Malignant spinal cord compression — steroids, MRI and 24-hour window

Recognition. Known cancer + progressive nocturnal back pain + new bilateral upper-motor weakness = malignant spinal cord compression until MRI proves otherwise. Ambulatory status at presentation predicts outcome — he is already losing independent gait; the clock to irreversible cord injury is measured in hours.^[3]

Bedside assessment. Motor MRC grades all myotomes; reflexes/Babinski; sensory level; DRE (anal tone, perianal sensation); bladder scan for retention; document ASIA baseline; spinal precautions if cervical concern.^[3]

Immediate drugs. Dexamethasone 10 mg IV now (do not wait for MRI if suspicion high), then 4 mg every 6 hours. Analgesia (e.g. morphine 5 mg IV titrated). Catheterise if retention. VTE prophylaxis plan. Avoid hypotension.^[3]

Imaging. Urgent MRI whole spine with gadolinium within 4–6 hours — not single-level only (skip lesions). Bilsky ESCC grade communicates cord compromise.^[2] CT for bony detail/surgical planning as adjunct.

Definitive pathway. Parallel referral neurosurgery + radiation oncology. For single-level MSCC in a fit patient with reasonable survival, direct decompressive surgery plus radiotherapy is superior to RT alone for maintaining ambulation (Patchell 2005).^[1] Radiosensitive multi-level disease or poor surgical candidate may receive RT alone. Target definitive treatment within ~24 hours.