Synopsis
Recognise metastatic spinal instability and neurological compression early, activate the NICE emergency pathway and coordinate safe positioning, whole-spine MRI, corticosteroid and definitive surgery or radiotherapy.
- 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.
Key red flags
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.
Investigation priorities
Identify all levels of epidural compression, cord signal, marrow disease, fracture and soft-tissue extent.
Management branches
Cancer and new weakness, gait, sensory or bladder or bowel dysfunction indicate possible compression.
- Contact the MSCC coordinator and spinal or oncology service immediately and document the time and neurological baseline.
- Give dexamethasone 16 mg promptly, then 16 mg daily while definitive treatment is awaited, with glucose and gastric protection.
- Immobilise if instability is suspected, transfer with alignment protection and individualise position for breathing and pressure safety.
- Obtain whole-spine MRI as soon as possible and within 24 hours, escalating any deterioration during the wait.