Spinal metastasis and cord compression

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Ask every patient with cancer and back pain about walking, falls, leg heaviness, hand dexterity, numbness, a band around the trunk, saddle sensation, urinary initiation, bladder awareness, retention, incontinence and bowel control. Define pain site, progression, night waking, cough or strain provocation and whether turning, sitting or standing causes severe mechanical pain. Establish cancer histology, previous spinal radiotherapy or surgery, systemic control, performance status and goals without allowing prognostic discussion to delay neurological rescue.

Perform and document a repeatable neurological baseline: mental state, cranial findings when relevant, tone, power by myotome, reflexes, plantar responses, sensory level, saddle sensation, coordination and gait only if safe. Palpate focal spinal tenderness and assess pain with carefully controlled movement rather than forceful testing. Check bladder volume when retention is possible, skin and pressure areas and respiratory function for high lesions. Do not repeatedly transfer an unstable painful spine for non-essential examinations.

Call the local 24-hour MSCC pathway immediately when neurological symptoms or signs are present. This contact coordinates oncology, spinal surgery, radiology and transfer. Give dexamethasone 16 mg orally or equivalent parenterally as soon as possible, then 16 mg daily while surgery or radiotherapy is awaited. Start proton-pump protection according to NICE and monitor glucose. If imaging rules out MSCC, stop or reduce corticosteroid safely; once definitive treatment begins, taper gradually under the treating team.

MRI must cover the whole spine because clinically silent non-contiguous disease is common. NICE specifies sagittal T1 and STIR sequences of the entire spine with sagittal T2 and targeted axial imaging through significant abnormalities. Obtain it as soon as possible and within 24 hours for suspected MSCC. Do not send the patient to a service unable to deliver emergency imaging without an agreed transfer plan. If MRI is contraindicated, CT is used and CT myelography is considered only after specialist discussion.

Movement safety is active treatment. If neurological signs occur with suspected instability, start immobilisation immediately. Keep the spine aligned and initially supine when tolerated, using log rolling for necessary care. Severe pain on movement without neurology also supports temporary protection while expert advice is obtained. Prolonged flat positioning can worsen breathing, aspiration, delirium and pressure damage, so the MSCC team should individualise tilt, sitting and mobilisation promptly from imaging, symptoms and stability.

Assess stability clinically and anatomically. The Spinal Instability Neoplastic Score combines location, mechanical pain, lesion quality, alignment, collapse and posterolateral involvement and helps structure referral. It does not determine treatment alone. CT defines cortex, posterior elements and surgical instrumentation corridors, while MRI shows cord and epidural disease. A spine can be neurologically compressed without gross instability, or mechanically unstable before neurological deficit; both dimensions enter the decision.

Surgery provides direct decompression, tissue diagnosis and stabilisation and is favoured when the patient can benefit from neurological recovery or durable mechanical control, particularly with instability, radioresistant tumour, uncertain histology or bony retropulsion. Timing is urgent and should not be rejected solely from an arbitrary duration of paralysis. When surgery is unsuitable, NICE recommends urgent radiotherapy, generally as soon as possible and within 24 hours of the decision. Fractionation reflects prognosis, prior radiation and treatment field.

Supportive care begins beside emergency treatment. Catheterise confirmed retention with a plan for review, institute bowel care, pressure-relieving surfaces and regular skin inspection, assess VTE and bleeding risk and provide respiratory support. Rehabilitation physicians, physiotherapists and occupational therapists set transfer, wheelchair, brace and home goals early. Continue tumour-specific systemic and bone-modifying treatment after acute control. Explain recurrence symptoms and ensure one named team owns steroid taper, wound or radiation review and neurological follow-up.

Key points

Cancer plus new weakness, gait change, sensory loss or sphincter disturbance is MSCC until proved otherwise and requires immediate coordinator contact.
Gold-standard imaging is whole-spine MRI, completed urgently and no later than 24 hours whenever metastatic cord compression is suspected.
Do not use plain spinal radiography to exclude MSCC; CT is used for bony stability or when MRI is contraindicated, with myelography only in specialist settings.
For neurological symptoms or signs, give dexamethasone 16 mg promptly, continue 16 mg daily while definitive surgery or radiotherapy is awaited and monitor glucose and gastrointestinal risk.
Begin immobilisation without delay when neurological features accompany suspected instability; individualise supine positioning if pain, breathing or pressure risk makes it harmful.
Use the Spinal Instability Neoplastic Score as decision support alongside clinical and imaging judgement, not as a substitute for spinal surgical review.
Definitive first-line local treatment is urgent decompression with stabilisation for suitable patients or urgent radiotherapy when surgery is unsuitable.
Start bladder, bowel, pressure-area, thrombosis and rehabilitation care at presentation because preserving survival without function is an avoidable failure.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Vertebral metastatic disease

Breast, prostate, lung, kidney and other cancers seed vertebral marrow, most often in thoracic, lumbar and cervical regions with red marrow.

Epidural tumour extension

Tumour passes from the vertebral body through the posterior cortex or neural foramen into the epidural space and compresses neural tissue.

Pathological vertebral collapse

Lytic or mixed destruction removes anterior and middle-column support, producing kyphosis, retropulsion and dynamic compression during movement.

Haematological infiltration

Myeloma and lymphoma can replace marrow, form epidural soft tissue and fracture vertebrae, with corticosteroid timing linked to diagnostic plans.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Venous and vascular compromise
Epidural pressure first impedes venous outflow, causing oedema, then reduces arterial perfusion and creates irreversible cord infarction if compression persists.
2
Mechanical instability
Loss of vertebral integrity permits painful translation or collapse under physiological load, causing repeated deformation even before fixed neurological deficit appears.
3
Cord and root dysfunction
Compression disrupts long motor and sensory tracts and segmental roots, creating weakness, sensory level, radicular pain and upper-motor-neurone signs below the lesion.
4
Autonomic pathway injury
Later or severe compression impairs bladder, bowel and sexual pathways; painless retention and overflow can be mistaken for medication or constipation effects.
5
Time-dependent reversibility
Ambulatory function at treatment strongly predicts outcome because prolonged severe compression permits demyelination, axonal loss and ischaemic necrosis that decompression cannot reverse.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Progressive mechanical spinal pain

Pain intensified by movement, cough, strain or upright posture can mark vertebral instability before neurological loss.

New gait deterioration

Leg heaviness, falls or inability to climb stairs may precede obvious power loss on a brief bed examination.

Sensory level or radiculopathy

A trunk band, dermatomal shooting pain or a reproducible sensory boundary localises cord or root involvement.

Upper-motor-neurone signs

Spasticity, brisk reflexes, clonus and extensor plantar responses below the lesion support cord-tract compression.

Autonomic dysfunction

Loss of bladder awareness, hesitancy, retention, overflow or new bowel dysfunction signals advanced neurological involvement.

Unstable vertebral phenotype

Collapse, deformity, translation and posterior-element destruction with load pain indicate mechanical instability requiring spinal review.

Red flags requiring action

New weakness, falls, gait change, sensory level or limb numbness in a person with current or previous cancer is possible cord compression.
Urinary retention, overflow, loss of bladder sensation, faecal incontinence or saddle sensory change suggests cord or cauda-equina dysfunction.
Severe progressive night spinal pain, band-like radicular pain, pain on coughing or movement and focal tenderness can precede neurological loss.
Mechanical pain that prevents sitting, standing or turning suggests vertebral instability and requires movement protection while stability is assessed.
A normal spinal radiograph cannot exclude epidural tumour, marrow replacement or cord compression and must not delay emergency MRI.
When lymphoma or myeloma is suspected without neurological signs, discuss corticosteroid timing with haematology because treatment can reduce diagnostic tissue yield.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Gold-standard whole-spine MRI within 24 hoursFirst step
Why
Identify all levels of epidural compression, cord signal, marrow disease, fracture and soft-tissue extent.
Interpretation and limitations
Use complete sagittal whole-spine and targeted axial sequences; the clinically painful level may not be the only consequential site.
02
CT for stability and operative anatomy
Why
Define vertebral cortex, collapse, alignment, posterior elements and fixation corridors and provide an alternative when MRI is impossible.
Interpretation and limitations
CT cannot match MRI for cord and epidural soft tissue; CT myelography requires specialist performance when further canal definition is essential.
03
Repeat neurological and bladder assessment
Why
Detect progression during imaging and transfer and establish a baseline for treatment response.
Interpretation and limitations
Record power, sensation, reflexes, gait if safe, saddle function and post-void volume rather than simply writing neurology intact.
04
Spinal Instability Neoplastic Score
Why
Structure assessment of location, pain, lesion type, alignment, collapse and posterior-element involvement.
Interpretation and limitations
Use as validated decision support; clinical mechanical pain, imaging and spinal expertise determine protection and surgery.
05
Treatment-safety and histology tests
Why
Assess blood count, renal, liver, calcium, coagulation and glucose and determine whether tissue is needed before treatment.
Interpretation and limitations
Do not postpone neurological rescue for routine bloods; discuss steroid timing before biopsy in suspected haematological disease without neurological deficit.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Degenerative cord or cauda compression

Disc prolapse or stenosis can cause similar deficits, but cancer history and destructive vertebral change mandate the emergency metastatic pathway until imaging clarifies.

Spinal epidural abscess

Fever, bacteraemia, immunosuppression and raised inflammation suggest infection, which also requires urgent MRI, cultures and surgical review.

Vertebral compression fracture

Osteoporotic collapse causes acute pain but no epidural tumour; MRI distinguishes oedema, posterior-wall compromise and malignant marrow replacement.

Treatment-related neuropathy

Chemotherapy can cause symmetrical distal sensory loss and weakness without a sensory level, yet it must not explain away new back pain or sphincter change.

Intramedullary or leptomeningeal tumour

Multilevel, cranial or non-mechanical neurological patterns may reflect disease within cord or meninges and need neuroradiology and oncology assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Immediate neurologicalActivate MSCC rescueFirst stepCancer and new weakness, gait, sensory or bladder or bowel dysfunction indicate possible compression.

1Contact the MSCC coordinator and spinal or oncology service immediately and document the time and neurological baseline.
2DefinitiveGive dexamethasone 16 mg promptly, then 16 mg daily while definitive treatment is awaited, with glucose and gastric protection.
3Immobilise if instability is suspected, transfer with alignment protection and individualise position for breathing and pressure safety.
4EscalationObtain whole-spine MRI as soon as possible and within 24 hours, escalating any deterioration during the wait.

02Imaging and stabilitySeparate compression from collapseMRI confirms spinal metastatic disease or symptoms suggest mechanical instability.

1Review all spinal levels for epidural compression, cord signal, vertebral fracture and non-contiguous disease.
2Add CT where cortex, alignment or instrumentation planning requires it and calculate SINS as structured support.
3Maintain or relax movement restriction only after specialist stability advice, not from pain improvement after steroid.
4DefinitiveObtain biopsy through the planned route when histology is unknown and tissue will change definitive treatment.

03Definitive surgeryDecompress and stabilise selected patientsDefinitiveNeurological recovery or durable stability is achievable and operative benefit exceeds burden.

1Decide urgently through spinal surgery, oncology and radiology using neurology, stability, tumour biology, prior radiation and systemic prognosis.
2Perform decompression and stabilisation with tissue sampling as indicated, avoiding delay for arbitrary duration rules alone.
3Plan postoperative radiotherapy or systemic control after wound assessment according to histology and margin.
4Begin mobilisation, bladder and bowel rehabilitation and thrombosis prevention as soon as construct and physiology permit.

04Definitive radiotherapyTreat urgently when surgery is unsuitableDefinitiveMSCC is confirmed but operative decompression or stabilisation is not appropriate.

1Deliver urgent radiotherapy as soon as possible and within the NICE timeframe after the treatment decision.
2Select fractionation from prior radiotherapy, prognosis, field size and risk of adverse effects.
3DefinitiveContinue dexamethasone during the bridge, then taper gradually once definitive treatment is established.
4Reassess power, sensation, bladder, pain and stability and provide brace or mobility guidance rather than assuming radiation makes movement safe.

Key medicines and prescribing safety3 treatments · regimens, roles and cautions

Reduces tumour-associated oedema and can preserve or improve neurological function while definitive decompression or radiation is arranged.

Dexamethasone for neurological MSCC

Give 16 mg orally as soon as possible, or an equivalent parenteral dose when oral administration is unsuitable, then continue 16 mg daily while surgery or radiotherapy is awaited.

Monitor capillary glucose, infection, delirium, myopathy and gastrointestinal risk; provide proton-pump protection and taper after treatment begins, stopping safely if MSCC is excluded.

Provides gastric protection during the acute corticosteroid course recommended in the NICE MSCC pathway.

Omeprazole during high-dose corticosteroid treatment

Use omeprazole 20 mg orally once daily while high-dose dexamethasone is required, adjusting choice and route for interactions, swallowing and local formulary guidance.

Review magnesium and infection risk with prolonged use and interactions where relevant; it does not remove the need to minimise steroid duration.

Reduces thrombosis during cancer-related paresis, immobility and hospital treatment.

VTE prophylaxis when risk outweighs bleeding

Prescribe the locally approved pharmacological regimen after assessing weight, renal function, platelet history, spinal procedure timing and bleeding risk, with mechanical measures when appropriate.

Coordinate doses around neuraxial procedures and surgery and reassess after bleeding, thrombocytopenia or mobility change; spinal haematoma risk requires exact timing.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Permanent paralysis

Delayed recognition can convert reversible weakness into irreversible loss of walking, transfers and independent pressure relief.

Bladder and bowel failure

Retention, infection, incontinence and constipation require catheter, bowel and skin plans and can persist despite successful local tumour control.

Pressure injury and thrombosis

Immobility, sensory loss and cancer combine to increase skin breakdown, venous thromboembolism, chest infection and deconditioning.

Spinal deformity and pain

Progressive collapse produces kyphosis, instability and chronic mechanical pain even when radiotherapy controls the epidural component.

Corticosteroid toxicity

Hyperglycaemia, infection, delirium, proximal weakness, gastritis and adrenal suppression complicate high-dose treatment unless monitored and tapered appropriately.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Repeat and time-stamp power, sensation, reflexes, gait when safe, saddle function and bladder findings during transfer and treatment delay.
Monitor capillary glucose, infection, mental state, proximal weakness and gastrointestinal symptoms during dexamethasone therapy.
Inspect skin and pressure points at every turn and document how spinal alignment is maintained during care.
Review catheter indication, bowel regimen, respiratory function, VTE risk and pain control daily.
After surgery or radiotherapy, track neurological recovery, stability advice, loading, brace use and rehabilitation goals.
Ensure steroid taper, oncology control, wound or radiation review and recurrence safety-netting each have named ownership at discharge.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Walking status predicts recovery

Patients treated while ambulant have a better chance of retaining walking, making early symptom recognition clinically decisive.

Whole spine means whole spine

A painful level can distract from another silent site that actually threatens the cord or changes radiation planning.

Compression and instability differ

Epidural tumour can compress a stable spine, while destructive collapse can be mechanically dangerous without neurological signs.

Steroid is a bridge

Dexamethasone reduces oedema but neither removes tumour nor reconstructs a failing vertebral column.

Flat is not forever

Initial alignment protection must be balanced quickly against respiratory, aspiration, delirium and pressure harms through specialist stability advice.

Lymphoma changes biopsy timing

Without neurological compromise, corticosteroid can obscure haematological tissue diagnosis, so haematology advice should precede treatment when feasible.

11Common pitfallsFrequent interpretation and management errors.

01
Sending neurological cancer symptoms through routine back-pain imaging or outpatient oncology review.
02
Using plain radiographs to exclude epidural compression or marrow disease.
03
Ordering MRI of only the painful level and missing non-contiguous cord-threatening disease.
04
Giving dexamethasone but failing to activate definitive surgery or radiotherapy in parallel.
05
Keeping every patient flat for days without reassessing respiratory, pressure and stability consequences.
06
Mobilising after pain improves on steroid without specialist evaluation of vertebral mechanical stability.