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Metastatic spinal cord compression (MSCC)
Metastatic spinal cord compression is an oncological emergency: new back pain in a cancer patient is a warning, and the fast decisions — whole-spine MRI, dexamethasone, and surgery or radiotherapy — decide whether the patient walks or is paralysed.
Why it matters in the exam
The scenario is a patient with breast, lung, prostate, kidney cancer or myeloma, with thoracic back pain worse at night, lying flat and on coughing, and sometimes leg weakness, a sensory level or urinary retention. The tests check when to suspect it (pain comes before deficit), which test (whole-spine MRI, because there are sometimes several levels), the immediate drug (dexamethasone 16 mg daily with gastric protection), and the choice between surgery and radiotherapy. The surgical decision rests on spinal stability, the patient's general condition, tumour type and the number of levels. Radiosensitive tumours such as lymphoma, myeloma and small-cell lung cancer are usually treated with radiotherapy. Common distractors: a plain X-ray instead of MRI, imaging one region only, or waiting for a neurological deficit before work-up. The most important predictor of outcome is the ability to walk at diagnosis.
Key points
- New back pain in a cancer patient warns of a spinal metastasis, usually thoracic.
- Urgent whole-spine MRI when neurological symptoms are present.
- Dexamethasone 16 mg daily at once, with gastric protection.
- Surgery then radiotherapy in a suitable patient; radiotherapy alone for a radiosensitive tumour.
- Walking ability at diagnosis is the most important predictor of outcome.
Summary table
| Stage | What to do | Key detail |
|---|---|---|
| Suspicion | New or worsening back pain in a cancer patient, especially thoracic, nocturnal, band-like or worse on coughing | The thoracic spine is the common site |
| Imaging | Whole-spine MRI | Within 24 hours when neurological symptoms are present; immediately if the deficit is progressing |
| Immediate treatment | Dexamethasone 16 mg daily orally or intravenously, with a proton pump inhibitor | Taper after definitive treatment; monitor glucose |
| Definitive treatment | Decompressive surgery with stabilisation followed by radiotherapy in a suitable patient; radiotherapy alone for a radiosensitive tumour or when the patient is not a surgical candidate | Surgery plus radiotherapy improved walking compared with radiotherapy alone in selected patients |
| Stability and support | If instability is suspected — lie flat and log-roll until assessed | Bladder monitoring, VTE and pressure-ulcer prevention, pain control |
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Sources
- NICE Guideline NG234: Spinal Metastases and Metastatic Spinal Cord Compression, 2023 — Imaging, corticosteroids and definitive treatment
- Direct Decompressive Surgical Resection in the Treatment of Spinal Cord Compression (Patchell et al., Lancet), 2005 — Surgery plus radiotherapy versus radiotherapy alone
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.