# Metastatic spinal cord compression: recognition, MSCC coordinator, MRI, dexamethasone, radiotherapy and surgery

Source: https://onco.cc/protocols/metastatic-spinal-cord-compression-emergency/  
OnCo record `metastatic-spinal-cord-compression-emergency` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Cancer that has spread to the spine can press on the spinal cord. New back or neck pain that is severe, worse at night or on coughing, or any weakness, numbness, or trouble passing urine or stools, needs a same-day call to your cancer team. The hospital should do an MRI of the whole spine within 24 hours, give dexamethasone, and plan radiotherapy or surgery quickly, to keep you walking.

## Summary

NICE NG234 (2023) sets out the UK pathway. Anyone with a past or current cancer who develops symptoms or signs of cord compression (bladder or bowel dysfunction, gait disturbance, limb weakness, sensory loss, radicular pain) is an oncological emergency: contact the MSCC coordinator immediately, a service that must be covered 24 hours a day. Pain suggesting spinal metastases alone (severe, progressive, mechanical, worse on straining, waking at night, localised tenderness) needs coordinator advice within 24 hours and an MRI within a week.

Suspected MSCC: MRI as soon as possible and always within 24 hours, locally, with sagittal T1 and/or STIR of the whole spine; overnight MRI only if treatment would start immediately; CT if MRI is contraindicated; never a plain X-ray. Immobilise without delay if there are neurological signs or suspected instability, lying flat. Give dexamethasone 16 mg as soon as possible and daily until surgery or radiotherapy, then taper, with glucose monitoring and a proton pump inhibitor; stop it if MSCC is ruled out.

Treatment is planned by the MSCC multidisciplinary team. Surgery to halt or reverse neurological decline as soon as possible after onset (Patchell 2005: 84% walking after surgery plus radiotherapy against 57% after radiotherapy alone). Otherwise urgent radiotherapy within 24 hours, 8 Gy in one fraction unless at high risk of side effects; NICE excludes people with complete paralysis for 2 weeks or more with controlled pain, or a poor prognosis. SCORAD III found single-fraction 8 Gy narrowly missed non-inferiority to 20 Gy in 5 fractions for walking at 8 weeks (69.3% against 72.7%). ASTRO 2024 recommends 8 Gy/1, 16 Gy/2, 20 Gy/5 or 30 Gy/10 for patients not having surgery, and conditionally recommends surgery with postoperative radiotherapy over radiotherapy alone.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: MSCC protocol; malignant spinal cord compression; spinal cord compression emergency; cauda equina compression in cancer; NICE NG234
- Tags: protocol; acute-oncology; oncological-emergency

## Connected records

- cancers: [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [Lung cancer (all types)](https://onco.cc/cancers/lung-cancer/), [Multiple myeloma](https://onco.cc/cancers/multiple-myeloma/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- technologies: [MRI](https://onco.cc/technologies/mri/), [Palliative radiotherapy](https://onco.cc/technologies/palliative-radiotherapy/), [SBRT / SABR (stereotactic radiotherapy)](https://onco.cc/technologies/sbrt/)
- drugs: [Dexamethasone](https://onco.cc/drugs/dexamethasone/)
- institutions: [American Society for Radiation Oncology](https://onco.cc/institutions/astro/), [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Bone metastases and skeletal-related events](https://onco.cc/terms/bone-metastases/), [Metastatic spinal cord compression (MSCC)](https://onco.cc/terms/metastatic-spinal-cord-compression/)
- key papers: [Effect of Single-Fraction vs Multifraction Radiotherapy on Ambulatory Status Among Patients With Spinal Canal Compression From Metastatic Cancer: The SCORAD Randomized Clinical Trial](https://onco.cc/key-papers/paper-hoskin-jama/)
- protocols: [Acute oncology telephone triage: the 24-hour helpline and the UKONS red, amber and green grading](https://onco.cc/protocols/acute-oncology-telephone-triage/), [Raised intracranial pressure in cancer: recognition, urgent scan, dexamethasone and referral](https://onco.cc/protocols/raised-intracranial-pressure/), [Superior vena cava obstruction in cancer: recognition, imaging, stenting and treatment of the cause](https://onco.cc/protocols/svc-obstruction/)

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