Metastatic Spinal Cord Compression (MSCC)

Safety

Recognise MSCC — Keep a High Index of Suspicion

Done

Any cancer patient with neurological symptoms or signs of cord compression is an oncological emergency. Spinal metastases are commonest in prostate, lung, breast cancer and myeloma.

Spinal/back pain Severe, progressive or unremitting; may be radicular ("band-like"), nocturnal (preventing sleep), or worse on straining/coughing/standing. May not be present.

Limb weakness Out of proportion to general condition; difficulty walking; claudication-like leg pain.

Sensory changes Tingling, numbness, "my legs do not feel like mine"; look for a sensory level.

Bladder/bowel Difficulty passing urine (usually late), constipation or faecal incontinence; distended bladder.

Signs Localised spinal tenderness, limb weakness, absent or increased reflexes, extensor plantars, clonus.

A normal neurological examination does NOT exclude MSCC — investigate if concerning symptoms are present.

MSCC affects 5–10% of cancer patients and is a catastrophic event. Because symptoms can be vague and a normal exam is falsely reassuring, the threshold to investigate must be very low — the window to preserve neurological function is short.

Diagnose

Focused Assessment & Examination

Done

Pain history

Character (band-like/radicular), nocturnal or worse on straining/coughing; thoracic back pain in a cancer patient is MSCC until proven otherwise.

Neuro exam

Limb power, tone, reflexes (absent or brisk), plantars, clonus; look for a sensory level and saddle sensation.

Walking & bladder

Gait/Romberg; ask about and palpate for urinary retention; reduced anal tone is a late sign.

Localise

Spinal percussion tenderness helps localise; but the clinical level is unreliable — hence whole-spine imaging.

Remember

A normal examination does not exclude MSCC — act on the symptoms.

A structured neurological examination establishes whether function is already threatened and provides the baseline against which response to treatment is judged — but because compression can exist with a near-normal exam and at a level distant from the pain, the assessment lowers the threshold to image rather than ever providing reassurance to wait.

Diagnose

Causes & Differential

Done

Commonest primaries

Prostate, breast, lung and myeloma account for most spinal metastases; renal and thyroid also metastasise to bone.

Mechanism

Vertebral body metastasis collapsing posteriorly onto the cord, or direct epidural extension; the thoracic spine is the commonest site (~70%).

May be first presentation

MSCC can be the index presentation of an unknown primary — investigate accordingly.

Differential

Benign causes (disc, abscess, haematoma), degenerative stenosis, or non-compressive paraneoplastic/leptomeningeal disease — MRI distinguishes them.

Knowing which cancers cause MSCC sharpens suspicion in the right patients and guides the hunt for an unknown primary when MSCC presents de novo; recognising that the thoracic spine and multiple levels are typical is exactly why whole-spine MRI, not a targeted film, is mandated.

Treat

Start High-Dose Dexamethasone Immediately

Done

Commence high-dose steroids immediately on clinical suspicion, even before the diagnosis is confirmed.

Loading dose

Dexamethasone 16mg oral (or 13.2mg SC) stat.

Maintenance

Then 8mg twice daily oral (or 6.6mg SC BD — morning & lunch). Continue 8mg BD or 16mg once daily until MSCC excluded, surgery completed, or radiotherapy started.

During radiotherapy

Maintain 8mg oral each morning until treatment completes.

Gastroprotection

Co-prescribe a PPI with high-dose steroids; monitor blood glucose.

VTE

Assess whether thromboprophylaxis is appropriate.

Taper

Reduce/discontinue over 1–2 weeks after radiotherapy/surgery. If neurology deteriorates during reduction, return to the last effective dose for a further 2 weeks before retrying.

Dexamethasone reduces vasogenic oedema around the cord, buying time and improving outcome before definitive treatment. It is given on suspicion because waiting for MRI confirmation risks irreversible paralysis.

Investigate

Immobilise & Image — Whole-Spine MRI Within 24 Hours

Done

Immobilise

Immobilise without delay (including transfer) if suspected MSCC + signs of spinal instability. Consider immobilisation if suspected spinal mets/MSCC + moderate–severe movement-related pain. Otherwise nurse flat per local guidance.

Imaging

Urgent MRI of the whole spine within 24 hours of clinical suspicion. If MRI contraindicated → CT whole spine with thin slices + sagittal reconstruction.

Bloods

As indicated for the underlying malignancy and fitness for treatment.

Whole-spine MRI is essential because compression is frequently at multiple levels and the clinical level is unreliable. Imaging within 24h is the NICE standard for suspected MSCC.

Refer

Same-Day Referral & MSCC Coordinator

Done

Urgent same-day referral to the Network MSCC coordinator (or oncology out-of-hours) for radiotherapy and/or surgical decompression.

MSCC coordinator

Refer same day for radiotherapy ± chemotherapy advice. (Greater Manchester: Christie MSCC service / hotline.)

Consider surgery if

No tissue diagnosis yet; limited levels of compression; minor neurological impairment; progressive weakness despite prior radiotherapy at that level; instability with life expectancy ≥6 months and fit for surgery.

Aims

Prevent permanent paralysis & bladder/bowel loss; maximise neuro recovery; local tumour control; pain control; spinal stability; good nursing, pressure-area care, psychological support and rehab.

Last days of life

If the patient is dying, admission/radiotherapy may be inappropriate → seek specialist palliative advice and focus on symptom control.

Outcome is dictated by speed: function present at treatment is usually preserved, but function already lost rarely returns. The MSCC coordinator route exists to compress referral-to-treatment time.

Treat

Definitive Treatment

Done

Most patients

Urgent radiotherapy

Within 24 hours of diagnosis for most — controls tumour, relieves pain and preserves function; under dexamethasone cover.

Selected patients

Surgical decompression ± stabilisation

Single-level compression, spinal instability, good performance status and life expectancy ≥6 months, or progression despite prior radiotherapy — surgery then post-op radiotherapy.

Tumour-specific

Systemic therapy

Hormone therapy / chemotherapy for highly chemo-/hormone-sensitive tumours (e.g. prostate, lymphoma, myeloma, small-cell).

Radiotherapy is the default because it relieves compression for most tumour types quickly and non-invasively, but surgery is preferred where the spine is unstable, the compression is from bone rather than radiosensitive tumour, or a single level can be decompressed in a patient fit enough to benefit — with the decision driven by performance status and predicted survival.

Support

Supportive Care & Rehabilitation

Done

Pressure & VTE care Meticulous pressure-area care while immobile; reassess thromboprophylaxis; bowel regimen.

Bladder & bowel Continence support, catheter/intermittent catheterisation, bowel management for cord dysfunction.

Rehabilitation Early physiotherapy/OT, mobility aids, falls prevention; spinal-cord-injury rehab where appropriate.

Psychological & social Support patient and family, equipment and care-package planning for new disability.

Whatever the definitive treatment, many MSCC patients are left with mobility, bladder and bowel impairment, so coordinated nursing, continence and rehabilitation care determines their quality of life — and proactive pressure-area and VTE care prevents the predictable complications of immobility.

Follow-up

Steroid Taper, Prognosis & Safety-net

Done

Steroid taper

Reduce dexamethasone over 1–2 weeks after radiotherapy/surgery; if neurology worsens on reduction, return to the last effective dose for 2 weeks. Keep PPI cover and monitor glucose.

Prognosis & ACP

MSCC signals advanced disease — discuss prognosis and advance care planning; ambulant status at treatment is the key predictor of staying ambulant.

Safety-net (cancer patients)

Warn patients with known cancer to report new or worsening back pain, leg weakness/numbness or bladder/bowel change immediately — do not wait.

Re-refer urgently

New or progressing neurology after treatment → urgent re-imaging / oncology review.

Because function present at treatment is usually preserved while function already lost rarely returns, the most powerful long-term intervention is teaching every cancer patient the early MSCC symptoms so they present before they lose the ability to walk; careful steroid tapering then avoids both rebound oedema and the harms of prolonged high-dose steroid.