Synopsis
Recognise malignant spinal cord or cauda-equina compression before irreversible disability, protect the spine, obtain whole-spine MRI within the correct timeframe and coordinate dexamethasone, surgery, radiotherapy, rehabilitation and goal-concordant supportive care.
- 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.
Key red flags
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.
Declining power, inability to stand or new sphincter dysfunction demands immediate MSCC coordination and imaging rather than routine outpatient referral.
Investigation priorities
Document power, reflexes, sensory level, saddle and sphincter features, gait only if safe, spinal pain, deformity and last functional baseline.
Management branches
A person with cancer develops weakness, gait, sensory or sphincter change suggesting MSCC.
- Contact the named MSCC service immediately, record neurological baseline and timing, assess instability and support alignment while providing adequate analgesia.
- Give dexamethasone 16 mg by a feasible route for neurological symptoms or signs, monitor glucose and obtain whole-spine MRI within 24 hours.
- Send images promptly for spinal surgical and oncology review and communicate the likely options, uncertainty and interim movement plan to patient and team.