Malignant Spinal Cord Compression

MSCC is compression of the spinal cord or cauda equina by tumour, requiring immediate dexamethasone and urgent MRI. Ambulant patients treated promptly have ~80% chance of remaining ambulant. Sphincter dysfunction lasting >24–48h is rarely reversible.

NICE MSCC Pathway

The pathway

1 · Recognise

Back pain + any neurological sign in a cancer patient = MSCC until proven otherwise.
Weakness, sensory level, sphincter disturbance.

2 · Dexamethasone immediately

16mg PO/IV stat. Reduces perilesional oedema.
Do not wait for imaging.

3 · Urgent MRI whole spine

Within 24h.
Within 4h if neurological deterioration or sphincter involvement.
CT misses ~30% of MSCC.

4 · Assess sphincter function

Bladder retention or bowel dysfunction = same-day emergency. Catheterise if in retention.

5 · Same-day specialist discussion

Oncology (radiotherapy) + spinal surgery same-day. Surgery if: unstable spine, unknown primary, radioresistant tumour.

6 · Definitive treatment

Radiotherapy: most cases.
Surgery: instability, radioresistant, neurological failure despite steroids.
Then maintain dexamethasone 8mg BD, weaning over 2 weeks.

Drugs

Drug	Dose	Route	Notes
Dexamethasone	16mg	PO/IV	Stat immediately. Maintenance 8mg BD. Wean over 2 weeks post-treatment.
PPI	Omeprazole 20mg	PO	Gastroprotection with dexamethasone.
Morphine	2.5–5mg	SC/IV	Titrate for pain. Avoid NSAIDs if renal impairment.
Dalteparin	5000 units	SC	VTE prophylaxis once surgery/radiotherapy decision made. Check platelet count.

When to escalate

Neurological deterioration despite dexamethasone — expedite imaging and surgical referral,Sphincter dysfunction — immediate urology/neurosurgery same day,Unknown primary tumour — urgent biopsy discussion before radiotherapy,Cauda equina syndrome — emergency surgical decompression may be required

Reference: NICE NG127 (2019) — Metastatic Spinal Cord Compression in Adults

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