Spinal cord compression
Catch it while they can still walk. Back pain in someone with cancer is metastatic spinal cord compression until proven otherwise. Look for the red flags, examine the neurology, arrange urgent MRI of the whole spine, and involve the MSCC coordinator. Built for revision, not live patient decisions.
Settle them, and check the basics
urgent MRIRed flags — what each should make you think
Outcome depends on how well the patient walks at the time of treatment. People who can walk when treated usually keep walking, while those who are already paralysed rarely recover. Don't wait for weakness: act on the pain.
First actions (NICE NG234)
- 🦵Neuro exam
- MRIMRI whole spine
- DxDexamethasone
- 🛏Spinal precautions
- 📟Bladder scan
- ☎MSCC coordinator / acute oncology
Understand the patient
who · what nextWho gets MSCC?
- Breast, lung, prostate, kidney cancer and myeloma most commonly; lymphoma
- Up to a fifth have no known cancer diagnosis at presentation
- Thoracic spine most often affected
Definitive treatment
- Spinal surgery (decompression/stabilisation) for selected patients, ideally before loss of mobility
- Radiotherapy, usually within 24 h of MRI diagnosis if not having surgery
- Oncology input for systemic treatment
- VTE prophylaxis, pressure care, bladder/bowel care, analgesia
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Back pain with any red flag in a cancer patient; progressive neurology.
MRI whole spine.
Dexamethasone if neuro deficit, MSCC coordinator, surgery or radiotherapy.
Fever, back pain, IVDU, diabetes, recent procedure.
MRI with contrast, cultures, CRP.
Antibiotics, surgical drainage.
Back pain and progressive weakness after spinal procedure or on anticoagulation.
Emergency MRI.
Reverse anticoagulation, emergency neurosurgical decompression.
Lower motor neurone signs, saddle anaesthesia, sphincter dysfunction.
Emergency MRI.
See the cauda equina page.
Investigate — what to order, when, and what it tells you
test with a question in mindMRI whole spine
Bloods
Bladder scan
How the plan comes together
disposition · handoveradmit
Suspected MSCC with neuro signs: admit, MRI, steroids, oncology/spinal plan.
urgent outpatient
Pain only, no neuro signs, MRI within 1 week arranged, clear safety-net.
Hand over: cancer type, neuro exam, MRI timing, steroids given.
Cancer plus back pain means MSCC until proven otherwise. Examine, scan the whole spine on time, give dexamethasone for deficits, and call the MSCC coordinator. Nicely done getting here.
Clerking template
copy or downloadSpinal cord compression — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 11 knownFrequently asked questions
quick answersWhat are the red flags for spinal cord compression?
- Known cancer + new back/neck pain — think spinal metastases
- Thoracic or band-like pain — think MSCC
- Pain worse lying flat, coughing, at night — think MSCC
- Leg weakness, sensory level — think cord compression
- Bladder/bowel dysfunction — think late cord compression
- Fever, IVDU — think epidural abscess
- Anticoagulated, recent spinal procedure — think epidural haematoma
What is the initial management of spinal cord compression?
- Neuro exam — power, tone, reflexes, sensory level, saddle sensation, bladder
- MRI whole spine — immediately/within 24 h if neurological symptoms or signs; within 1 week if pain only
- Dexamethasone — if neurological deficit: 16 mg as soon as possible, with PPI cover and glucose monitoring
- Spinal precautions — if mechanical instability suspected (severe movement-related pain)
- Bladder scan — retention
- MSCC coordinator / acute oncology — same day
Always alongside senior support and your local guideline.
What diagnoses must you not miss in spinal cord compression?
- Metastatic spinal cord compression — cancer + back pain
- Spinal epidural abscess — fever · IVDU
- Spinal epidural haematoma — anticoagulant / epidural
- Cauda equina syndrome — lumbar · saddle
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for spinal cord compression?
- MRI whole spine — Immediately/within 24 h with neuro symptoms or signs; within 1 week if pain alone suggests spinal metastases.
- Bloods — FBC, U&E, calcium, LFT, CRP, glucose (before steroids).
- Bladder scan — Retention.
Admit or discharge: how is the plan decided for spinal cord compression?
- Admit — Suspected MSCC with neuro signs: admit, MRI, steroids, oncology/spinal plan.
- Urgent outpatient — Pain only, no neuro signs, MRI within 1 week arranged, clear safety-net.
Is there a clerking template for spinal cord compression?
Yes — there is a clerking template for spinal cord compression on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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