Malignant spinal cord compression pathway: A new step toward standard of care for a critical oncological finding

Malignant spinal cord compression pathway: A new step toward standard of care for a critical oncological finding | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Malignant spinal cord compression pathway: A new step toward standard of care for a critical oncological finding Abdulrahman Aldakheel, Nasser Al-Rajhi, Mohammed Alshabanah, Mohammed Alwhaid, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4488241/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Malignant cord compression syndrome (MCCS) must be addressed clinically using whole-spine magnetic resonance imaging in suspected patients and managed accordingly. Establishing a Malignant spinal cord compression pathway is crucial for addressing these patients sequentially with an immediate management plan. Here, we reported the outcomes of a Malignant spinal cord compression pathway and compared the results with those before its implementation. Methods: This is a prospective observational study where data collection was performed for patients with activated cord compression pathway between July 2021 and October 2022. Collected data was including demographics of patients, presenting symptoms, time of recorded clinical pathway activation and subsequent events including final management plan. Retrospective data collection was done for 52 patients whom were treated from the period between 2018-2019. Non-parametric test was used to compare medians for both groups. Results : In total, 170 patients were included, and 52 of them were treated based on positive magnetic resonance imaging (MRI) findings of Malignant spinal cord compression pathway between 2018 and 2019. Moreover, 118 patients were identified during the implementation of the cord compression pathway in 2020–2022. Three main targeted intervals were calculated in hours using medians and means: interval 1, time from cord compression suspicion to MRI; interval 2, MRI completion to MRI report; and interval 3, cord compression suspicion to intervention. In 2018–2019, medians of these three intervals were 9.5, 12, and 110 h, and in 2020–2022, they substantially decreased to 6, 3, and 24 h, respectively. An independent nonparametric test was performed to compare the medians, and statistically significant results were obtained for intervals between MRI completion and MRI report (p = 0.001) as well as between cord compression suspicion and intervention (p = 0.001). Conclusions: The use of the malignant spinal cord compression pathway effectively shortens the time needed for identifying patients at risk, reduces the time to report critical findings, and significantly shortens the interval between identification and treatment. In our study, clinical pathway reduced time needed to identify, diagnose and manage such disease. Spinal-Cord Compression Spinal metastases Patients’ Safety Patients’ Quality of life Palliative radiotherapy Figures Figure 1 Figure 2 Figure 3 Introduction Malignant spinal cord compression (MSCC) is a well-recognized complication of cancer and usually presents as an oncological emergency. It occurs in 2.5–5% of all patients with cancer. 1 This could be translated to approximately 4000 cases annually in England and Wales (National Institute for Health and Care Excellence, 2008). It is more common in patients with breast, prostate, and lung cancers. Although the true incidence of MSCC is unknown, it occurs in approximately 15% of patients with advanced cancer. 2 MSCC is usually caused by the collapse or compression of a vertebral body with metastatic disease; however, it can also be caused by direct tumor extension into the vertebral column. Cord compression initially causes edema, venous congestion, and demyelination, which are reversible. Chronic compression leads to vascular injury, cord necrosis, and permanent damage. Patients who have no neurological function for > 48 h are unlikely to improve. 2 This condition must be addressed because the life quality of patients is significantly affected. Moreover, untreated cord compression has various complications, such as limp weakness, sphincter incontinence, and sensory and/or motor loss. Thus, developing an effective systematic approach for diagnosing those at a greater risk of cord compression is an urgent need. Multiple guidelines have been established across nations for the diagnosis and management of MSCC. Macdonald et al. published clear guidelines on these. 3 The National Institute for Health and Care Excellence (NICE) published another guideline for the risk assessment, diagnosis, and management of MSCC in 2008 and updated it in 2019 and 2023. 4 In 2020, Patnaik et al. published another important article on the effective clinical approach, clinical assessment, diagnosis, and management of MSCC. 5 The mainstay of the reviewed guidelines was on the management of patients at high risk based on their presenting chief complaints and presence of any motor weakness, sensory deficit, and/or sphincter incontinence, i.e., to start intravenous steroid therapy at a given loading dose (10–16 mg) and then perform whole-spine magnetic resonance imaging (MRI) within 24 h in patients suspected with cord compression. To the best of our knowledge, only NICE has proposed recommendations for MSCC. 4 Other institutions have established guidelines, which are accessible over the intranet; however, these guidelines are not published in scientific journals. Moreover, the published recommendations from NICE and the guidelines established in other institutions agreed on performing MRI within 24 h and then administering steroids. The King Faisal Specialists Hospital and Research Center in Riyadh (KFSHRC) established a cord compression pathway in 2020. This clinical pathway involves a focused oncological history and physical examination. If there is a high suspicion of the activation of the cord compression pathway, a sequence of events is followed: ( 1 ) administration of loading dose of steroids followed by the maintenance dose, ( 2 ) urgent whole-spine MRI, ( 3 ) consultations with concerned services, and ( 4 ) provision of intervention. This study aimed to report the outcomes of using the MSCC suspicion clinical pathway from January 2018 to October 2022 in an oncology center and compare them with those before the establishment of this clinical pathway. Methods and materials Data of patients with activated Malignant spinal cord compression pathway were collected from the Quality and Assurance Department of KFSHRC, Riyadh, between 2020 and 2022. Data were recorded prospectively and analyzed retrospectively. For comparison, data of patients under the computed tomography simulation scan and urgent radiotherapy treatment category were collected from the Radiation Oncology Department of KFSHRC between 2018 and 2019. Patients in whom the Malignant spinal cord compression pathway was activated between October 2020 and October 2022 were included. All included patients had a history of confirmed malignancy based on biopsy and/or clinical diagnosis and a confirmed diagnosis of malignancy under the CT-Simulation and urgent treatment (Sim&treat) category in the Aria system. Patients who were not diagnosed with malignancy, in whom the cord compression pathway was activated due to mechanical causes, and who were treated without an MRI were excluded from the data analysis. Demographics of the patients, cancer site, pathology type, and presenting symptoms were collected. For all patients, three calculated intervals were generated: interval 1, which was defined as the time from the clinical suspicion of cord compression to MRI completion; interval 2, which was defined as the time from MRI completion to MRI report; and interval 3, which was defined as the time from the clinical suspicion of cord compression to the final intervention. All data were extracted into an Excel sheet and transferred and analyzed in IBM SPSS Statistics version 23 (IBM Corp., Armonk, NY, USA). Results The outcomes before the implementation of the Malignant spinal cord compression pathway (2018–2019, group 1) and those after its establishment (2020–2022, group 2) are shown in Tables 1 and 2, respectively. Period before establishing Malignant spinal cord compression pathway 2018–2019: In 2018–2019, when the Malignant spinal cord compression pathway was not yet established, 52 patients had an MRI of any segments of the spine or whole-spine MRI. All patients who were treated without MRI were excluded. Of the 52 patients, 24 (46.2%) were female, and 28 (53.8%) were male, with a mean age of 48 years. Moreover, 32 (61.5%) patients had Eastern Cooperative Oncology Group performance status of (ECOG PS) of 3, 11 (21.2%) had ECOG PS of 2, 8 (15.4%) had ECOG PS of 4, and 1 (1.9%) had ECOG PS of 1 at presentation. Regarding the primary site of malignancy, 8 (15.4%) patients had breast cancer, 7 (13.5%) had sarcoma, 4 (9.6%) had lung cancer, and the remaining patients (61.5%) had tumors at different sites. Adenocarcinoma was the most common histopathological type, which occurred in 20 (38.5%) patients, followed by clear cell carcinoma in 4 (7.7%) and squamous cell carcinoma in 4 (7.7%). In the disease burden category, 49 (94.2%) patients had metastatic disease upon presentation to the emergency department (ED), whereas 3 (5.8%) patients had a nonmetastatic disease. Among the patients who were suspected to have cord compression clinically, 36 (69.2%) were either seen in the clinic and transferred to the ED or presented initially to the ED, whereas 16 (30.8%) patients were identified as at-risk for cord compression during their admission course. Regarding the symptoms that triggered the suspicion of cord compression, 44 (84.6%) patients had back pain and/or radicular neuropathic pain initially, which was followed by neurological deficit in 38 (73.1%) (with motor or sensory involvement) and isolated motor weakness of any limb in 24 (46.2%) patients. In patients whom were suspected to have cord compression clinically, interval 1 was 9.5 h, with a mean of 27 h (for both patients who presented to the emergency department or those who were admitted). For interval 2, the median time was 12 h, with a mean time of 32 h. Finally, for interval 3, the median and mean times were 110 and 144 h, respectively. Analysis of patients who underwent MRI revealed that the most affected vertebral segment was the thoracic spine in 27 (51.9%) patients, lumbar spine in 20 (38.5%), cervical spine in 10 (19.2%), and sacrum in 6 (11.5%). Only 43 (82.7%) patients had whole-spine MRI, and the remaining patients had MRIs of one or two segments of the spine. Period after establishing Malignant spinal cord compression pathway 2020–2022: In 2020–2022, when the cord compression pathway was fully implemented, 118 patients were identified. Of these, 63 (53.4%) patients were female and 55 (46.6%) were male. Their mean age was 51 years. In addition, 51 (43.2%) patients had ECOG PS of 3, 38 (32.2%) had ECOG PS of 2, 14 (11.9%) had ECOG PS of 4, and 10 (8.5%) had ECOG PS of 1. Upon presentation, breast cancer was the most common site of malignancy in 29 (24.6%) patients, followed by lymphoma in 21 (17.8%), sarcoma in 17 (14.4%), and prostate cancer in 10 (8.5%); the remaining patients (34.7%) had malignancy in other sites. Adenocarcinoma was the most recorded, occurring in 52 (44.1%) patients, followed by hematological malignancies in 15 (12.7%) and squamous cell carcinoma in 7 (5.9%). The remaining 44 (37.3%) patients had other histopathological types. Of all patients, 111 (94%) had metastatic disease at clinical suspicion of cord compression and 7 (6%) only had locally advanced disease. Moreover, 97 (82.2%) patients presented to the ED, whereas 21 (17.8%) were admitted at the time of clinical suspicion of cord compression. Symptoms upon presentation included neurological deficit in 91 (77.1%) patients, back pain and/or neurological radicular pain in 84 (71.2%), motor weakness in 53 (44.9%), sensory impairment in 28 (23.7%), and fecal and/or urine incontinence in 10 (8.5%). During the implementation period, the cord compression pathway was activated in 118 patients. In interval 1, the median and mean times were 6 and 16.5 h, respectively. In interval 2, the median and mean times were 3 and 7.5 h, respectively. In interval 3, the median and mean times were 24 and 47 h, respectively. In the sub-analysis, MRI was positive for cord compression in 54 (45.8%) patients. The most common vertebral segment affected by metastatic disease was the thoracic spine in 36 (66.6%) patients, followed by the lumbar spine in 22 (40.7%), cervical spine in 14 (25.9%), and sacrum in 6 (11.1%). Nonparametric test was used to compare the medians of both groups (group 1 = 2018–2019; group 2 = 2020–2022). The median times of intervals 1, 2, and 3 were compared (in this order) between the two groups. In the independent test, the comparison of the median time in interval 1 was not significant, with a p-value of 0.13. However, the comparisons of the median times in intervals 2 and 3 were statistically significant, with a p-value of 0.001. Discussion Acute cord compression secondary to cancer is a rare diagnosis, and it represents a true oncological emergency because it may lead to devastating outcomes if treatment is delayed or left untreated. The true incidence of malignant cord compression is unknown. However, it occurs in 5–15% of all patients with cancer. 6 All patients diagnosed with malignant cord compression can become paraplegic if left untreated, with varying severity of co-existing symptoms such as pain, sensory loss, and/or sphincter incontinence. 6 The results of this study were consistent with those of two retrospective analyses focusing on patients’ characteristics at presentation and the expected outcomes. 7,8 De novo metastatic cancer near the spine causing cord compression or the primary cancer near the spinal cord could be the initial presentation of patients. However, malignant cord compression is more prevalent in disseminated disease. 2 Patients with metastatic disease, particularly those diagnosed with malignant spinal cord compression, have limited survival; however, one-third of these patients survive for more than 1 year. 6 Thus, aggressive therapy to preserve and/or improve neurological function is of utmost importance to maintain the quality of life and prevent further deterioration. Early detection of such an entity in patients with critical findings and initiation of management within a given timeframe remain challenging. Multiple recommendations are available for such patients. NICE has published a clinical guideline in 2008 and updated it in 2019 and 2023. It presents detailed recommendations on how to identify and manage such patients. 4 Identification of at-risk patients, provision of appropriate interventions at a given timeframe, and finalization of the treatment plan are challenging because of various reasons. Effective communication between the stakeholders of such cases is the main point. In the recent decade, evidence-based clinical pathways have been increasingly utilized and have shown excellent clinical improvement in the hospital workflow, particularly in oncology field. Moreover, they have shown a great potential in shortening the time needed by oncologists to identify, workup, and finalize treatment recommendations for patients with cancer. They are cost-effective and reduce hospital costs and utilization of resources. 9 Clinical pathways are also known as urgent care set, care maps, and/or integrated care pathways. A clinical pathway is more or less used as the guideline. Clinical pathways are more directed to standardizing the treatment of specific patients with a specific diagnosis rather than listing the treatment options for a set of patients. 10 The process of clinical pathway formation is quite complicated. Unlike guidelines, where a panel of experts votes for a given recommendation, the creation of clinical pathways involves committees of physician peers with disease expertise to decide the most appropriate option based on multiple factors, such as efficacy, toxicities, applicability, and cost. 10 In a systematic review published in 2020, Jolanda et al. analyzed eight major studies involving > 4000 patients with cancer. They examined the effect of the clinical pathways. 11 They clearly concluded the positive effect of the implementation of clinical pathways on cost, length of stay, and patient satisfaction and quality of life. 11 Furthermore, Roschke et al. demonstrated the feasibility of the standardization the clinical approach, work-up and management at their institution in addressing pediatric patients with severe cancer at a greater risk of developing life-threatening conditions. 12 Moreover, Feinberg et al. analyzed the successful implementation of clinical pathways and their maintenance. 13 At present, data on the implementation of clinical pathways to either standardize an approach or intervention and/or reduce costs are sufficient and have shown positive effects in many clinical aspects. 10,11,12,13 KFSHRC established a cord compression pathway in 2020 for the identification and provision of urgent interventions in patients who are clinically suspected with cord compression. This study analyzed 118 patients in whom the clinical pathway for cord compression was used, and the 18-month outcomes before and after its implementation in 2018–2020 were compared. The results revealed that the cord compression pathway substantially reduced the time needed for the identification of patients at risk and provision of treatment at the median time of 24 h. Our results revealed that 40.1% of the patients at the time of the diagnosis had ECOG PS of ≤ 2 compared with 23.1% in 2018–2019 (before the implementation of the clinical pathway). This may indicate marked improvement in the suspicion threshold of such diagnosis among the targeted patients. Moreover, the diagnosis was made in the ED more frequently in 2020–2022 (82.2%) than in 2018–2019 (69.2%). This improvement continues as noted in the rate of patients undergoing whole-spine MRI. All patients in 2020–2022 underwent whole-spine MRI. However, some patients could not tolerate the whole procedure; in 2018–2019, 93.2% patients had whole-spine MRI and 82.7% had MRIs of one or two spine segments. Multiple intervals were calculated as described in the results. Interval 1 covered the period from the suspicion of cord compression to MRI. Nearly 30% improvement was noted in the time needed to perform an MRI from suspicion in 2020–2022 with a median of 6 h compared with that in 2018–2019 with a median of 9.5 h. The gap between the two groups continues to substantially widen; in interval 2, the time needed to report MRI findings was significantly reduced by at least threefold. The median time in 2020–2022 was 3 h compared with 12 h in 2018–2019. This substantial difference continued to affect interval 3, which covered the period from cord compression suspicion to treatment, and nearly threefold improvement was found in 2020–2022 with a median of 24 h compared with 110 h in 2018–2019. The implementation of the cord compression pathway in the study center has shown a marked improvement based on the recorded results. Standardization of the entire process, from the suspicion of cord compression to the administration of medications, whole-spine MRI, consultation with concerned services, and delivery of appropriate treatment tailored to the patient, has remarkably improved. MSCC is an oncological emergency. One could consider it a limp-saving clinical pathway because time plays a major role in managing such patients. Patchell et al. 14 demonstrated the importance of timely recognizing patients in their trial and proceeding accordingly. In our study, oncologists and medical staff appeared more encouraged to activate the clinical pathway once cord compression was suspected. This was evident by the number of patients for whom the clinical pathway was activated in the ED settings in 2020–2022 compared with that in 2018–2019. Clearly, more patients were identified during the ED visit instead of being missed and identified during admission. Limitations: We acknowledge the limitations of being this research single center based and part of the data being collected retrospectively. Conclusions The malignant cord compression pathway is extremely effective in shortening the time needed for identifying patients at risk, reducing the time needed to report such critical findings, and significantly shortening the interval between identification and treatment. The malignant cord compression pathway can be used as the standard of care in oncological centers. Abbreviations Malignant spinal cord compression (MSCC). Magnetic resonance imaging (MRI) The National Institute for Health and Care Excellence (NICE) King Faisal Specialists Hospital and Research Center in Riyadh (KFSHRC) CT-Simulation and urgent treatment (Sim&treat). Eastern cooperative Oncology Group Performance Status Scale (ECOG PS). Declarations This study was approved by the ethical committee of oncology research center in KFSHRC with IRB approval number 2231271 to be executed and published. Involved patients were consented at the registry to the hospital to obtain medical record numbers and human ethics and consent forms were reviewed by the ethical committee of the research center of KFSHRC. This research was not funded neither directly or indirectly. All authors report no conflict of interests. The first and corresponding authors were involved more frequently to produce this paper. All other authors have contributed equally to produce this paper. Conflict of interest: The Author, co-Authors as well as the corresponding author do not have any conflict of interest. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Funding Declaration: None Clinical Trial Number: not applicable Human Ethics and Consent to Participate declarations: not applicable Author Contribution Authors: 1. Abdulrahman A. Aldakheel. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected] . c. Phone: +966533333048. d. First Author. e. Responsible for statistics 2. Nasser M Al-Rajhi. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected] . c. Phone: +966505144655.d. Co-Author. 3. Mohammed Alshabanah. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected] . c. Phone: +966557678130. d. Co-Author. 4. Mohammed S, Alwhaid. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected] . c. Phone: +966542959414. d. Co-Author. 5. Bedour Julaidan. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected] . c. Phone: +966555303374. d. Co-Author. 6. Faisal A, Alsamari. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected] . c. Phone: +966536647881. d. Co-Author. 7. Mohammed M. Aldehaim. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected] . c. Phone: +966506288013. d. Corresponding Author. References Cole JS, Patchell RA. Metastatic epidural spinal cord compression. Lancet Neurol . 2008;7:459–466. 10.1016/S1474-4422(08)70089-9 . PMID: 18420159. Kwok Y, Tibbs PA, Patchell RA. Clinical approach to metastatic epidural spinal cord compression. Hematol Oncol Clin North Am . 2006;20:1297–1305. 10.1016/j.hoc.2006.09.008 . PMID: 17113464. Macdonald AG, Lynch D, Garbett I, Nazeer N. Malignant spinal cord compression. J R Coll Physicians Edinb . 2019;49:151–156. 10.4997/JRCPE.2019.217 . PMID: 31188350. Robson P. Metastatic spinal cord compression: a rare but important complication of cancer. Clin Med (Lond). 2014;14:542–5. 10.7861/clinmedicine.14-5-542 . PMID: 25301920; PMCID: PMC4951968. Patnaik S, Turner J, Inaparthy P, Kieffer WK. Metastatic spinal cord compression. Br J Hosp Med (Lond) . 2020;81:1–10. 10.12968/hmed.2019.0399 . PMID: 32339020. Byrne TN. Spinal cord compression from epidural metastases. N Engl J Med . 1992;327:614–619. 10.1056/NEJM199208273270907 . PMID: 1296600. De Martino L, Spennato P, Vetrella S, Capasso M, Porfito C, Ruotolo S, Abate ME, Cinalli G, Quaglietta L. Symptomatic malignant spinal cord compression in children: a single-center experience. Ital J Pediatr. 2019;45:80. 10.1186/s13052-019-0671-5 . PMID: 31300063; PMCID: PMC6626347. Rasool MT, Fatima K, Manzoor NA, et al. Profile of malignant spinal cord compression: one year study at regional cancer center. Indian J Palliat Care. 2016;22:125–9. 10.4103/0973-1075.179605 . PMID: 27162421; PMCID: PMC4843549. Gesme DH, Wiseman M. Strategic use of clinical pathways. J Oncol Pract. 2011;7:54–6. 10.1200/JOP.2010.000193 . PMID: 21532812; PMCID: PMC3014512. Chiang AC, Ellis P, Zon R. Perspectives on the use of clinical pathways in oncology care. Am Soc Clin Oncol Educ Book . 2017;37:155–159. 10.1200/EDBK_175533 . PMID: 28561702. van Hoeve JC, Vernooij RWM, Fiander M, Nieboer P, Siesling S, Rotter T. Effects of oncological care pathways in primary and secondary care on patient, professional and health systems outcomes: a systematic review and meta-analysis. Syst Rev. 2020;9:246. 10.1186/s13643-020-01498-0 . PMID: 33100227; PMCID: PMC7586678. Reschke A, Richards RM, Smith SM, et al. Development of clinical pathways to improve multidisciplinary care of high-risk pediatric oncology patients. Front Oncol. 2022;12:1033993. 10.3389/fonc.2022.1033993 . PMID: 36523979; PMCID: PMC9744920. Feinberg BA, Lang J, Grzegorczyk J et al. Implementation of cancer clinical care pathways: a successful model of collaboration between payers and providers. J Oncol Pract . 2012;8:e38s-43s. 10.1200/JOP.2012.000564 . PMID: 22942833; PMCID: PMC3348604. 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Tables Table 1 Demographics of the patients. 2018–2019 (group 1) 2020–2022 (group 2) Number of patients 52 118 Mean age 48 51 ECOG PS* 1 2 3 4 1 (1.9%) 11 (21.2%) 32 (61.5%) 8 (15.4%) 10 (8.5%) 38 (32.2%) 51 (43.2%) 14 (11.9%) Primary site Breast cancer Lymphoma Sarcoma Lung cancer Prostate Others 8 (15.4%) 6 (11.5%) 7 (13.5%) 5 (9.6%) 3 (5.8%) 24 (44.2%) 29 (24.6%) 21 (17.8%) 17 (14.4%) 9 (7.6%) 10 (8.5%) 32 (27.1%) Histopathology Adenocarcinoma Clear cell Hematological SCC Others 20 (38.5%) 4 (7.7%) 4 (7.7%) 4 (7.7%) 20 (38.4%) 52 (44.1%) 6 (5%) 15 (12.7%) 7 (5.9%) 38 (32.2%) Disease burden Locally advanced Metastatic cancer 3 (5.8%) 49 (94.2%) 7 (6%) 111 (94%) Encounter type ED visit Admission 36 (69.2%) 16 (30.8%) 97 (82.2%) 21 (17.8%) Pain 44 (84.6%) 844 (71.2%) Incontinence 4 (7.7%) 10 (8.5%) Sensory 10 (19.2%) 28 (23.7%) Weakness 24 (46.2%) 53 (44.9%) Neurological deficit 38 (73.1%) 91 (77.1%) * Eastern cooperative Oncology Group Performance Status Scale (ECOG PS). Table 2: Cord compression statistics. 2018–2019 (group 1) 2020–2022 (group 2) Independent nonparametric test Interval 1: Cord compression suspicion to MRI Mean Median 27 h 9.5 h 16.5 h 6 h P-value = .013 Interval 2: MRI completion to MRI report Mean Median 32 h 12 h 7.5 h 3 h P-value = .00 1 Interval 3: Cord compression suspicion to final intervention. Mean Median 144 h 110 h 47 h 24 h P-value = .00 1 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4488241","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313570768,"identity":"bdba34f2-9c1e-465d-b9f5-0a906cd9743e","order_by":0,"name":"Abdulrahman Aldakheel","email":"","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":false,"prefix":"","firstName":"Abdulrahman","middleName":"","lastName":"Aldakheel","suffix":""},{"id":313570770,"identity":"fc74f015-350a-4c34-a891-0acafcb0d605","order_by":1,"name":"Nasser Al-Rajhi","email":"","orcid":"","institution":"King Faisal 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Aldehaim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYFAC5gYJxgYGHgb2NoYPQAYIGBDQwgjVwnOMcQZJWhgYJNKI1KLbfrDxxscddjK6M58lNv7ccU+egb15mwTDHzucWszOJDZbzjyTzGN2O+1gM++ZYsMGnmNlEoxtybi1HEhsk+ZtYwZqSW9/zNiWkMAgkWMGdCozbi3nH7ZJ/22r5zG7ebyx8SdIi/wbM6DD6nFruQG0hbHtMI/ZDbaDDbxgW3iAWtgO49HysNmyt+04j9mZtMRmoBbDNp60YovEtuN4HJZ88MbPtmp7s+PHDEEOk+dnP7zxxoc/1Ti1YAI2EJFAgoZRMApGwSgYBZgAAJ0sWB/yyjCzAAAAAElFTkSuQmCC","orcid":"","institution":"King Faisal Specialist Hospital \u0026 Research Centre","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Aldehaim","suffix":""}],"badges":[],"createdAt":"2024-05-28 05:33:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4488241/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4488241/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58753321,"identity":"aa7c02a5-1750-4b76-94fe-0e8d05f56411","added_by":"auto","created_at":"2024-06-20 16:17:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":40089,"visible":true,"origin":"","legend":"\u003cp\u003eNon-parametric test comparing medians for both groups for the first interval which is from Cord-compression suspicion to MRI being it done.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4488241/v1/66ee61a97204ec3aa40794ca.png"},{"id":58753322,"identity":"64d4528b-6cae-4196-b5e7-6c55f7b92d13","added_by":"auto","created_at":"2024-06-20 16:17:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34067,"visible":true,"origin":"","legend":"\u003cp\u003eNon-parametric test comparing medians for both groups for the second interval which is from MRI being it done to MRI being it reported.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4488241/v1/7d3db33bcf5e1176e17969f0.png"},{"id":58753324,"identity":"56abd87b-1bd3-4277-82a7-fdf3a24250c1","added_by":"auto","created_at":"2024-06-20 16:17:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":41674,"visible":true,"origin":"","legend":"\u003cp\u003eNon-parametric test comparing medians for both groups for the third interval which is from being it suspected to intervention being it provided.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4488241/v1/9d4148b974ca4d79599be156.png"},{"id":59769094,"identity":"407f3540-9c85-4793-a6b0-a24238a407b2","added_by":"auto","created_at":"2024-07-06 10:31:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":559587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4488241/v1/afe34943-d14f-4f70-8f60-453cfceee4ae.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Malignant spinal cord compression pathway: A new step toward standard of care for a critical oncological finding","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMalignant spinal cord compression (MSCC) is a well-recognized complication of cancer and usually presents as an oncological emergency. It occurs in 2.5\u0026ndash;5% of all patients with cancer.\u003csup\u003e1\u003c/sup\u003e This could be translated to approximately 4000 cases annually in England and Wales (National Institute for Health and Care Excellence, 2008). It is more common in patients with breast, prostate, and lung cancers. Although the true incidence of MSCC is unknown, it occurs in approximately 15% of patients with advanced cancer.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMSCC is usually caused by the collapse or compression of a vertebral body with metastatic disease; however, it can also be caused by direct tumor extension into the vertebral column. Cord compression initially causes edema, venous congestion, and demyelination, which are reversible. Chronic compression leads to vascular injury, cord necrosis, and permanent damage. Patients who have no neurological function for \u0026gt;\u0026thinsp;48 h are unlikely to improve.\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis condition must be addressed because the life quality of patients is significantly affected. Moreover, untreated cord compression has various complications, such as limp weakness, sphincter incontinence, and sensory and/or motor loss. Thus, developing an effective systematic approach for diagnosing those at a greater risk of cord compression is an urgent need.\u003c/p\u003e \u003cp\u003e Multiple guidelines have been established across nations for the diagnosis and management of MSCC. Macdonald et al. published clear guidelines on these.\u003csup\u003e3\u003c/sup\u003e The National Institute for Health and Care Excellence (NICE) published another guideline for the risk assessment, diagnosis, and management of MSCC in 2008 and updated it in 2019 and 2023.\u003csup\u003e4\u003c/sup\u003e In 2020, Patnaik et al. published another important article on the effective clinical approach, clinical assessment, diagnosis, and management of MSCC.\u003csup\u003e5\u003c/sup\u003e The mainstay of the reviewed guidelines was on the management of patients at high risk based on their presenting chief complaints and presence of any motor weakness, sensory deficit, and/or sphincter incontinence, i.e., to start intravenous steroid therapy at a given loading dose (10\u0026ndash;16 mg) and then perform whole-spine magnetic resonance imaging (MRI) within 24 h in patients suspected with cord compression.\u003c/p\u003e \u003cp\u003eTo the best of our knowledge, only NICE has proposed recommendations for MSCC.\u003csup\u003e4\u003c/sup\u003e Other institutions have established guidelines, which are accessible over the intranet; however, these guidelines are not published in scientific journals. Moreover, the published recommendations from NICE and the guidelines established in other institutions agreed on performing MRI within 24 h and then administering steroids.\u003c/p\u003e \u003cp\u003eThe King Faisal Specialists Hospital and Research Center in Riyadh (KFSHRC) established a cord compression pathway in 2020. This clinical pathway involves a focused oncological history and physical examination. If there is a high suspicion of the activation of the cord compression pathway, a sequence of events is followed: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) administration of loading dose of steroids followed by the maintenance dose, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) urgent whole-spine MRI, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) consultations with concerned services, and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) provision of intervention.\u003c/p\u003e \u003cp\u003eThis study aimed to report the outcomes of using the MSCC suspicion clinical pathway from January 2018 to October 2022 in an oncology center and compare them with those before the establishment of this clinical pathway.\u003c/p\u003e"},{"header":"Methods and materials","content":"\u003cp\u003eData of patients with activated Malignant spinal cord compression pathway were collected from the Quality and Assurance Department of KFSHRC, Riyadh, between 2020 and 2022. Data were recorded prospectively and analyzed retrospectively. For comparison, data of patients under the computed tomography simulation scan and urgent radiotherapy treatment category were collected from the Radiation Oncology Department of KFSHRC between 2018 and 2019.\u003c/p\u003e \u003cp\u003ePatients in whom the Malignant spinal cord compression pathway was activated between October 2020 and October 2022 were included. All included patients had a history of confirmed malignancy based on biopsy and/or clinical diagnosis and a confirmed diagnosis of malignancy under the CT-Simulation and urgent treatment (Sim\u0026amp;treat) category in the Aria system. Patients who were not diagnosed with malignancy, in whom the cord compression pathway was activated due to mechanical causes, and who were treated without an MRI were excluded from the data analysis.\u003c/p\u003e \u003cp\u003eDemographics of the patients, cancer site, pathology type, and presenting symptoms were collected. For all patients, three calculated intervals were generated: interval 1, which was defined as the time from the clinical suspicion of cord compression to MRI completion; interval 2, which was defined as the time from MRI completion to MRI report; and interval 3, which was defined as the time from the clinical suspicion of cord compression to the final intervention. All data were extracted into an Excel sheet and transferred and analyzed in IBM SPSS Statistics version 23 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe outcomes before the implementation of the Malignant spinal cord compression pathway (2018\u0026ndash;2019, group 1) and those after its establishment (2020\u0026ndash;2022, group 2) are shown in Tables 1 and 2, respectively.\u003c/p\u003e\n\u003ch2\u003ePeriod before establishing Malignant spinal cord compression pathway 2018\u0026ndash;2019:\u003c/h2\u003e\n\u003cp\u003eIn 2018\u0026ndash;2019, when the Malignant spinal cord compression pathway was not yet established, 52 patients had an MRI of any segments of the spine or whole-spine MRI. All patients who were treated without MRI were excluded. Of the 52 patients, 24 (46.2%) were female, and 28 (53.8%) were male, with a mean age of 48 years. Moreover, 32 (61.5%) patients had Eastern Cooperative Oncology Group performance status of (ECOG PS) of 3, 11 (21.2%) had ECOG PS of 2, 8 (15.4%) had ECOG PS of 4, and 1 (1.9%) had ECOG PS of 1 at presentation. Regarding the primary site of malignancy, 8 (15.4%) patients had breast cancer, 7 (13.5%) had sarcoma, 4 (9.6%) had lung cancer, and the remaining patients (61.5%) had tumors at different sites. Adenocarcinoma was the most common histopathological type, which occurred in 20 (38.5%) patients, followed by clear cell carcinoma in 4 (7.7%) and squamous cell carcinoma in 4 (7.7%). In the disease burden category, 49 (94.2%) patients had metastatic disease upon presentation to the emergency department (ED), whereas 3 (5.8%) patients had a nonmetastatic disease.\u003c/p\u003e\n\u003cp\u003eAmong the patients who were suspected to have cord compression clinically, 36 (69.2%) were either seen in the clinic and transferred to the ED or presented initially to the ED, whereas 16 (30.8%) patients were identified as at-risk for cord compression during their admission course.\u003c/p\u003e\n\u003cp\u003eRegarding the symptoms that triggered the suspicion of cord compression, 44 (84.6%) patients had back pain and/or radicular neuropathic pain initially, which was followed by neurological deficit in 38 (73.1%) (with motor or sensory involvement) and isolated motor weakness of any limb in 24 (46.2%) patients.\u003c/p\u003e\n\u003cp\u003eIn patients whom were suspected to have cord compression clinically, interval 1 was 9.5 h, with a mean of 27 h (for both patients who presented to the emergency department or those who were admitted). For interval 2, the median time was 12 h, with a mean time of 32 h. Finally, for interval 3, the median and mean times were 110 and 144 h, respectively.\u003c/p\u003e\n\u003cp\u003eAnalysis of patients who underwent MRI revealed that the most affected vertebral segment was the thoracic spine in 27 (51.9%) patients, lumbar spine in 20 (38.5%), cervical spine in 10 (19.2%), and sacrum in 6 (11.5%). Only 43 (82.7%) patients had whole-spine MRI, and the remaining patients had MRIs of one or two segments of the spine.\u003c/p\u003e\n\u003ch2\u003ePeriod after establishing Malignant spinal cord compression pathway 2020\u0026ndash;2022:\u003c/h2\u003e\n\u003cp\u003eIn 2020\u0026ndash;2022, when the cord compression pathway was fully implemented, 118 patients were identified. Of these, 63 (53.4%) patients were female and 55 (46.6%) were male. Their mean age was 51 years. In addition, 51 (43.2%) patients had ECOG PS of 3, 38 (32.2%) had ECOG PS of 2, 14 (11.9%) had ECOG PS of 4, and 10 (8.5%) had ECOG PS of 1. Upon presentation, breast cancer was the most common site of malignancy in 29 (24.6%) patients, followed by lymphoma in 21 (17.8%), sarcoma in 17 (14.4%), and prostate cancer in 10 (8.5%); the remaining patients (34.7%) had malignancy in other sites. Adenocarcinoma was the most recorded, occurring in 52 (44.1%) patients, followed by hematological malignancies in 15 (12.7%) and squamous cell carcinoma in 7 (5.9%). The remaining 44 (37.3%) patients had other histopathological types. Of all patients, 111 (94%) had metastatic disease at clinical suspicion of cord compression and 7 (6%) only had locally advanced disease. Moreover, 97 (82.2%) patients presented to the ED, whereas 21 (17.8%) were admitted at the time of clinical suspicion of cord compression.\u003c/p\u003e\n\u003cp\u003eSymptoms upon presentation included neurological deficit in 91 (77.1%) patients, back pain and/or neurological radicular pain in 84 (71.2%), motor weakness in 53 (44.9%), sensory impairment in 28 (23.7%), and fecal and/or urine incontinence in 10 (8.5%).\u003c/p\u003e\n\u003cp\u003eDuring the implementation period, the cord compression pathway was activated in 118 patients. In interval 1, the median and mean times were 6 and 16.5 h, respectively. In interval 2, the median and mean times were 3 and 7.5 h, respectively. In interval 3, the median and mean times were 24 and 47 h, respectively. In the sub-analysis, MRI was positive for cord compression in 54 (45.8%) patients. The most common vertebral segment affected by metastatic disease was the thoracic spine in 36 (66.6%) patients, followed by the lumbar spine in 22 (40.7%), cervical spine in 14 (25.9%), and sacrum in 6 (11.1%).\u003c/p\u003e\n\u003cp\u003eNonparametric test was used to compare the medians of both groups (group 1 = 2018\u0026ndash;2019; group 2 = 2020\u0026ndash;2022). The median times of intervals 1, 2, and 3 were compared (in this order) between the two groups. In the independent test, the comparison of the median time in interval 1 was not significant, with a p-value of 0.13. However, the comparisons of the median times in intervals 2 and 3 were statistically significant, with a p-value of 0.001.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAcute cord compression secondary to cancer is a rare diagnosis, and it represents a true oncological emergency because it may lead to devastating outcomes if treatment is delayed or left untreated. The true incidence of malignant cord compression is unknown. However, it occurs in 5\u0026ndash;15% of all patients with cancer.\u003csup\u003e6\u003c/sup\u003e All patients diagnosed with malignant cord compression can become paraplegic if left untreated, with varying severity of co-existing symptoms such as pain, sensory loss, and/or sphincter incontinence.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe results of this study were consistent with those of two retrospective analyses focusing on patients\u0026rsquo; characteristics at presentation and the expected outcomes.\u003csup\u003e7,8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eDe novo metastatic cancer near the spine causing cord compression or the primary cancer near the spinal cord could be the initial presentation of patients. However, malignant cord compression is more prevalent in disseminated disease.\u003csup\u003e2\u003c/sup\u003e Patients with metastatic disease, particularly those diagnosed with malignant spinal cord compression, have limited survival; however, one-third of these patients survive for more than 1 year.\u003csup\u003e6\u003c/sup\u003e Thus, aggressive therapy to preserve and/or improve neurological function is of utmost importance to maintain the quality of life and prevent further deterioration.\u003c/p\u003e \u003cp\u003eEarly detection of such an entity in patients with critical findings and initiation of management within a given timeframe remain challenging. Multiple recommendations are available for such patients. NICE has published a clinical guideline in 2008 and updated it in 2019 and 2023. It presents detailed recommendations on how to identify and manage such patients.\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIdentification of at-risk patients, provision of appropriate interventions at a given timeframe, and finalization of the treatment plan are challenging because of various reasons. Effective communication between the stakeholders of such cases is the main point. In the recent decade, evidence-based clinical pathways have been increasingly utilized and have shown excellent clinical improvement in the hospital workflow, particularly in oncology field. Moreover, they have shown a great potential in shortening the time needed by oncologists to identify, workup, and finalize treatment recommendations for patients with cancer. They are cost-effective and reduce hospital costs and utilization of resources.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eClinical pathways are also known as urgent care set, care maps, and/or integrated care pathways. A clinical pathway is more or less used as the guideline. Clinical pathways are more directed to standardizing the treatment of specific patients with a specific diagnosis rather than listing the treatment options for a set of patients.\u003csup\u003e10\u003c/sup\u003e The process of clinical pathway formation is quite complicated. Unlike guidelines, where a panel of experts votes for a given recommendation, the creation of clinical pathways involves committees of physician peers with disease expertise to decide the most appropriate option based on multiple factors, such as efficacy, toxicities, applicability, and cost.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn a systematic review published in 2020, Jolanda et al. analyzed eight major studies involving\u0026thinsp;\u0026gt;\u0026thinsp;4000 patients with cancer. They examined the effect of the clinical pathways.\u003csup\u003e11\u003c/sup\u003e They clearly concluded the positive effect of the implementation of clinical pathways on cost, length of stay, and patient satisfaction and quality of life.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFurthermore, Roschke et al. demonstrated the feasibility of the standardization the clinical approach, work-up and management at their institution in addressing pediatric patients with severe cancer at a greater risk of developing life-threatening conditions.\u003csup\u003e12\u003c/sup\u003e Moreover, Feinberg et al. analyzed the successful implementation of clinical pathways and their maintenance.\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAt present, data on the implementation of clinical pathways to either standardize an approach or intervention and/or reduce costs are sufficient and have shown positive effects in many clinical aspects.\u003csup\u003e10,11,12,13\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eKFSHRC established a cord compression pathway in 2020 for the identification and provision of urgent interventions in patients who are clinically suspected with cord compression.\u003c/p\u003e \u003cp\u003eThis study analyzed 118 patients in whom the clinical pathway for cord compression was used, and the 18-month outcomes before and after its implementation in 2018\u0026ndash;2020 were compared. The results revealed that the cord compression pathway substantially reduced the time needed for the identification of patients at risk and provision of treatment at the median time of 24 h.\u003c/p\u003e \u003cp\u003eOur results revealed that 40.1% of the patients at the time of the diagnosis had ECOG PS of \u0026le;\u0026thinsp;2 compared with 23.1% in 2018\u0026ndash;2019 (before the implementation of the clinical pathway). This may indicate marked improvement in the suspicion threshold of such diagnosis among the targeted patients. Moreover, the diagnosis was made in the ED more frequently in 2020\u0026ndash;2022 (82.2%) than in 2018\u0026ndash;2019 (69.2%).\u003c/p\u003e \u003cp\u003eThis improvement continues as noted in the rate of patients undergoing whole-spine MRI. All patients in 2020\u0026ndash;2022 underwent whole-spine MRI. However, some patients could not tolerate the whole procedure; in 2018\u0026ndash;2019, 93.2% patients had whole-spine MRI and 82.7% had MRIs of one or two spine segments.\u003c/p\u003e \u003cp\u003eMultiple intervals were calculated as described in the results. Interval 1 covered the period from the suspicion of cord compression to MRI. Nearly 30% improvement was noted in the time needed to perform an MRI from suspicion in 2020\u0026ndash;2022 with a median of 6 h compared with that in 2018\u0026ndash;2019 with a median of 9.5 h. The gap between the two groups continues to substantially widen; in interval 2, the time needed to report MRI findings was significantly reduced by at least threefold. The median time in 2020\u0026ndash;2022 was 3 h compared with 12 h in 2018\u0026ndash;2019. This substantial difference continued to affect interval 3, which covered the period from cord compression suspicion to treatment, and nearly threefold improvement was found in 2020\u0026ndash;2022 with a median of 24 h compared with 110 h in 2018\u0026ndash;2019.\u003c/p\u003e \u003cp\u003eThe implementation of the cord compression pathway in the study center has shown a marked improvement based on the recorded results. Standardization of the entire process, from the suspicion of cord compression to the administration of medications, whole-spine MRI, consultation with concerned services, and delivery of appropriate treatment tailored to the patient, has remarkably improved.\u003c/p\u003e \u003cp\u003eMSCC is an oncological emergency. One could consider it a limp-saving clinical pathway because time plays a major role in managing such patients. Patchell et al.\u003csup\u003e14\u003c/sup\u003e demonstrated the importance of timely recognizing patients in their trial and proceeding accordingly.\u003c/p\u003e \u003cp\u003eIn our study, oncologists and medical staff appeared more encouraged to activate the clinical pathway once cord compression was suspected. This was evident by the number of patients for whom the clinical pathway was activated in the ED settings in 2020\u0026ndash;2022 compared with that in 2018\u0026ndash;2019. Clearly, more patients were identified during the ED visit instead of being missed and identified during admission.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eWe acknowledge the limitations of being this research single center based and part of the data being collected retrospectively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe malignant cord compression pathway is extremely effective in shortening the time needed for identifying patients at risk, reducing the time needed to report such critical findings, and significantly shortening the interval between identification and treatment. The malignant cord compression pathway can be used as the standard of care in oncological centers.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003col\u003e\n \u003cli\u003eMalignant spinal cord compression (MSCC).\u003c/li\u003e\n \u003cli\u003eMagnetic resonance imaging (MRI)\u003c/li\u003e\n \u003cli\u003eThe National Institute for Health and Care Excellence (NICE)\u003c/li\u003e\n \u003cli\u003eKing Faisal Specialists Hospital and Research Center in Riyadh (KFSHRC)\u003c/li\u003e\n \u003cli\u003eCT-Simulation and urgent treatment (Sim\u0026amp;treat).\u003c/li\u003e\n \u003cli\u003eEastern cooperative Oncology Group Performance Status Scale (ECOG PS). \u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was approved by the ethical committee of oncology research center in KFSHRC with IRB approval number 2231271 to be executed and published. Involved patients were consented at the registry to the hospital to obtain medical record numbers and human ethics and consent forms were reviewed by the ethical committee of the research center of KFSHRC. This research was not funded neither directly or indirectly. All authors report no conflict of interests. The first and corresponding authors were involved more frequently to produce this paper. All other authors have contributed equally to produce this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Author, co-Authors as well as the corresponding author do not have any conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration:\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate declarations:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors: 1. Abdulrahman A. Aldakheel. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected]. c. Phone: +966533333048. d. First Author. e. Responsible for statistics 2. Nasser M Al-Rajhi. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected]. c. Phone: +966505144655.d. Co-Author. 3. Mohammed Alshabanah. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected]. c. Phone: +966557678130. d. Co-Author. 4. Mohammed S, Alwhaid. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected]. c. Phone: +966542959414. d. Co-Author. 5. Bedour Julaidan. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected]. c. Phone: +966555303374. d. Co-Author. 6. Faisal A, Alsamari. a. Radiation oncology department, KFSHRC, SA, Riyadh, Resident. b. Email: [email protected]. c. Phone: +966536647881. d. Co-Author. 7. Mohammed M. Aldehaim. a. Radiation oncology department, KFSHRC, SA, Riyadh, Consultant. b. Email: [email protected]. c. Phone: +966506288013. d. Corresponding Author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCole JS, Patchell RA. Metastatic epidural spinal cord compression. \u003cem\u003eLancet Neurol\u003c/em\u003e. 2008;7:459\u0026ndash;466. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1474-4422(08)70089-9\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(08)70089-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 18420159.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwok Y, Tibbs PA, Patchell RA. 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PMID: 21532812; PMCID: PMC3014512.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiang AC, Ellis P, Zon R. Perspectives on the use of clinical pathways in oncology care. \u003cem\u003eAm Soc Clin Oncol Educ Book\u003c/em\u003e. 2017;37:155\u0026ndash;159. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/EDBK_175533\u003c/span\u003e\u003cspan address=\"10.1200/EDBK_175533\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 28561702.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Hoeve JC, Vernooij RWM, Fiander M, Nieboer P, Siesling S, Rotter T. Effects of oncological care pathways in primary and secondary care on patient, professional and health systems outcomes: a systematic review and meta-analysis. Syst Rev. 2020;9:246. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13643-020-01498-0\u003c/span\u003e\u003cspan address=\"10.1186/s13643-020-01498-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 33100227; PMCID: PMC7586678.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReschke A, Richards RM, Smith SM, et al. Development of clinical pathways to improve multidisciplinary care of high-risk pediatric oncology patients. Front Oncol. 2022;12:1033993. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fonc.2022.1033993\u003c/span\u003e\u003cspan address=\"10.3389/fonc.2022.1033993\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 36523979; PMCID: PMC9744920.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeinberg BA, Lang J, Grzegorczyk J et al. Implementation of cancer clinical care pathways: a successful model of collaboration between payers and providers. \u003cem\u003eJ Oncol Pract\u003c/em\u003e. 2012;8:e38s-43s. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JOP.2012.000564\u003c/span\u003e\u003cspan address=\"10.1200/JOP.2012.000564\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 22942833; PMCID: PMC3348604.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. \u003cem\u003eLancet\u003c/em\u003e. 2005;366:643\u0026ndash;648. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(05)66954-1\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(05)66954-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 16112300.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Demographics of the patients.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"395\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e2018\u0026ndash;2019 (group 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e2020\u0026ndash;2022\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(group 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eMean age\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eECOG PS*\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e4\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003cp\u003e11 (21.2%)\u003c/p\u003e\n \u003cp\u003e32 (61.5%)\u003c/p\u003e\n \u003cp\u003e8 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (8.5%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e38 (32.2%)\u003c/p\u003e\n \u003cp\u003e51 (43.2%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e14 (11.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003ePrimary site\u003c/p\u003e\n \u003cp\u003eBreast cancer\u003c/p\u003e\n \u003cp\u003eLymphoma\u003c/p\u003e\n \u003cp\u003eSarcoma\u003c/p\u003e\n \u003cp\u003eLung cancer\u003c/p\u003e\n \u003cp\u003eProstate\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (15.4%)\u003c/p\u003e\n \u003cp\u003e6 (11.5%)\u003c/p\u003e\n \u003cp\u003e7 (13.5%)\u003c/p\u003e\n \u003cp\u003e5 (9.6%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (5.8%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e24 (44.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e29 (24.6%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21 (17.8%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (14.4%)\u003c/p\u003e\n \u003cp\u003e9 (7.6%)\u003c/p\u003e\n \u003cp\u003e10 (8.5%)\u003c/p\u003e\n \u003cp\u003e32 (27.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eHistopathology\u003c/p\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003cp\u003eClear cell\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHematological\u003c/p\u003e\n \u003cp\u003eSCC\u003c/p\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (38.5%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;4 (7.7%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (7.7%)\u003c/p\u003e\n \u003cp\u003e4 (7.7%)\u003c/p\u003e\n \u003cp\u003e20 (38.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e52 (44.1%)\u003c/p\u003e\n \u003cp\u003e6 (5%)\u003c/p\u003e\n \u003cp\u003e15 (12.7%)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (5.9%)\u003c/p\u003e\n \u003cp\u003e38 (32.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eDisease burden\u003c/p\u003e\n \u003cp\u003eLocally advanced\u003c/p\u003e\n \u003cp\u003eMetastatic cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (5.8%)\u003c/p\u003e\n \u003cp\u003e49 (94.2%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;7 (6%)\u003c/p\u003e\n \u003cp\u003e111 (94%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eEncounter type\u003c/p\u003e\n \u003cp\u003eED visit\u003c/p\u003e\n \u003cp\u003eAdmission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e36 (69.2%)\u003c/p\u003e\n \u003cp\u003e16 (30.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e97 (82.2%)\u003c/p\u003e\n \u003cp\u003e21 (17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e44 (84.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e844 (71.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eIncontinence\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e4 (7.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e10 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eSensory\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e10 (19.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e28 (23.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eWeakness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e24 (46.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e53 (44.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"37.721518987341774%\" valign=\"top\"\u003e\n \u003cp\u003eNeurological deficit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.075949367088608%\" valign=\"top\"\u003e\n \u003cp\u003e38 (73.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.20253164556962%\" valign=\"top\"\u003e\n \u003cp\u003e91 (77.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;* Eastern cooperative Oncology Group Performance Status Scale (ECOG PS). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Cord compression statistics.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.942215088282506%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91653290529695%\" valign=\"top\"\u003e\n \u003cp\u003e2018\u0026ndash;2019\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(group 1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.792937399678973%\" valign=\"top\"\u003e\n \u003cp\u003e2020\u0026ndash;2022\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(group 2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.348314606741575%\" valign=\"top\"\u003e\n \u003cp\u003eIndependent nonparametric test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.942215088282506%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInterval 1:\u003c/p\u003e\n \u003cp\u003eCord compression suspicion to MRI\u003c/p\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003eMedian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91653290529695%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 h\u003c/p\u003e\n \u003cp\u003e9.5 h\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.792937399678973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16.5 h\u003c/p\u003e\n \u003cp\u003e6 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.348314606741575%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP-value = .013\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.942215088282506%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInterval 2:\u003c/p\u003e\n \u003cp\u003eMRI completion to MRI report\u003c/p\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91653290529695%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 h\u003c/p\u003e\n \u003cp\u003e12 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.792937399678973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.5 h\u003c/p\u003e\n \u003cp\u003e3 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.348314606741575%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP-value = .00\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.942215088282506%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eInterval 3:\u003c/p\u003e\n \u003cp\u003eCord compression suspicion to final intervention.\u003c/p\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003cp\u003eMedian\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.91653290529695%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e144 h\u003c/p\u003e\n \u003cp\u003e110 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.792937399678973%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e47 h\u003c/p\u003e\n \u003cp\u003e24 h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.348314606741575%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eP-value = .00\u003cspan dir=\"RTL\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spinal-Cord Compression, Spinal metastases, Patients’ Safety, Patients’ Quality of life, Palliative radiotherapy","lastPublishedDoi":"10.21203/rs.3.rs-4488241/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4488241/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMalignant cord compression syndrome (MCCS) must be addressed clinically using whole-spine magnetic resonance imaging in suspected patients and managed accordingly. Establishing a Malignant spinal cord compression pathway is crucial for addressing these patients sequentially with an immediate management plan. Here, we reported the outcomes of a Malignant spinal cord compression pathway and compared the results with those before its implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThis is a prospective observational study where data collection was performed for patients with activated cord compression pathway between July 2021 and October 2022. Collected data was including demographics of patients, presenting symptoms, time of recorded clinical pathway activation and subsequent events including final management plan. Retrospective data collection was done for 52 patients whom were treated from the period between 2018-2019. Non-parametric test was used to compare medians for both groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: In total, 170 patients were included, and 52 of them were treated based on positive magnetic resonance imaging (MRI) findings of Malignant spinal cord compression pathway between 2018 and 2019. Moreover, 118 patients were identified during the implementation of the cord compression pathway in 2020–2022. Three main targeted intervals were calculated in hours using medians and means: interval 1, time from cord compression suspicion to MRI; interval 2, MRI completion to MRI report; and interval 3, cord compression suspicion to intervention. In 2018–2019, medians of these three intervals were 9.5, 12, and 110 h, and in 2020–2022, they substantially decreased to 6, 3, and 24 h, respectively. An independent nonparametric test was performed to compare the medians, and statistically significant results were obtained for intervals between MRI completion and MRI report (p = 0.001) as well as between cord compression suspicion and intervention (p = 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The use of the malignant spinal cord compression pathway effectively shortens the time needed for identifying patients at risk, reduces the time to report critical findings, and significantly shortens the interval between identification and treatment. In our study, clinical pathway reduced time needed to identify, diagnose and manage such disease.\u003c/p\u003e","manuscriptTitle":"Malignant spinal cord compression pathway: A new step toward standard of care for a critical oncological finding","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-20 16:17:31","doi":"10.21203/rs.3.rs-4488241/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0479af18-94c6-4869-bfba-19a91cad5ebb","owner":[],"postedDate":"June 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-06T10:23:26+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-20 16:17:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4488241","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4488241","identity":"rs-4488241","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}