Synopsis
Detect malignant spinal pain before loss of walking or sphincter function, activate the MSCC pathway and coordinate steroid, imaging, stability and definitive oncological treatment.
- Metastatic epidural disease most often spreads from a vertebral metastasis, causing collapse, instability and compression; prostate, breast, lung, kidney, thyroid and myeloma are important sources.
- Pain is commonly the earliest feature: severe unremitting, progressive, night, mechanical or cough-and-strain pain, local tenderness or radicular pain in a person with cancer warrants urgent action.
- Weakness, gait disturbance, limb numbness, a sensory level and bladder or bowel dysfunction indicate established neural compromise and should be reported as MSCC immediately.
Key red flags
A patient with cancer develops severe progressive, unremitting or nocturnal spinal pain, pain worse on movement, coughing or straining, focal tenderness or new radicular pain before objective weakness appears.
Investigation priorities
Confirm level and degree of neural compression, cord signal, epidural mass and additional vertebral metastases for treatment planning.
Management branches
Cancer is known or suspected and new weakness, gait, sensory or sphincter dysfunction suggests compression.
- Contact the designated MSCC service immediately, perform a timed neurological and stability assessment and immobilise when neurological signs or movement pain suggest instability.
- Start dexamethasone 16 mg orally or equivalent parenterally as soon as possible unless contraindicated, add glucose and gastric monitoring and arrange whole-spine MRI within 24 hours.
Key medicines
DexamethasoneGive 16 mg orally or equivalent parenterally promptly, then 16 mg daily while definitive treatment is awaited.
AnalgesiaUse individualised multimodal treatment with rapid access to opioid titration for severe malignant pain.