The incidence of cancer is increasing; people are living longer with better quality of life, however, the risk of developing MSCC remains high for many patients. Prompt diagnosis and treatment is essential to prevent paralysis and failure to recognise the early signs can have devastating implications with the added financial burden of caring for bedbound patients.
All front-line clinicians have a vital role to play in referring suspected MSCC patients into the MSCC service in a timely manner. This includes physiotherapists working in most settings, e.g. MSK, A&E, walk-in centres, community and private sector.
According to NICE 2008, every region should have a MSCC coordinator service. Funding for this post in Manchester & Cheshire has provided a single point of referral for primary, secondary and tertiary care with the objective of enabling early diagnosis, treatment and rehabilitation.
The service, based at The Christie is led by a physiotherapist and supported by a radiographer (1.25 WTE). It offers advice and coordinated care following a pathway built on evidence-based guidelines. Patients are triaged for surgical opinion, radiotherapy, systemic treatment or best supportive care. Rehabilitation is firmly embedded within the pathway from diagnosis to care in the community. Education is core to the service and has encompassed training for clinicians at all levels and in all settings. To date, in excess of 700 physiotherapists have received training on identifying and managing MSCC which has contributed to physiotherapy direct referrals into our service.
Evaluation of the service compared to prior to its launch, has demonstrated a significant increase in timeliness of diagnosis and treatment with over 90% of patients undergoing an MR scan and treatment within 24 and 48 hours respectively. Between 2014 and 2016, 1915 referrals were received, 809 had MSCC, 256 had impending MSCC and 850 had no cord compression, demonstrating a 50/50 ratio of positive MSCC in all patients referred. Our median post-surgery survival of 377 days compares favourably to Patchell 2005 and Fehling 2015 who reported median survivals of 126 days and 230 days respectively following decompressive surgery for MSCC.
Cost and savings
The cost of the service per annum was funding to employ a full time band 8a physiotherapist and a band 7 radiographer 0.25 WTE.
Although we know that there are significant savings attached to the development of the service (patients are treated earlier, remain ambulant, prevent loss of function and bed bound 24/7 nursing care, etc.) it has not been possible to put a figure on the savings. Increased productivity and efficiency is a definite outcome of the service, as is increased awareness and knowledge through education to health professionals and patients.
The MSCC service has addressed inequalities in care in our region; post-code lottery discrepancies no longer affect MSCC patients.
The education component of this service has given large numbers of front-line clinicians, many of these physiotherapists, the skills to identify early cord compression whilst patients are still walking. Early diagnosis of patients with good performance status and prognosis allows them to access specialist spinal surgery with improved survival.
Future work must include collection of functional outcomes as required by NHS England Peer Review.
In order for quality of life and survival to continue to improve, Physiotherapists must remain at the forefront in recognising the early Red Flags for MSCC. Early diagnosis has the potential to prevent MSCC in the future, back pain is managed at an earlier stage, patients remain ambulant with better quality of life and improved survival and hospital admissions are reduced with significant financial benefits to the health service. This can only be achieved through continued education.
Top three learning points
- Recognising the early red flags for MSCC is the key to a favourable outcome
- A physiotherapist has the appropriate skill set to develop a MSCC coordinator service
- Education must be on-going taking into account rapid turnover of staff in any health care provider setting
This work was funded by the Christie NHS Foundation Trust.
This work was presented at Physiotherapy UK 2017.