Metastatic Spinal Cord Compression (MSCC) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Suspected MSCC?
   Cancer patient with back pain + neurological symptoms — suspected MSCC? (Oncological emergency (current or past cancer; ~20% as the first presentation; breast/prostate/lung/myeloma, thoracic spine most common). Red flags: severe back/band-like thoracic/radicular pain, worse on coughing/straining/lying flat, night pain + new limb weakness/sensory level/gait disturbance/bladder-bowel dysfunction (late). Do not wait for paralysis.)
   • Suspected/confirmed MSCC (neurological symptoms) → Suspected MSCC → steroid + MRI + radiotherapy
   • Back pain only, no neurological symptoms → Back pain only · urgent evaluation
2. [End] Back pain only · urgent evaluation
   Cancer patient with new/progressive back pain but no neurological symptoms yet: still evaluate urgently as suspected MSCC — whole-spine MRI within 24 h, analgesia, early specialist referral (spine surgery/oncology); steroids as appropriate for asymptomatic spinal metastases. Escalate immediately if neurological symptoms appear.
3. [End] Suspected MSCC → steroid + MRI + radiotherapy
   With neurological symptoms: 1) dexamethasone 16 mg/day (first dose as soon as possible after assessment, maintained while awaiting surgery/radiotherapy, tapered over 5–7 days after surgery/start of radiotherapy, with a PPI). 2) Whole-spine MRI <24 h (contrast CT if contraindicated). 3) Spinal immobilization (if unstable/not yet assessed) + analgesia. 4) Definitive treatment: radiotherapy ± surgical decompression and stabilization within 24 h (surgery preferred for spinal instability/bony compression/radioresistant tumor/need for biopsy). Multidisciplinary. Ambulatory status at treatment is the key prognostic factor.

Source guidelines & references

• NICE NG234 Spinal metastases and metastatic spinal cord compression

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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