Summary

Metastatic spinal cord compression (MSCC) is an oncological emergency where spinal metastases compress the spinal cord or cauda equina. It causes progressive neurological deficit — initially back pain, then weakness, sensory loss, and bowel/bladder dysfunction. Without prompt treatment, it leads to irreversible paralysis. Treatment is dexamethasone immediately (reduces oedema), urgent MRI whole spine, and definitive treatment (radiotherapy or surgery) within 24-48 hours. Neurological function at treatment determines outcome.

Key Facts

• Incidence: 5-10% of cancer patients; most common in lung, breast, prostate, myeloma
• Presentation: Back pain (95%), leg weakness, sensory level, bladder dysfunction
• Key investigation: MRI whole spine within 24 hours (or urgent OOH if weakness/bladder symptoms)
• Treatment: Dexamethasone 16mg STAT → radiotherapy or surgery
• Outcome: Ambulatory at treatment = ambulatory after; non-ambulatory = usually non-ambulatory after

Clinical Pearls

New back pain in a patient with cancer = MRI until proven otherwise (MSCC is common and devastating if missed)

Ambulatory status at diagnosis = ambulatory status after treatment — early detection is critical

Dexamethasone reduces cord oedema — give IMMEDIATELY while organising imaging

Why This Matters Clinically

MSCC is common, and delay leads to permanent paralysis. Every clinician should have a low threshold for suspecting MSCC and escalating immediately. The window for intervention is narrow.

Neurological Assessment

Motor:

• Power in hip flexion, knee extension, dorsiflexion (L2-S1)
• Document MRC grade
• UMN vs LMN pattern

Sensory:

• Check for sensory level (dermatomes T4-L1 most common)
• Perianal sensation (S2-S4)

Reflexes:

• Increased in cord compression (UMN)
• Decreased in cauda equina (LMN)
• Plantar response (upgoing in cord)

Bladder:

• Urinary retention
• Incontinence
• Check post-void residual (catheterisation)

Spine Examination

• Tenderness on palpation or percussion
• Local deformity

By Neurological Status (Tokuhashi)

• Ambulatory vs non-ambulatory at presentation
• Determines prognosis

By Urgency (NICE)

Prognosis Scoring (Tokuhashi, Tomita)

• Used to guide treatment (surgery vs radiotherapy vs palliation)
• Considers: Primary tumour type, visceral metastases, vertebral metastases, neurological status, performance status

Functional Outcome

Survival

• Depends on primary tumour
• Median survival: 3-6 months overall
• Better for breast, prostate; worse for lung

Key Guidelines

1. NICE CG75: Metastatic Spinal Cord Compression (2008)
2. NICE NG12: Suspected Cancer Recognition and Referral

Key Evidence

• Early treatment preserves function
• Surgery + radiotherapy superior to radiotherapy alone in selected patients (Patchell Trial)

What is Spinal Cord Compression?

Spinal cord compression happens when cancer spreads to the spine and presses on the nerves. It can cause pain, weakness in the legs, and problems with bladder or bowel control.

Warning Signs

• New or worsening back pain (especially with known cancer)
• Weakness in legs or difficulty walking
• Numbness in legs or around the bottom
• Difficulty passing urine or bowel movements

What Should I Do?

Tell your doctor or call the cancer helpline immediately if you have these symptoms.

Treatment

• Steroids to reduce swelling
• Radiotherapy or sometimes surgery
• Pain relief
• Physiotherapy

Resources

• Macmillan: Spinal Cord Compression
• Cancer Research UK