Metastatic spinal cord compression

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

Metastatic spinal cord compression occurs when tumour, vertebral collapse or pathological bone displaces into the spinal canal and compromises the cord or cauda equina. Thoracic disease is common, but any level can be affected and multiple non-contiguous metastases frequently coexist. Solid tumours such as breast, prostate and lung account for many cases; myeloma and lymphoma can produce vertebral and epidural disease through different biological routes. Sometimes MSCC is the first presentation of cancer, so absence of a known primary must not delay the emergency pathway.

Pain usually precedes neurological loss. Concerning pain is severe, progressive, nocturnal, radicular, worsened by coughing or straining, or mechanically triggered by sitting, standing or turning. Weakness, gait disturbance and sensory change follow as venous congestion, oedema and eventually arterial ischaemia damage neural tissue. Bladder or bowel dysfunction is late and ominous, but cauda-equina disease may present with retention or saddle sensory loss. Once established infarction occurs, decompression may prevent further harm without restoring lost function.

The diagnostic reference examination is MRI of the whole spine. Whole-spine coverage is necessary because symptoms can mislocalise and additional levels affect the treatment field. NICE requires suspected MSCC with neurological symptoms or signs to be imaged as soon as possible and always within 24 hours. When MRI is contraindicated, specialist CT with reconstruction and sometimes CT myelography is used. Plain radiographs have no exclusion role. Imaging must describe level, epidural disease, cord signal, number of levels, vertebral collapse and stability features, and should be available to spinal surgery and clinical oncology together.

Immediate management protects residual neurological function while a definitive plan is made. NICE advises dexamethasone 16 mg promptly for neurological symptoms or signs and continuation at 16 mg daily while awaiting surgery or radiotherapy, with taper after definitive treatment begins or if MSCC is excluded. Selected patients benefit from urgent decompression and stabilisation, particularly when instability, radioresistant disease, tissue need or a single compressive level makes surgery worthwhile. Others receive urgent radiotherapy. Decisions integrate neurological duration, stability, cancer biology, systemic burden, performance, prognosis and the patient's goals.

Key points

MSCC is cord or cauda-equina compression by epidural tumour, vertebral collapse or pathological fracture; neurological function at definitive treatment is the strongest practical predictor of recovery.
Key symptoms are severe progressive spinal or radicular pain, pain on movement or strain, weakness, gait change, sensory loss and new bladder or bowel dysfunction.
Contact the named MSCC pathway immediately; do not send a patient with neurological signs through a routine back-pain or outpatient cancer referral.
Gold-standard imaging is MRI of the whole spine, performed as soon as possible and always within 24 hours for suspected MSCC; do not use plain radiographs to exclude it.
If neurological symptoms or signs are present, give dexamethasone 16 mg orally or equivalent parenteral dose as soon as possible, then continue 16 mg daily while awaiting surgery or radiotherapy under NICE.
Protect movement when pain suggests instability, but individualise lying flat, log rolling and mobilisation to pain, respiratory risk and specialist stability assessment.
Definitive management is urgent spinal surgery with stabilisation for selected fit patients when decompression and stability offer benefit, or urgent radiotherapy when surgery is unsuitable.
Start rehabilitation, bladder and bowel care, pressure-area protection, thrombosis assessment and realistic goals early rather than waiting for oncological treatment to finish.

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

Vertebral metastatic disease

Breast, prostate, lung, renal and other solid cancers spread haematogenously to vertebral marrow and can extend posteriorly into the epidural space.

Haematological infiltration

Myeloma, lymphoma and leukaemia can infiltrate vertebrae or epidural tissue and cause collapse, soft-tissue mass or multifocal compression.

Pathological fracture and instability

Tumour-driven bone destruction weakens vertebral load bearing, producing collapse, deformity and retropulsed bone that narrows the canal.

Direct or paraspinal extension

A local tumour can invade through a neural foramen or adjacent structure, while leptomeningeal disease creates a different multifocal neurological pattern.

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

1
Epidural space narrowing
Tumour, collapsed vertebral body or displaced bone compresses the cord, cauda equina or exiting roots within a fixed canal.
2
Venous congestion and oedema
Compression obstructs epidural and cord venous drainage, causing vasogenic oedema that can initially respond to corticosteroid while definitive decompression is arranged.
3
Arterial ischaemia
Persistent pressure impairs arterial perfusion, causing infarction, demyelination and irreversible axonal injury; neurological status at treatment strongly predicts outcome.
4
Mechanical instability
Loss of vertebral integrity creates pain and dynamic deformity during loading, with further neurological injury possible during unsupported movement.

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

Malignant spinal pain

Unremitting, progressive, night or radicular pain and pain aggravated by cough, strain or movement should trigger the cancer spinal pathway before weakness develops.

Cord motor syndromeRed flag

Heavy legs, focal weakness, spasticity, hyperreflexia, extensor plantar responses, poor balance or inability to walk indicates long-tract compromise.

Sensory pathway changeRed flag

Numbness, paraesthesia, a truncal sensory level or saddle loss may be subtle and should be mapped and documented before transfer.

Autonomic dysfunctionRed flag

New hesitancy, retention, overflow, incontinence, constipation, faecal loss or sexual dysfunction indicates cord or cauda-equina involvement.

Mechanical instability

Pain sharply worsened by loading, sitting, standing or turning, deformity or collapse suggests a spine that may be unsafe to mobilise without specialist advice.

Occult primary presentation

MSCC with weight loss, a mass, anaemia or hypercalcaemia may reveal an undiagnosed malignancy, but tissue and primary search follow neural rescue.

Red flags requiring action

Progressive bilateral or unilateral limb weakness, gait failure or falls with spinal pain requires emergency MSCC assessment.
A sensory level, saddle sensory loss, urinary retention, overflow, faecal incontinence or reduced anal function suggests cord or cauda-equina compromise.
Severe unremitting spinal pain, night pain, pain worsened by movement, cough or strain, or new radicular pain in cancer is suspicious even before deficit.
Rapidly increasing mechanical pain on sitting, standing or turning suggests instability and requires protected movement and specialist review.
Normal plain radiographs or an old reassuring scan do not exclude epidural disease at another spinal level.

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 MRIFirst step
Why
Confirm compression, level, number of lesions, neural signal and vertebral or epidural anatomy for definitive planning.
Interpretation and limitations
Perform as soon as possible and within 24 hours for suspected MSCC. Include sagittal T1 and STIR or equivalent whole-spine sequences with targeted axial images through abnormalities.
02
CT spine with multiplanar reconstruction
Why
Define cortical bone, fracture and surgical anatomy or provide an alternative when MRI is contraindicated.
Interpretation and limitations
CT is valuable for stability and instrumentation planning but is less sensitive for cord and epidural soft tissue; CT myelography is reserved for specialist circumstances.
03
Documented neurological examination
Why
Establish baseline motor, sensory, reflex, gait and sphincter function and detect progression.
Interpretation and limitations
Record power by myotome, sensory level, perineal findings when indicated, anal function and bladder residual; trend changes during transfer and treatment.
04
Spinal stability assessment
Why
Estimate movement-related risk and the need for surgical stabilisation or external support.
Interpretation and limitations
Use pain, alignment, collapse and posterior-element imaging with a validated system such as SINS as an aid; the spinal team makes the final stability decision.
05
Bladder scan and renal assessment
Why
Detect retention and prevent overdistension or upper-tract injury.
Interpretation and limitations
A raised post-void residual supports autonomic dysfunction but medication, pain and constipation can contribute; catheterise when clinically required without delaying MRI.
06
Cancer staging and tissue strategy
Why
Define tumour biology and prognosis after the immediate compression pathway is activated.
Interpretation and limitations
Use prior histology when reliable; obtain tissue during surgery or from the safest site when the primary is unknown or biology may change treatment, without delaying neural rescue.

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

Degenerative cord or root disease

Disc prolapse, cervical myelopathy and lumbar stenosis cause pain or deficit, but cancer history, night pain and rapid progression lower the threshold for whole-spine MRI.

Spinal infection

Discitis or epidural abscess causes pain, fever and neurological loss, particularly during immunosuppression; blood cultures and infection review accompany urgent MRI.

Non-compressive cancer neurology

Leptomeningeal spread, paraneoplastic neuropathy, treatment neurotoxicity and brain metastasis can alter gait or sphincter function without a focal epidural lesion.

Benign vertebral fracture

Osteoporotic collapse can cause severe pain, but destructive imaging, soft-tissue mass or disproportionate neurological findings requires malignant and myeloma assessment.

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

01SuspectActivate the MSCC pathwayFirst stepCancer coexists with suspicious spinal pain, neurological symptom or sphincter change.

1Contact the named MSCC coordinator or on-call oncology and spinal service immediately and communicate time of onset, walking status, neurological findings, pain and current cancer treatment.
2Assess ABCDE, give analgesia, map motor, sensory and bladder function and protect the spine when movement-provoked pain or instability is suspected.
3Give dexamethasone promptly for neurological symptoms or signs and arrange whole-spine MRI as soon as possible and within 24 hours.

02Image and decideChoose surgery or radiotherapyMRI confirms epidural compression or unstable metastatic vertebral disease.

1Review imaging urgently with spinal surgery and clinical oncology, incorporating stability, duration and severity of deficit, disease radiosensitivity, systemic burden, performance and patient priorities.
2Offer decompression and stabilisation when a patient can benefit from mechanical and neurological rescue, obtaining tissue during surgery when diagnosis is uncertain.
3If surgery is unsuitable, deliver urgent radiotherapy under the MSCC protocol; use systemic therapy alone only for selected highly responsive disease with explicit specialist neurological surveillance.

03SupportPrevent secondary disabilityDefinitiveThe patient has pain, weakness or immobility while definitive treatment is delivered.

1Provide bladder and bowel management, pressure-area protection, thrombosis assessment, respiratory care, adequate analgesia and glucose and gastric review during corticosteroid treatment.
2Begin physiotherapy and occupational assessment as soon as stability permits, selecting graded mobilisation, brace, transfer equipment and home adaptation from function and goals.
3Discuss prognosis and achievable outcomes honestly, involving rehabilitation and palliative care alongside active cancer treatment rather than after it fails.

04After treatmentTaper safely and monitor recoverySurgery or radiotherapy has started or imaging excludes MSCC.

1Reduce dexamethasone gradually after surgery or radiotherapy begins, or stop it if MSCC is excluded, adjusting the taper for duration, symptoms and adrenal risk.
2EscalationRepeat neurological and pain assessment and obtain postoperative or response imaging when the specialist plan indicates; any new deterioration requires immediate re-escalation.
3Coordinate bone-targeted and systemic cancer treatment, falls and fracture prevention, ongoing rehabilitation and a clear urgent-contact plan for new spinal symptoms.

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

Reduces vasogenic oedema around the compressed cord and may preserve or improve neurological function while definitive decompression is arranged.

Dexamethasone for neurological MSCC

Give dexamethasone 16 mg orally, or an equivalent parenteral dose, as soon as possible when neurological symptoms or signs are present, then continue 16 mg daily while awaiting surgery or radiotherapy before a specialist-guided taper.

Monitor glucose, infection, delirium, proximal weakness, gastrointestinal risk and sleep. Do not use routine high-dose steroid in every asymptomatic vertebral metastasis; if MSCC is excluded, stop or taper according to exposure and adrenal risk.

Controls malignant and mechanical pain during imaging, transfer and definitive treatment and permits safer assessment and care.

Opioid analgesia

For severe pain in an opioid-naive adult, a common starting approach is immediate-release oral morphine 2.5 to 5 mg every 4 hours with the same dose available for breakthrough, titrated to response and renal function.

Prescribe laxative and antiemetic when indicated, monitor sedation and respiration and select an alternative in significant renal impairment; analgesic response never excludes instability or compression.

Reduces immobility- and cancer-associated thrombosis during admission and neurological rehabilitation.

Venous thromboembolism prophylaxis

Use the current hospital low-molecular-weight heparin prophylactic regimen adjusted for body weight, renal function, platelets, bleeding, surgery timing and neuraxial procedures when risk assessment supports treatment.

Coordinate with spinal surgery and radiotherapy procedures; active bleeding, severe thrombocytopenia and neuraxial timing can contraindicate or modify pharmacological prophylaxis.

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

Permanent paralysis

Untreated ischaemic cord injury can permanently remove motor, sensory and autonomic function; the ability to walk before treatment is a major prognostic factor.

Bladder bowel and sexual dysfunction

Autonomic pathway injury produces retention, incontinence, constipation and sexual impairment, with infection and renal consequences from chronic bladder dysfunction.

Venous thromboembolism and pressure injury

Immobility, malignancy and corticosteroids increase thrombosis, skin breakdown, chest infection and deconditioning unless prevention and rehabilitation begin early.

Spinal deformity and chronic pain

Collapse and instability can leave kyphosis, load-related pain and ongoing brace or reconstructive needs even after tumour control.

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

Repeat documented motor, sensory, gait and sphincter assessment during transfer, after imaging and after definitive treatment; escalate any deterioration immediately.
Track pain at rest and with movement because increasing load-related pain can indicate instability even when neurological power is unchanged.
Monitor bladder volume, catheter need, bowel function, skin integrity, thrombosis risk, respiratory status and nutrition throughout immobility.
During dexamethasone, review glucose, infection, mental state, sleep, proximal strength and gastric risk and document the taper and adrenal safety plan.
After surgery, monitor wound, stability, neurological recovery and rehabilitation; after radiotherapy, review pain flare, marrow exposure and response.
Ensure the patient and carers have a rapid return route for new pain, weakness, sensory or bladder change at any spinal level.

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

Pain is the rescue window

Suspicious spinal pain often appears before weakness, creating the best opportunity for imaging while walking function can still be preserved.

Whole spine means whole spine

A symptom level may not identify every metastasis, and a second lesion can change the surgical approach or radiotherapy field.

MRI is the reference test

Plain films cannot assess epidural soft tissue or safely exclude cord compression, while CT is primarily an alternative and stability tool.

Steroid is a bridge

Dexamethasone reduces oedema but does not stabilise a fractured vertebra or remove tumour; definitive planning remains urgent.

Walking status predicts outcome

Patients ambulant at treatment are more likely to remain ambulant, which is why delay until paralysis is clinically costly.

11Common pitfallsFrequent interpretation and management errors.

01
Sending neurological symptoms through a routine two-week cancer or musculoskeletal referral.
02
Using a normal plain radiograph to rule out MSCC.
03
Requesting MRI of only the painful region when whole-spine imaging is required.
04
Delaying dexamethasone in a patient with neurological symptoms while waiting for MRI.
05
Mobilising severe movement-provoked pain without considering instability and protected transfer.
06
Treating dexamethasone as definitive therapy and delaying surgery or radiotherapy review.
07
Stopping prolonged corticosteroid abruptly without considering adrenal suppression.