Synopsis
Recognise malignant bone pain and its structural and metabolic emergencies, select imaging by clinical question, combine analgesia with radiotherapy or stabilisation, and prevent skeletal complications through tumour-specific multidisciplinary care.
- 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.
Key red flags
Severe progressive back pain, night pain, radicular symptoms or pain on coughing with new weakness, gait or sphincter change suggests MSCC.
Sudden focal pain, deformity, inability to weight bear or pain on minimal load suggests pathological fracture or an imminently unstable long bone.
Confusion, vomiting, constipation, polyuria, dehydration or arrhythmia with bone disease may indicate malignant hypercalcaemia.
Fever, focal bony tenderness, prosthesis or immunosuppression requires consideration of osteomyelitis or septic arthritis rather than metastasis alone.
Pain flaring after radiotherapy can occur, but new neurology or mechanical instability must not be attributed to an expected flare.
Bisphosphonate or denosumab treatment with jaw pain, exposed bone or hypocalcaemic symptoms requires urgent treatment-specific review.
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.
Investigation priorities
Assess focal tenderness, deformity, loading, range, distal neurovascular status, spinal percussion, power, sensation, reflexes, gait and sphincter symptoms.
Management branches
Focal bone pain is clinically or radiologically attributed to metastasis without current fracture or cord compression.
- Assess structural and neurological risk, give mechanism-based analgesia and obtain imaging appropriate to the painful site and tumour pathway.
- Refer promptly for palliative radiotherapy, with single-fraction 8 Gy considered for uncomplicated pain, or tumour-specific systemic and antiresorptive treatment.
- Review pain, function, flare and analgesic toxicity over ensuing days and weeks and consider re-irradiation or another diagnosis for non-response.