Synopsis
Recognise cord or cauda-equina compromise before irreversible neurological loss, protect the spine, obtain whole-spine MRI within the emergency window and coordinate definitive surgery, radiotherapy and cancer care.
- 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.
Key red flags
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.
Heavy legs, focal weakness, spasticity, hyperreflexia, extensor plantar responses, poor balance or inability to walk indicates long-tract compromise.
Numbness, paraesthesia, a truncal sensory level or saddle loss may be subtle and should be mapped and documented before transfer.
New hesitancy, retention, overflow, incontinence, constipation, faecal loss or sexual dysfunction indicates cord or cauda-equina involvement.
Investigation priorities
Confirm compression, level, number of lesions, neural signal and vertebral or epidural anatomy for definitive planning.
Management branches
Cancer coexists with suspicious spinal pain, neurological symptom or sphincter change.
- Contact 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.
- Assess ABCDE, give analgesia, map motor, sensory and bladder function and protect the spine when movement-provoked pain or instability is suspected.
- Give dexamethasone promptly for neurological symptoms or signs and arrange whole-spine MRI as soon as possible and within 24 hours.