Key Facts

Metastatic spinal cord compression is an oncological emergency that requires immediate recognition and treatment to prevent irreversible neurological damage. Delay in diagnosis and treatment is the most important modifiable factor.

Epidemiology

• Affects 5-10% of cancer patients
• Accounts for approximately 4,000 cases per year in England and Wales
• Most common primary cancers: lung (25%), breast (20%), prostate (15%), myeloma (10%), lymphoma (5%), renal (5%)
• Thoracic spine: 60-70%; lumbosacral: 20-30%; cervical: 10%

Aetiology

• Vertebral metastases with posterior expansion into the epidural space (85%)
• Direct epidural extension without bony involvement (10%)
• Paravertebral tumour extending through neural foramina (5%)
• Pathological vertebral collapse causing cord compression

Pathophysiology

• Tumour in epidural space compresses the spinal cord
• Compression causes venous congestion → vasogenic oedema → spinal cord ischaemia
• If untreated: irreversible infarction and permanent neurological damage
• Speed of onset influences prognosis: gradual onset (better) vs rapid (worse)
• Dexamethasone reduces vasogenic oedema, providing temporary neuroprotection

Early Symptoms

• Back pain (90%): localised, progressive, worse on coughing/straining/lying flat
• Pain may precede neurological symptoms by weeks to months
• Radicular pain (nerve root distribution)
• Band-like pain around trunk

Progressive Neurological Deficit

• Motor weakness (60-85%): upper motor neuron pattern below level of compression
• Sensory loss (40-90%): sensory level; may start distally and ascend
• Bladder/bowel dysfunction (40-60%): late sign; poor prognostic indicator; urinary retention, overflow incontinence
• Autonomic dysfunction: postural hypotension

Red Flags

• New back pain in a known cancer patient (assume MSCC until excluded)
• Progressive limb weakness
• Sensory level on examination
• Urinary retention or new-onset incontinence
• Bilateral radiculopathy
• Saddle anaesthesia (cauda equina)

Bedside

• Full neurological examination (motor, sensory level, reflexes, tone, plantar response)
• Bladder assessment (post-void residual; catheterise if retention)
• Straight leg raising, anal tone
• Spinal tenderness to percussion

Bloods

• FBC, U&Es, LFTs, bone profile (calcium)
• Myeloma screen: protein electrophoresis, immunoglobulins, Bence-Jones protein
• PSA (if prostate cancer suspected)
• CRP, ESR (infection vs malignancy)

Imaging

• MRI whole spine (with gadolinium): gold standard; must image entire spine (10-38% have multiple levels of compression)
• Requested urgently: within 24 hours if suspected on clinical grounds (NICE NG149)
• Plain X-rays: may show vertebral collapse but low sensitivity (<60%); do NOT rely on negative X-rays
• CT spine: if MRI contraindicated (pacemaker)

Special Tests

• CT-guided biopsy: if no known primary and tissue diagnosis needed
• Bone scan: assess extent of skeletal metastases

Non-pharmacological

• Spinal precautions: log-roll, flat bed rest if neurological deficit
• Nurse on pressure-relieving mattress
• VTE prophylaxis (LMWH; high DVT risk due to immobility)
• Urgent contact MSCC coordinator (each cancer network has one)

Pharmacological

• Dexamethasone 16mg IV/PO stat, then 16mg OD (reduce and taper after definitive treatment over 5-7 days)
• PPI cover (omeprazole 20mg OD)
• Blood glucose monitoring (steroid-induced hyperglycaemia)
• Analgesia: paracetamol ± opioids (morphine titrated); avoid NSAIDs if renal impairment
• Laxatives: senna 15mg ON, movicol 1 sachet OD (prevent constipation)
• Catheterisation if urinary retention

Surgical/Interventional

• Radiotherapy: most common definitive treatment; 20 Gy in 5 fractions or 30 Gy in 10 fractions; start within 24 hours
• Surgery (direct decompressive surgery + post-op RT): for selected patients meeting criteria:
  • Single or oligometastatic level of compression
  • Good performance status (ECOG 0-2)
  • Expected survival >3 months
  • Spinal instability (SINS score ≥7)
  • Progressive neurological deficit during RT
• Patchell trial evidence: surgery + RT maintained ambulation in 84% vs 57% with RT alone
• Vertebroplasty/kyphoplasty: for pain from vertebral collapse without cord compression

Referral Criteria

• Any suspected MSCC: contact MSCC coordinator immediately (NICE NG149)
• Urgent MRI within 24 hours
• Oncology and spinal surgery joint review
• Rehabilitation input: physiotherapy, occupational therapy early

• Ambulatory at treatment: >80% remain ambulatory after treatment
• Paraparetic at treatment: 30-40% regain ambulation
• Paraplegic >24-48 hours: <5-10% regain ambulation (often irreversible)
• Median survival after MSCC: approximately 3-6 months (varies by primary cancer and overall disease burden)
• Prostate and breast cancer: better survival (median 9-12 months)
• Lung cancer: worse survival (median 3-4 months)
• Bladder dysfunction at presentation: poor prognostic indicator for functional recovery

MSCC Management Pathway (NICE NG149)

Spinal Instability Neoplastic Score (SINS)