticanres.12817
  5. Brooks FM, Ghatahora A, Brooks MC et al (2014) Management of metastatic spinal cord compression: awareness of NICE guidance. European Journal of Orthopaedic Surgery and Traumatology. 24, Suppl1, S255-S259. doi: 10.1007/s00590-014-1438-8
  6. Cancer Research UK (2021) Cancer Incidence by Age: All Cancers Combined Incidence by Age. http://www.cancerresearchuk.org/health-professional/cancer-statistics/incidence/age#heading-Zero (Last accessed: 18 July 2022.)
  7. Cancer Research UK (2022) Our Research into the Impact of COVID-19 on Cancer. http://www.cancerresearchuk.org/health-professional/our-research-into-the-impact-of-covid-19-on-cancer (Last accessed: 18 July 2022.)
  8. Gandham S, Clark S, DeMatas M (2021) Management of malignant spinal cord compression. Surgery. 39, 8, 529-539. doi: 10.1016/j.mpsur.2021.06.010
  9. Guddati AK, Kumar G, Shapira I (2017) Early intervention results in lower mortality in patients with cancer hospitalized for metastatic spinal cord compression. Journal of Investigative Medicine. 65, 4, 787-793. doi: 10.1136/jim-2016-000334
  10. Husband DJ (1998) Malignant spinal cord compression: prospective study of delays in referral and treatment. BMJ. 317, 7150, 18-21. doi: 10.1136/bmj.317.7150.18
  11. Joint Formulary Committee (2022) Dexamethasone. British National Formulary. No. 83. BMJ Group and the Royal Pharmaceutical Society of Great Britain, London.
  12. Levack P, Graham J, Collie D et al (2002) Don’t wait for a sensory level – listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clinical Oncology. 14, 6, 472-480. doi: 10.1053/clon.2002.0098
  13. Macmillan Cancer Support (2020) Malignant Spinal Cord Compression (MSCC). http://macmillan.org.uk/cancer-information-and-support/impacts-of-cancer/malignant-spinal-cord-compression (Last accessed: 18 July 2022.)
  14. Macdonald AG, Lynch D, Garbett I et al (2019) Malignant spinal cord compression. Journal of the Royal College of Physicians of Edinburgh. 49, 2,151-156. doi: 10.4997/JRCPE.2019.217
  15. National Confidential Enquiry into Patient Outcome and Death (2008) For Better, for Worse? A Review of the Care of Patients Who Died Within 30 Days of Receiving Systemic Anti-Cancer Therapy. http://www.ncepod.org.uk/2008report3/Downloads/SACT_report.pdf (Last accessed: 18 July 2022.)
  16. National Institute for Health and Care Excellence (2008) Metastatic Spinal Cord Compression in Adults: Risk Assessment, Diagnosis and Management. Clinical guideline No. 75. NICE, London.
  17. National Institute for Health and Care Excellence (2020) COVID-19 Rapid Guideline: Delivery of Systemic Anticancer Treatments. NICE guideline No. 161. NICE, London.
  18. Neville-Webbe HL, Carser JE, Wong H et al (2013) The impact of a new acute oncology service in acute hospitals: experience from the Clatterbridge Cancer Centre and Merseyside and Cheshire Cancer Network. Clinical Medicine. 13, 6, 565-569. doi: 10.7861/clinmedicine.13-6-565
  19. NHS England and NHS Improvement (2022a) Online Library of Quality, Service Improvement and Redesign Tools. Plan Do Study Act (PDSA) Cycles and the Model for Improvement. http://england.nhs.uk/wp-content/uploads/2022/01/qsir-pdsa-cycles-model-for-improvement.pdf (Last accessed: 18 July 2022.)
  20. NHS England and NHS Improvement (2022b) Online Library of Quality, Service Improvement and Redesign Tools: Stakeholder Analysis. http://england.nhs.uk/wp-content/uploads/2022/02/qsir-stakeholder-analysis.pdf (Last accessed: 18 July 2022.)
  21. O’Sullivan L, Clayton-Lea A, McArdle O et al (2013) A prospective study of patients with impending spinal cord compression treated with palliative radiotherapy alone. Journal of Radiotherapy Practice. 12, 3, 218-225. doi: 10.1017/S1460396912000301
  22. Putnam AL (2015) Mnemonics in education: current research and applications. Translational Issues in Psychological Science. 1, 2, 130-139. doi: 10.1037/tps0000023
  23. Radović T, Manzey D (2019) The impact of a mnemonic acronym on learning and performing a procedural task and its resilience toward interruptions. Frontiers in Psychology. 10, 2522. doi: 10.3389/fpsyg.2019.02522
  24. Shah S, Kutka M, Lees K et al (2021) Management of metastatic spinal cord compression in secondary care: a practice reflection from Medway Maritime Hospital, Kent, UK. Journal of Personalised Medicine. 11, 12, 110. doi: 10.3390/jpm11020110
  25. Turnpenney J, Greenhalgh S, Richards L et al (2015) Developing an early alert system for metastatic spinal cord compression (MSCC): Red Flag credit cards. Primary Health Care Research and Development. 16, 1, 14-20. doi: 10.1017/S1463423613000376
  26. Twycross R, Wilcock A (2016) Introducing Palliative Care. Fifth edition. Palliativedrugs.com, Nottingham.
  27. UK Acute Oncology Society (2022) Acute Oncology Nursing. http://ukacuteoncology.co.uk/training-and-education/acute-oncology-nursing (Last accessed: 18 July 2022.)

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