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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.
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.
Why: Most cord compression starts at home, and time to treatment decides whether someone keeps walking.
“Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers know who to contact if they develop new symptoms or signs (see box 1 ) or if their existing symptoms worsen.”
Why: Weakness, numbness or bladder and bowel problems mean the cord is already under pressure.
“Immediately contact the MSCC coordinator if a person with a past or current diagnosis of cancer presents with the symptoms or signs of cord compression listed in box 1. Treat this as an oncological emergency.”
Why: Pain often comes before compression; finding the metastasis early allows treatment before nerves are damaged.
“Seek advice through the MSCC coordinator (within 24 hours) if a person with a past or current diagnosis of cancer presents with pain with the characteristics suggesting spinal metastases listed in box 1.”
Why: An unstable spine can collapse further with movement.
“Start immobilisation without delay (including for transfer to hospital) for people with: suspected or confirmed MSCC and neurological symptoms or signs suggesting spinal instability”
Why: Pain is usually severe and should not wait for the diagnosis.
“Ensure pain relief is provided promptly for people with suspected or confirmed spinal metastases or MSCC, including while the person is waiting for investigations or treatment.”
Why: Dexamethasone reduces swelling around the cord while definitive treatment is arranged.
“Offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible.”
Why: High-dose steroids raise blood sugar and irritate the stomach, and are not needed once the cause is treated or excluded.
“If dexamethasone is given before imaging, and spinal metastases and MSCC are subsequently ruled out, discontinue it.”
Why: MRI shows where and how badly the cord is compressed, which decides surgery or radiotherapy.
“Offer an MRI scan to people with suspected MSCC (see recommendation 1.3.2 ), to be done: as soon as possible (and always within 24 hours) at the local hospital or appropriate centre with direct access to imaging facilities.”
Why: Metastases are often at more than one level.
“MRI of the spine should include: sagittal T1 and/or short TI inversion recovery (STIR) sequences of the whole spine, to identify spinal metastases”
Why: Plain X-rays miss most spinal metastases and cord compression.
“Do not do a plain X-ray of the spine to diagnose or rule out spinal metastases or MSCC.”
Why: The choice between surgery and radiotherapy depends on stability, neurology, the cancer and prognosis.
“Before an invasive intervention is offered, make a treatment plan in discussion with the appropriate specialists (such as an oncologist and spinal surgeon) within the MSCC service multidisciplinary team.”
Why: In a randomised trial, more people walked after surgery followed by radiotherapy than after radiotherapy alone.
“Offer surgical intervention intended to halt or reverse neurological decline as soon as possible after the onset of neurological symptoms or signs indicating MSCC.”
Why: Radiotherapy shrinks the tumour pressing on the cord; a single dose means one visit.
“Use 8 Gy single fraction radiotherapy for people with MSCC having radiotherapy unless they are at high risk of side effects.”
Why: Radiotherapy after surgery treats the tumour left behind.
“Offer postoperative radiotherapy after the person has recovered from surgery for spinal metastases or MSCC.”
Why: Getting up safely and early prevents the harms of bed rest; a rise in pain or new weakness means stop and reassess.
“If assessment, including imaging, suggests spinal stability is likely (before or after treatment), start testing this by graded sitting followed by weight bearing.”
Why: Many people need equipment, carers' training and community support to go home.
“Start planning for discharge and ongoing care, including rehabilitation, on admission to hospital.”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
NICE NG234 (2023) is the most recent full guideline that could be read: immediate MSCC coordinator contact for neurological signs, MRI of the whole spine within 24 hours, dexamethasone 16 mg as soon as possible, immobilisation for suspected instability, surgery as soon as possible after neurological onset where suitable, and otherwise radiotherapy within 24 hours as 8 Gy in one fraction. ASTRO 2024 agrees on dexamethasone for cord compression and conditionally recommends surgery with postoperative radiotherapy over radiotherapy alone, but accepts four schedules (8 Gy/1, 16 Gy/2, 20 Gy/5, 30 Gy/10) for those not having surgery, where NICE prefers the single fraction. The trial evidence behind the choice: SCORAD III found 8 Gy in one fraction did not formally meet non-inferiority against 20 Gy in 5 fractions for walking at 8 weeks (69.3% against 72.7%; lower confidence bound -11.5% against a -11% margin), and Patchell 2005 found surgery plus radiotherapy kept more people walking than radiotherapy alone (84% against 57%).
NICE 2023 · ASTRO, Practical Radiation Oncology 2024 · JAMA 2019 · The Lancet 2005
Where it differs: For cord or cauda equina compression in people not eligible for surgery, recommends 8 Gy in 1 fraction, 16 Gy in 2, 20 Gy in 5 or 30 Gy in 10, chosen after a whole-person assessment and shared decision making, rather than a default single fraction.
Evidence: Recommendation strength and evidence quality assessed by the ASTRO task force from an AHRQ systematic review; only the abstract was read, so the printed grades are not quoted.
Where it differs: Considers multiple-fraction radiotherapy when a large treatment field is needed or there has been previous radiotherapy.
Evidence: NICE recommendation; NICE does not grade.
Where it differs: Randomised 686 people in UK and Australian centres to 8 Gy once or 20 Gy in 5 daily fractions. Walking at 8 weeks was 69.3% against 72.7%, narrowly missing the non-inferiority criterion; at 1, 4 and 12 weeks single fraction met it, and survival at 12 weeks was similar.
Evidence: Randomised controlled trial (abstract read).
| Recommendation | Grade, as printed | Source |
|---|---|---|
| MRI within 24 hours for suspected MSCC | not graded (NICE uses wording, 'offer') | NICE 2023 |
| Dexamethasone 16 mg as soon as possible for neurological symptoms or signs | not graded (NICE uses wording, 'offer') | NICE 2023 |
| 8 Gy single fraction unless at high risk of side effects | not graded (NICE uses wording, 'use') | NICE 2023 |
| Surgery and postoperative radiotherapy over radiotherapy alone for cord or cauda equina compression “Regarding other modalities with RT, for patients with spine metastases causing spinal cord or cauda equina compression, surgery and postoperative RT are conditionally recommended over RT alone.” | conditional recommendation | ASTRO, Practical Radiation Oncology 2024 |
| Dexamethasone for spine metastases with cord or cauda equina compression “Furthermore, dexamethasone is recommended for spine metastases with spinal cord or cauda equina compression.” | recommended (strength not stated in abstract) | ASTRO, Practical Radiation Oncology 2024 |
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