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 or unstable bone
Back pain with neurological change, or focal bone pain with deformity, inability to weight bear or impending collapse, requires urgent imaging and specialist treatment.
Action: Immobilise and handle safely, document a full neurological and limb assessment and contact the acute oncology, spinal or orthopaedic service. For suspected neurological MSCC, obtain MRI as soon as possible and always within 24 hours and give dexamethasone 16 mg promptly when indicated while definitive surgery or radiotherapy is arranged.
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.
Key red flags
Severe progressive back pain, night pain, radicular symptoms or pain on coughing with new weakness, gait or sphincter change suggests MSCC.
Pathological fracture
Sudden pain, deformity, shortening, crepitus or inability to weight bear requires immobilisation and urgent orthopaedic assessment.
Investigation priorities
01
First-line structural and neurological examinationFirst stepFirst line
Painful metastasisRelieve pain and obtain definitive local control
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.
Key medicines
Dexamethasone for neurological MSCCGive 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.
Ibuprofen for selected bone painWhen 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.
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.