Metastatic spinal cord compression

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

Tumour in a vertebral body, epidural space or paraspinal tissue can collapse bone or extend into the canal. Compression impairs venous drainage, produces oedema and then compromises arterial perfusion, causing ischaemic cord injury. Thoracic disease is most common, but lesions can be multiple and symptoms may localise poorly; this is why imaging only the painful segment is unsafe.

Ask every person with current or previous cancer about new back or neck pain and neurological change. Mechanical pain worsens on movement or loading; radicular pain shoots around the chest or down a limb; cord dysfunction causes heaviness, falls, altered sensation, brisk reflexes and a sensory level. Cauda-equina disease may instead cause saddle numbness, lower-motor-neurone weakness, urinary retention or faecal dysfunction.

Contact the local MSCC coordinator or acute oncology service immediately when neurological symptoms or signs are present. Record the exact onset and progression, last safe walking time, bladder volume or catheter status and current anticoagulants. If instability is possible, use supported neutral alignment and log-roll techniques until specialist assessment; give adequate analgesia and explain why movement is being limited.

MRI should be performed as soon as possible and always within 24 hours for suspected MSCC. It should include sagittal T1 and STIR sequences of the whole spine with axial imaging through significant abnormalities. For cancer-related pain that suggests spinal metastasis without cord-compression features, NICE recommends MRI within one week. CT is an alternative when MRI cannot be done and also defines bone for surgical planning.

Dexamethasone reduces oedema around compressed neural tissue. For neurological symptoms or signs, give 16 mg daily promptly, continue while awaiting surgery or radiotherapy and taper after definitive treatment begins. Check glucose, infection, mental state and gastrointestinal risk. Routine steroid use for pain alone is not recommended, although severe pain and suspected haematological malignancy require specialist discussion because steroids can obscure lymphoma or myeloma diagnosis.

Definitive treatment must be decided quickly. Surgery can decompress the cord, obtain tissue and stabilise a mechanically unsafe spine, particularly with a single suitable level, neurological decline and fitness for recovery. If surgery is unsuitable, radiotherapy should usually start urgently and within 24 hours of the decision. Tumour radiosensitivity, previous radiation, burden, prognosis and the person's priorities shape fractionation and intent.

Palliative care runs alongside rescue treatment. Explain realistic possibilities for walking, continence, pain and care needs without promising recovery. Provide analgesia, venous-thromboembolism review, catheter and bowel management, pressure-area protection, physiotherapy and occupational assessment. A person choosing not to pursue surgery or radiotherapy still needs corticosteroid review, symptom control, safe positioning and a clear plan for evolving dependency.

Key points

Metastatic spinal cord compression is an oncological emergency: new weakness, gait change, sensory loss, radicular pain or bladder and bowel dysfunction in a person with cancer needs immediate MSCC-pathway contact.
Pain often precedes neurological loss. Progressive night pain, movement pain, coughing or straining pain and a band-like radicular quality are high-risk patterns.
First-line examination records power, reflexes, sensory level, gait if safe, saddle sensation, anal function when indicated, bladder retention and spinal tenderness without forcing movement.
Gold-standard imaging is urgent MRI of the whole spine with axial sequences through abnormalities; complete it within 24 hours when MSCC is suspected.
Do not use a normal plain spinal radiograph to exclude metastasis or cord compression. Use CT with multiplanar reconstruction when MRI is contraindicated and myelography only after specialist discussion.
Give dexamethasone 16 mg orally, or an equivalent parenteral dose, as soon as possible for neurological symptoms or signs while definitive treatment is arranged.
Protect alignment when instability is suspected, provide analgesia and pressure care, but avoid prolonged flat bed rest once stability and safe mobilisation have been assessed.
Spinal surgical and oncology teams decide decompression or stabilisation versus urgent radiotherapy from neurological trajectory, imaging, mechanical stability, tumour biology, prognosis and patient goals.
Preserve function beyond tumour treatment: plan bladder and bowel care, thrombosis prevention, skin protection, rehabilitation, equipment and discharge support from the start.
Document the pre-treatment neurological baseline and time of every step because delay can convert reversible impairment into permanent paralysis.

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

Vertebral metastatic collapse

Tumour weakens a vertebral body, which collapses or retropulses into the canal and may create both mechanical instability and neural compression.

Epidural tumour extension

Cancer spreads from bone or paravertebral tissue through foramina into the epidural space, narrowing the canal before obvious fracture occurs.

Haematological infiltration

Myeloma, lymphoma and other marrow malignancies can infiltrate vertebrae or epidural tissue, sometimes at several non-contiguous spinal levels.

Treatment and structural contributors

Previous surgery, radiotherapy, osteoporosis and degenerative stenosis can reduce reserve, complicate imaging and influence stabilisation or re-irradiation options.

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

1
Canal encroachment
Expanding tumour, pathological fracture or displaced bone reduces space around the cord, conus or cauda equina.
2
Venous congestion
Epidural pressure obstructs low-pressure venous drainage, producing cord oedema and worsening conduction before arterial flow necessarily fails.
3
Ischaemic neural injury
Persistent pressure compromises capillary and arterial perfusion, causing infarction, axonal loss and progressively less reversible neurological disability.
4
Mechanical instability
Loss of vertebral integrity creates painful abnormal movement and can cause episodic or progressive neural injury during loading or transfers.
5
Multilevel disease
Non-contiguous metastases can compress at more than one level, so the symptomatic level alone cannot define the complete disease burden.

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

High-risk spinal pain

Severe progressive night pain, pain on movement or recumbency and pain provoked by cough, sneeze or strain can precede neurological deficit.

Radicular warning

A band around the chest or abdomen or shooting limb pain suggests nerve-root involvement close to epidural disease.

Early cord dysfunction

Leg heaviness, subtle gait change, falls, reduced dexterity, brisk reflexes or altered plantar responses may occur before complete weakness.

Sensory pathway change

Numbness, paraesthesia, a truncal sensory level or saddle alteration helps localise cord, conus or cauda-equina involvement.

Autonomic dysfunction

New urinary hesitancy or retention, overflow, loss of bladder sensation, constipation or faecal incontinence indicates advanced neural compromise.

Rapid neurological progressionRed flag

Declining power, inability to stand or new sphincter dysfunction demands immediate MSCC coordination and imaging rather than routine outpatient referral.

Red flags requiring action

New limb weakness, gait disturbance or inability to stand in a person with current or previous cancer is an emergency.
Urinary retention, loss of bladder sensation, saddle numbness or faecal incontinence suggests conus or cauda-equina compromise.
A truncal sensory level, bilateral radicular pain or rapidly ascending numbness localises possible cord disease.
Severe movement-related pain or deformity suggests mechanical instability and makes unsupported mobilisation hazardous.
Fever, immunosuppression or recent bacteraemia with spinal pain raises epidural abscess as an equally urgent alternative.
A normal plain radiograph does not exclude vertebral metastasis, epidural tumour or cord compression.
Steroids before tissue diagnosis can complicate suspected lymphoma or myeloma; obtain immediate specialist advice without delaying neural rescue.

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
Immediate neurological and stability assessmentFirst step
Why
Document power, reflexes, sensory level, saddle and sphincter features, gait only if safe, spinal pain, deformity and last functional baseline.
Interpretation and limitations
Progression and instability determine movement precautions, dexamethasone and the urgency of surgical and radiotherapy decisions.
02
Whole-spine MRI within 24 hours
Why
Image sagittal T1 and STIR across the entire spine with axial sequences through significant lesions and compression.
Interpretation and limitations
This is the diagnostic gold standard for suspected MSCC and defines level, multiplicity, soft tissue, cord oedema and treatment anatomy.
03
MRI within one week for pain-only suspicion
Why
Investigate cancer-related pain patterns suggesting spinal metastasis when no cord-compression symptoms or signs are present.
Interpretation and limitations
This earlier pathway can detect metastatic disease before neurological loss; any new deficit immediately changes the deadline to 24 hours.
04
CT with multiplanar reconstruction
Why
Assess bone integrity and surgical anatomy or provide alternative imaging when MRI is contraindicated or impossible.
Interpretation and limitations
CT is strong for fracture and stability but less sensitive for cord, epidural soft tissue and marrow; specialist myelography is rarely needed.
05
Targeted baseline blood assessment
Why
Check full blood count, renal and liver function, calcium, coagulation and glucose for treatment fitness, steroid safety and alternative causes.
Interpretation and limitations
Blood results do not exclude MSCC; they support anaesthetic, contrast, radiotherapy and supportive planning without delaying imaging.
06
Multidisciplinary prognostic and stability tools
Why
Use validated stability and prognosis frameworks alongside tumour biology, performance, disease burden and the person's goals.
Interpretation and limitations
Scores support but never replace specialist judgement, particularly when rapid neurological rescue or pain relief may still be achievable.

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

Benign mechanical back pain

Local movement pain without cancer red flags or neurological findings is common, but a new pattern in cancer still warrants pathway assessment.

Vertebral infection

Fever, bacteraemia risk, inflammatory markers and disc-endplate change suggest discitis or epidural abscess, which can also require emergency decompression.

Degenerative compression

Disc prolapse, stenosis or spondylosis can produce radiculopathy or myelopathy; imaging and cancer context distinguish coincidental disease from metastasis.

Leptomeningeal disease

Multifocal cranial, radicular and cord symptoms without one compressive lesion suggests malignant involvement of meninges and cerebrospinal fluid.

Peripheral or cerebral lesion

Neuropathy, plexopathy, brain metastasis, stroke and medication weakness may mimic cord dysfunction but usually have a different anatomical examination pattern.

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

01Immediate pathwayProtect neurology while obtaining MRIFirst stepA person with cancer develops weakness, gait, sensory or sphincter change suggesting MSCC.

1Contact the named MSCC service immediately, record neurological baseline and timing, assess instability and support alignment while providing adequate analgesia.
2Give dexamethasone 16 mg by a feasible route for neurological symptoms or signs, monitor glucose and obtain whole-spine MRI within 24 hours.
3Send images promptly for spinal surgical and oncology review and communicate the likely options, uncertainty and interim movement plan to patient and team.

02Operative branchSelect surgery for neural rescue and stabilityImaging shows surgically addressable compression or instability and recovery burden is proportionate to likely benefit.

1Spinal MDT reviews level, neurological trajectory, stability, tumour sensitivity, prior treatment, systemic disease, fitness, prognosis and patient-defined outcome.
2Explain decompression, fixation, tissue diagnosis, complications, rehabilitation and alternatives, then optimise analgesia, thrombosis and perioperative care without avoidable delay.
3Arrange postoperative radiotherapy when indicated and begin coordinated bladder, bowel, skin and functional rehabilitation with an explicit discharge plan.

03Radiotherapy branchDeliver urgent treatment when surgery is unsuitableMSCC is confirmed and surgery is not appropriate, declined or unlikely to add sufficient benefit.

1Radiation oncology selects urgent treatment based on radiosensitivity, previous dose, compression extent, neurological duration, prognosis and comfort with attendance.
2Start radiotherapy as soon as possible and within 24 hours of the treatment decision unless a recognised exception makes benefit unlikely.
3Continue steroid and analgesic support, then taper dexamethasone after treatment begins while monitoring neurology and organising equipment and care.

04Supportive branchPreserve comfort and function at every stageDefinitiveDefinitive treatment is completed, not beneficial or not wanted, or disability persists despite treatment.

1Agree safe position and mobilisation after stability review and provide pressure relief, venous-thrombosis assessment, bladder drainage and a planned bowel regimen.
2Use multimodal analgesia and rehabilitation to maximise transfers, self-care and participation; provide orthosis or equipment only when comfortable and useful.
3EscalationDiscuss expected functional change, caregiver capacity, place of care and escalation, ensuring rapid review for new pain or neurological deterioration.

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

Reduces oedema around compressed neural tissue and may preserve or improve function while definitive decompression or radiotherapy is organised.

Immediate dexamethasone for neurological MSCC

Give 16 mg orally as soon as possible, or an equivalent parenteral dose when oral treatment is unreliable, then continue 16 mg daily while awaiting surgery or radiotherapy and taper after definitive treatment begins.

Monitor glucose, infection, delirium, sleep, proximal weakness and gastrointestinal risk; discuss severe pain without deficit and suspected haematological malignancy with specialists before routine use.

Controls severe mechanical, bony and radicular pain sufficiently for imaging, positioning, radiotherapy and essential care.

Goal-matched analgesia during spinal rescue

Use regular paracetamol when appropriate plus immediate-release opioid titrated to pain and renal function, converting to a stable regular regimen once requirement is known; add neuropathic treatment only after safety review.

Avoid masking neurological reassessment through avoidable sedation; prescribe bowel care with opioids and monitor respiratory rate, cognition, renal clearance and movement-related breakthrough pain.

Reduces venous thromboembolism risk during paralysis, bed rest and hospital treatment when bleeding risk is acceptable.

Thrombosis prophylaxis after individual review

Use the locally recommended low-molecular-weight heparin regimen only after bleeding, renal function, platelet count, planned surgery or neuraxial procedure and mobility have been reviewed.

Coordinate timing with spinal surgery and invasive procedures; avoid automatic prescribing during active bleeding, severe thrombocytopenia or a comfort-only dying phase.

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

Permanent motor disability

Delayed decompression allows infarction and fixed weakness; walking ability at treatment is a major predictor of subsequent ambulation.

Bladder and bowel failure

Autonomic pathway injury causes retention, overflow, incontinence, constipation, infection and major loss of independence and dignity.

Pain and unstable fracture

Vertebral collapse produces severe movement pain, deformity and risk of further neural injury during unassessed transfer or mobilisation.

Immobility injury

Paralysis and bed rest increase venous thrombosis, pulmonary complications, pressure damage, contracture, deconditioning and caregiver burden.

Corticosteroid toxicity

Hyperglycaemia, infection, delirium, insomnia, proximal weakness and gastrointestinal harm can accumulate while dexamethasone awaits review or taper.

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

Repeat and document power, sensory level, gait if safe and bladder and bowel function during transfer and while awaiting definitive treatment.
Record pain at rest and on movement and seek urgent review for worsening pain, deformity or a new level of symptoms.
During dexamethasone monitor capillary glucose, infection, mood, sleep, delirium, gastrointestinal symptoms and proximal strength.
Confirm MRI completion, image review and named surgical and oncology decisions against the 24-hour emergency timeline.
Inspect skin and pressure areas, monitor catheter need, bowel output and venous-thromboembolism risk during reduced mobility.
After surgery or radiotherapy track function meaningful to the person, treatment toxicity and rehabilitation or equipment needs.
Revisit prognosis and preferences if neurological recovery is limited, avoiding abandonment when the plan shifts toward comfort.

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

Pain is often the first deficit

Waiting for weakness loses the interval in which spinal metastasis can be treated before irreversible cord injury develops.

One painful level is not enough

Metastatic lesions may be non-contiguous, so whole-spine MRI prevents a second silent compression from being missed.

Ambulation predicts ambulation

People walking when treatment starts are more likely to remain mobile, making early symptom recognition clinically decisive.

Flat bed rest has harms

Alignment protection is appropriate when unstable, but prolonged immobility after specialist clearance worsens thrombosis, skin injury and deconditioning.

Steroids are a bridge

Dexamethasone supports neural rescue while surgery or radiotherapy is arranged; it is not definitive treatment and needs a taper plan.

Function needs a parallel plan

Bladder, bowel, skin, transfers, equipment and caregiver support should not wait until antitumour treatment has finished.

11Common pitfallsFrequent interpretation and management errors.

01
Waiting for paralysis before treating a high-risk spinal pain pattern seriously.
02
Sending routine outpatient imaging after new gait, sensory or sphincter dysfunction.
03
Imaging only the painful spinal segment instead of the whole spine.
04
Using a normal plain radiograph to reassure against MSCC.
05
Forcing gait or unsupported transfers when mechanical instability is possible.
06
Delaying dexamethasone in neurological MSCC while waiting for MRI reporting.
07
Using dexamethasone indiscriminately before diagnostic advice in possible lymphoma.
08
Letting prognostic scores replace urgent spinal and oncology judgement.
09
Failing to prescribe bowel, bladder, skin and thrombosis support during immobility.
10
Continuing high-dose steroid after definitive treatment without an explicit taper review.