01OverviewDefinition, clinical context and the essential points that orientate the chapter.
Malignant bone pain is usually deep, localised and worse with movement or loading, but vertebral disease may begin as vague night pain or radicular discomfort. Ask about ability to stand, transfer, cough and sleep, and examine focal tenderness, deformity, neurological function and distal neurovascular status. A patient who can no longer weight bear needs structural assessment before repeated mobilisation.
Spinal pain deserves a low threshold for emergency review. NICE identifies severe unremitting, progressive, mechanical or night pain, local tenderness, claudication and pain worsened by coughing or straining as concerning in a person with cancer. Add limb weakness, sensory loss, gait disturbance or bladder or bowel dysfunction and manage as an oncological emergency. MRI should not be delayed by a trial of analgesia or a normal plain film.
Imaging should answer a question. Plain radiographs help identify fracture and gross cortical loss in a painful long bone. CT shows cortical anatomy and supports operative or radiotherapy planning. MRI identifies marrow, epidural, neural and soft-tissue disease and is the reference for MSCC. Nuclear medicine and PET assess distribution in selected cancers but may not define mechanical stability. Review images with oncology, radiology and orthopaedics rather than relying on a report phrase alone.
Radiotherapy reduces pain by controlling local tumour and modifying the bone microenvironment. For an uncomplicated painful metastasis without cord compression or fracture requiring surgery, a single 8 Gy fraction is widely used and reduces travel burden. Benefit often begins over days and continues over weeks; not every patient responds and transient flare can occur. Re-irradiation may be possible after specialist review.
Surgery or stabilisation comes first when structure is failing. Long-bone fracture-risk tools such as Mirels can support but not replace orthopaedic judgment. Vertebral instability, radioresistant disease, tissue diagnosis, prognosis, neurological function and surgical fitness influence spinal decisions. Analgesia, handling precautions, thromboprophylaxis and rehabilitation continue while the definitive plan is made.
Antiresorptive therapy is tumour specific. Zoledronic acid and denosumab can reduce skeletal-related events in eligible metastatic disease or myeloma, with regimens determined by oncology protocols. Check calcium, vitamin D, renal function for bisphosphonate, dental health and jaw symptoms. Correct hypocalcaemia and arrange dental assessment when feasible without delaying urgent oncological treatment.
Pain control remains active during investigation. Use an opioid for severe nociceptive pain, add a short NSAID trial only when renal, gastrointestinal, bleeding and cardiovascular risks permit, and treat a neuropathic component separately. Provide pressure-relieving positioning, mobility aids, safe transfer advice and psychological support. Reassess after radiotherapy or fixation and reduce analgesia if tumour treatment succeeds.
Key points
- Characterise focal ache, night pain, movement pain, weight-bearing ability, neurological symptoms and recent cancer trajectory and examine the painful structure.
- First-line action is emergency triage for MSCC, fracture and hypercalcaemia before routine analgesic escalation.
- Plain radiography can show fracture or major cortical destruction but a normal film does not exclude early metastasis or cord-threatening disease.
- MRI of the whole spine is the gold-standard imaging pathway for suspected MSCC and should occur as soon as possible and within 24 hours when neurological signs are present.
- For neurological MSCC, NICE recommends dexamethasone 16 mg orally or equivalent parenteral dose as soon as possible, continued daily while awaiting surgery or radiotherapy unless contraindicated or revised by the specialist team.
- Palliative external-beam radiotherapy is first-line definitive analgesic treatment for many uncomplicated painful bone metastases; a single 8 Gy fraction is a standard evidence-based regimen.
- Mechanical instability or impending long-bone fracture needs orthopaedic or spinal stabilisation assessment before radiotherapy alone.
- Analgesia is multimodal: opioid, short NSAID trial when safe, neuropathic adjuvant, positioning, equipment and disease treatment each address different components.
- Bisphosphonates or denosumab prevent skeletal events in selected tumour pathways but do not replace urgent fracture, cord-compression or pain treatment.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Bone metastasis
Breast, prostate, lung, renal and thyroid cancers commonly spread to bone, but almost any malignancy can produce focal or multifocal skeletal disease.
Myeloma and primary bone disease
Plasma-cell neoplasia and primary bone tumours cause lytic injury, marrow expansion, fracture and pain through distinct oncological pathways.
Treatment-related fragility
Hormone deprivation, corticosteroids, menopause, immobility and malnutrition reduce bone strength and can cause insufficiency fracture alongside metastatic disease.
Non-malignant mimics
Osteoporosis, arthritis, infection, trauma, Paget disease and referred visceral or neuropathic pain remain important explanations in a person with cancer.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Osteoclast activation
Tumour mediators and altered RANK-ligand signalling stimulate resorption, acidify the local environment and activate nociceptors in mineralised tissue and marrow.
- 2Periosteal and marrow pressure
Expanding tumour, oedema and cortical distortion stimulate richly innervated periosteum, producing deep focal ache and tenderness.
- 3Microfracture and instability
Loss of cortical or trabecular strength creates movement-related mechanical pain and can progress to collapse or pathological fracture.
- 4Neural compression
Vertebral collapse, epidural tumour and foraminal extension irritate roots or compress cord and cauda equina, adding neuropathic pain and neurological loss.
- 5Calcium release
Accelerated resorption and tumour humoral factors can raise serum calcium, causing renal, gastrointestinal, cognitive and cardiac complications beyond local pain.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Deep persistent ache, night pain, movement provocation and local tenderness in a person with cancer supports osseous disease.
Severe pain on loading, turning or coughing with relief at rest suggests microfracture, cortical loss or vertebral instability.
Sudden pain, deformity, shortening, crepitus or inability to weight bear requires immobilisation and urgent orthopaedic assessment.
Radicular pain with weakness, gait, sensory, saddle or sphincter change requires immediate MSCC pathway activation.
Thirst, polyuria, constipation, nausea, weakness, confusion and dehydration suggest systemic calcium release and renal injury.
Transient increased pain shortly after treatment can occur, but structural and neurological deterioration must be excluded before reassurance.
05InvestigationsWhat to request, why it matters and how to interpret it.
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
First-line structural and neurological examinationFirst stepFirst line - Why
- Assess focal tenderness, deformity, loading, range, distal neurovascular status, spinal percussion, power, sensation, reflexes, gait and sphincter symptoms.
- Interpretation and limitations
- Instability or neurological deficit determines emergency protection and imaging before routine outpatient work-up.
- 02
Plain radiograph of the painful bone - Why
- Identify pathological fracture, major lytic or blastic change and cortical destruction in a focal long-bone presentation.
- Interpretation and limitations
- A normal radiograph does not exclude early marrow disease, spinal metastasis or a cause outside the imaged field.
- 03
MRI whole spine for suspected MSCC - Why
- Define vertebral, epidural, cord, cauda-equina, multilevel and soft-tissue involvement for definitive treatment planning.
- Interpretation and limitations
- This is the reference-standard investigation and should occur within the NICE urgency window; if MRI is contraindicated, obtain specialist-directed alternative imaging.
- 04
CT for cortical and procedural planning - Why
- Assess bone destruction, vertebral stability and anatomy relevant to biopsy, radiotherapy or fixation.
- Interpretation and limitations
- CT complements rather than replaces MRI when neurological compression is suspected.
- 05
Calcium, renal and metabolic profile - Why
- Detect hypercalcaemia, dehydration, renal impairment and treatment-relevant abnormalities before antiresorptive or analgesic decisions.
- Interpretation and limitations
- Correct albumin-adjusted or ionised calcium interpretation is needed; renal decline also changes opioid and bisphosphonate safety.
- 06
Staging or biopsy review - Why
- Establish disease distribution and tissue diagnosis when a solitary lesion, uncertain primary or management-changing uncertainty exists.
- Interpretation and limitations
- Do not delay stabilisation or MSCC treatment for biopsy when immediate neurological or structural safety is threatened.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Musculoskeletal degeneration
Osteoarthritis, tendon disease and mechanical back pain are common and usually have a reproducible movement and examination pattern without systemic progression.
Pathological fracture
Abrupt severe pain, deformity, crepitus or inability to load an affected limb indicates structural failure requiring immediate protection and imaging.
Spinal cord compression
Radicular or band-like pain with weakness, sensory change, gait impairment or sphincter dysfunction is an oncological emergency.
Bone or joint infection
Fever, inflammatory change, severe focal tenderness and immunosuppression increase the likelihood of osteomyelitis, discitis or septic arthritis.
Neuropathic treatment injury
Plexopathy, peripheral neuropathy and radiation fibrosis can cause limb or axial pain without active osseous progression and need different treatment.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Painful metastasisRelieve pain and obtain definitive local controlFirst stepDefinitiveFocal bone pain is clinically or radiologically attributed to metastasis without current fracture or cord compression.+
- 1Assess structural and neurological risk, give mechanism-based analgesia and obtain imaging appropriate to the painful site and tumour pathway.
- 2Refer promptly for palliative radiotherapy, with single-fraction 8 Gy considered for uncomplicated pain, or tumour-specific systemic and antiresorptive treatment.
- 3Review pain, function, flare and analgesic toxicity over ensuing days and weeks and consider re-irradiation or another diagnosis for non-response.
02Suspected MSCCProtect function within hoursA patient with cancer has spinal pain plus neurological, gait or sphincter symptoms or signs.+
- 1Treat as an oncological emergency, minimise unsafe movement, document neurological baseline and contact the MSCC coordinator or acute oncology team immediately.
- 2Give dexamethasone 16 mg promptly when neurological MSCC is suspected unless contraindicated and arrange whole-spine MRI as soon as possible and within 24 hours.
- 3DefinitiveCoordinate spinal surgery or urgent radiotherapy, taper corticosteroid according to the definitive plan and provide thrombosis, bladder, bowel, skin and rehabilitation care.
03Impending fractureStabilise before collapseA weight-bearing bone has severe mechanical pain, cortical destruction or a fracture-risk assessment suggesting instability.+
- 1Stop unsafe weight bearing, immobilise or support the limb, provide analgesia and obtain urgent orthopaedic and radiological assessment.
- 2Decide prophylactic fixation, arthroplasty or other stabilisation based on site, anatomy, prognosis, tumour sensitivity and patient goals, using radiotherapy in the coordinated sequence.
- 3Plan mobilisation, thromboprophylaxis, equipment and rehabilitation with explicit precautions and follow-up imaging when required.
04Skeletal-event preventionUse antiresorptive therapy safelyThe tumour-specific oncology pathway indicates bisphosphonate or denosumab to reduce future skeletal-related events.+
- 1Check eligibility, renal function, calcium, vitamin D, dental status, previous antiresorptive exposure and expected benefit timeframe.
- 2Give the protocol-selected agent and supplementation with dose and interval determined by cancer type, kidney function and product guidance.
- 3Monitor calcium, renal function where relevant, jaw and thigh symptoms and ongoing skeletal events and suspend or seek specialist review for serious toxicity.
Key medicines and prescribing safety5 treatments · regimens, roles and cautions+
Dexamethasone for neurological MSCC
Give dexamethasone 16 mg orally, or an equivalent parenteral dose, as soon as possible when neurological symptoms or signs of MSCC are present, then continue 16 mg daily while awaiting surgery or radiotherapy unless the specialist pathway changes it.Start glucose and gastrointestinal risk review, monitor infection, delirium and proximal weakness and taper after surgery or at radiotherapy start according to NICE and specialist advice.
Ibuprofen for selected bone pain
When renal, gastrointestinal, cardiovascular and bleeding risk is acceptable, use 200 to 400 mg orally up to three times daily with food for a short goal-directed trial under the BNF and local gastroprotection policy.Avoid in acute kidney injury, active ulcer or bleeding and severe heart failure and review anticoagulants, steroids, frailty and lack of therapeutic response.
Oral morphine for severe bone pain
Use the patient-specific maintenance and breakthrough regimen established by the strong-opioid pathway; for opioid-naive advanced progressive disease with suitable clearance, NICE's example begins with 20 to 30 mg total sustained-release morphine daily plus 5 mg immediate-release rescue.Adjust for frailty and avoid unreviewed use in severe renal impairment; prescribe laxative and monitor sedation, breathing, cognition, nausea and incident-pain overexposure.
Zoledronic acid in an eligible oncology protocol
A common skeletal-event regimen is 4 mg by intravenous infusion every 3 to 4 weeks, but cancer indication, renal dose adjustment, interval and duration must follow the current oncology protocol and product information.Check creatinine, calcium and vitamin D, provide dental risk assessment and monitor acute-phase reaction, hypocalcaemia, renal toxicity, atypical fracture and osteonecrosis of the jaw.
Denosumab in an eligible solid-tumour pathway
For prevention of skeletal-related events in adults with advanced solid-tumour bone involvement, the product regimen is 120 mg subcutaneously every 4 weeks with calcium and vitamin D supplementation unless contraindicated, under oncology supervision.Correct and monitor hypocalcaemia, especially in severe renal disease, assess dental health and jaw symptoms and avoid unplanned discontinuation without oncology review.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Pathological fracture
Cortical destruction can cause sudden limb or vertebral collapse, bleeding, immobility, hospitalisation and loss of independence.
Metastatic cord compression
Epidural disease or collapse can produce irreversible paralysis, sensory loss, pain and bladder, bowel and sexual dysfunction without prompt treatment.
Malignant hypercalcaemia
Raised calcium causes dehydration, renal injury, constipation, delirium, arrhythmia and coma and can accelerate opioid accumulation.
Immobility complications
Pain and instability promote deconditioning, pressure injury, pneumonia, venous thrombosis, constipation, dependence and substantial caregiver strain.
Antiresorptive toxicity
Bisphosphonates and denosumab can cause hypocalcaemia and osteonecrosis of the jaw; bisphosphonates also require renal consideration.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Repeat neurological examination during spinal pain investigation and after treatment because deterioration changes urgency immediately.
- Track weight-bearing ability, transfer pain and focal tenderness as functional measures of stability rather than pain score alone.
- Review radiotherapy response and flare over days to weeks and investigate new or non-improving symptoms rather than escalating indefinitely.
- Monitor calcium, renal function, hydration and cognition when metastatic burden or antiresorptive therapy makes metabolic change likely.
- Check corticosteroid glucose, infection, mood, sleep, proximal power and gastrointestinal risk and ensure a documented taper plan.
- During bisphosphonate or denosumab treatment ask about dental procedures, jaw pain, exposed bone and new thigh or groin pain.
- Reassess analgesic need after local control and reduce opioid or NSAID exposure when benefit permits.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Mechanical pain predicts structure
Pain provoked by loading or turning can signal instability even when background pain is controlled and should not be covered by sedation.
Normal radiograph can mislead
Marrow, epidural and early cortical disease may be occult, so modality follows the suspected complication rather than one reassuring film.
Single fraction reduces burden
Eight-gray single-fraction radiotherapy often provides similar pain relief to longer uncomplicated regimens with fewer hospital visits.
Radiotherapy is not immediate
Interim analgesia and handling precautions remain necessary because meaningful response usually develops over days rather than minutes.
Antiresorptives are preventive
They reduce future skeletal events in selected cancers but do not stabilise an acute fracture or decompress the spinal cord.
Bone and nerve pain coexist
Vertebral disease can require opioid for somatic pain, an adjuvant for radicular pain and urgent structural treatment simultaneously.
11Common pitfallsFrequent interpretation and management errors.
- 01
Calling new spinal pain routine without asking about gait and sphincter function.
- 02
Allowing a normal plain radiograph to exclude MSCC.
- 03
Mobilising a painful weight-bearing limb before assessing structural stability.
- 04
Waiting for MRI before contacting the emergency oncology pathway.
- 05
Using radiotherapy alone for a fracture requiring stabilisation.
- 06
Expecting immediate radiotherapy analgesia and omitting interim treatment.
- 07
Prescribing NSAIDs despite acute kidney injury or major bleeding risk.
- 08
Using corticosteroid indefinitely without glucose, infection and taper review.
- 09
Starting antiresorptive therapy without calcium, renal and dental safety checks.
- 10
Interpreting every post-radiotherapy pain increase as benign flare.