Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Cord compression, unstable pathological fracture or severe hypercalcaemia
New weakness, gait or sphincter change with spinal pain, inability to bear weight through a destructive lesion, or confusion, dehydration, renal injury and rhythm disturbance from raised calcium requires parallel emergency and cancer treatment.
Action: Use ABCDE care, protect a painful unstable spine or limb, provide analgesia and contact the MSCC or orthopaedic-oncology pathway immediately. Arrange whole-spine MRI within 24 hours for suspected cord compression and give dexamethasone 16 mg promptly when neurological signs are present; confirm severe hypercalcaemia, restore volume safely and involve acute oncology for antiresorptive treatment.
Synopsis
Recognise metastatic bone pain before fracture, cord compression or hypercalcaemia, choose imaging and biopsy by the clinical question and combine systemic cancer control, radiotherapy, stabilisation, antiresorptive treatment, analgesia, rehabilitation and dental safety.
Bone metastases most often involve spine, pelvis, ribs and proximal long bones and arise commonly from breast, prostate, lung, renal and thyroid cancers.
Deep progressive night pain is typical; movement- or weight-bearing pain suggests mechanical instability and may precede a pathological fracture.
First-line assessment of a focal symptomatic peripheral site is plain radiography in two planes, but a normal film does not exclude early marrow metastasis.
Key red flags
Progressive unremitting or night bone pain, particularly in spine, pelvis or proximal long bone, requires assessment for metastatic disease and structural failure.
Completed or impending fracture
Sudden deformity or inability to bear weight is a completed fracture; escalating functional pain with major cortical loss may be an impending one.
Investigation priorities
01
First-line two-plane radiographsFirst stepFirst line
Assess a symptomatic long bone or focal peripheral site for lysis, sclerosis, cortical loss, periosteal change and completed fracture.
02
Preferred MRI for marrow and neural diseasePreferred
Detect marrow replacement, soft-tissue extension, occult fracture and epidural, cord, cauda-equina or nerve-root compromise.
Management branches
New focal bone painSeparate uncomplicated pain from structural danger
A patient with known or possible cancer develops persistent localised skeletal pain.
Examine tenderness, load-related pain, gait, limb function and full spinal neurology and ask explicitly about night pain, weakness and bladder or bowel change.
Obtain site-appropriate radiographs and CT or MRI, protect weight bearing when failure is possible and stage the skeleton according to primary tumour biology.
Key medicines
Zoledronic acid for skeletal-event preventionGive zoledronic acid 4 mg intravenously every 3 to 4 weeks in the licensed adult skeletal-event setting, modifying dose and withholding according to renal function and the current product protocol.
Denosumab for skeletal-event preventionGive denosumab 120 mg subcutaneously once every 4 weeks for adults in the licensed and currently funded metastatic-bone population, with calcium and vitamin-D supplementation unless hypercalcaemia makes it inappropriate.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.