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Metastatic spinal cord compression
New back pain in a cancer patient is cord compression until proven otherwise: start dexamethasone at once when there is a neurological deficit, obtain whole-spine MRI urgently, and decide between decompressive and stabilising surgery followed by radiation or radiation alone — by stability, tumour radiosensitivity and the patient's condition.
Why it matters in the exam
Spinal cord compression is the most frequent oncologic emergency in the bank. The scenario is fixed: a patient with prostate, breast or lung cancer presents with back pain, leg weakness, sensory loss or sphincter disturbance, and the question asks the first step, the urgent test and when surgery beats radiation.
The treatment decision rests on four axes: neurological status and degree of compression (Bilsky), tumour radiosensitivity, spinal stability, and systemic disease status and life expectancy. The patient's function at diagnosis — whether they walk — is the strongest predictor of outcome, so time to treatment matters.
Key points
- New back pain in a cancer patient requires whole-spine MRI within 24 hours, even before a neurological deficit appears.
- Dexamethasone is given at once when there is a neurological deficit, reducing oedema and easing pain until definitive treatment.
- Decompressive and stabilising surgery followed by radiation suits instability, a single level and a resistant tumour in a fit patient.
- Radiosensitive tumours and patients with short life expectancy are treated with radiation alone in a short schedule.
- The ability to walk at diagnosis is the strongest predictor, so speed of diagnosis and treatment decides the outcome.
Summary table
| Issue | Recommendation | Exam detail |
|---|---|---|
| Clinical suspicion | New or worsening back pain, radicular pain, weakness, sensory or sphincter disturbance | Pain precedes the deficit by weeks; most cases are in the thoracic spine |
| Imaging | Whole-spine MRI within 24 hours | Multilevel metastases are common |
| Immediate treatment | Dexamethasone when there is a neurological deficit, analgesia, restricted movement when instability is suspected | In a patient without a known diagnosis of lymphoma — biopsy before steroids if possible |
| Surgery followed by radiation | High-grade compression at a single level, instability, a radioresistant tumour, life expectancy above 3 months and good performance status | Surgery plus radiation improved the ability to walk compared with radiation alone |
| Radiation alone | Radiosensitive tumour (lymphoma, myeloma, small cell, seminoma), multiple levels or short life expectancy | Short schedules such as 20 Gy in 5 fractions or a single 8 Gy fraction |
| Low-grade compression (Bilsky 0 to 1) | Radiation, and SBRT for a radioresistant tumour | In grade 2 to 3 with a resistant tumour — decompressive surgery followed by SBRT |
| Special cases | Untreated prostate cancer — urgent ADT, preferably an antagonist | An agonist alone may cause a flare and worsen the compression |
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Sources
- NICE Guideline NG234: Spinal metastases and metastatic spinal cord compression, 2023 — Assessment and treatment
- ESMO Clinical Practice Guideline: Bone health in cancer, 2020 — Spinal cord compression
- Gunderson and Tepper's Clinical Radiation Oncology, 5th ed. (2021) — Palliation of spinal cord compression
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.