What is a Metastatic Spinal Cord Compression (MSCC)?
The spinal cord is a bundle of nerves that runs from the brain and to the lower part of the back, and has important roles in functions such as movement, bladder and bowel functioning, sensations of touch, pain, and temperature.
Spinal cord compression occurs when there is pressure on the spinal cord, which can stop the nerves functioning normally. This can occur when cancer grows in the bones of the spine or in surrounding tissues of the spinal cord.
MSCC is rare, between 5 to 10% of cancer patients develop a spinal cord compression. The most common types of cancers that can spread to the bone is prostate, lung, and breast cancer.
If MSCC are not diagnosed/treated urgently, damage to the spinal cord can lead to permanent paralysis.
Metastatic Spinal Cord Compression- red flag symptoms
Please see below the list of some of the common signs and symptoms which patients diagnosed with MSCC have reported.
Diagnosing and early treatment is crucial to improve a patient’s quality of life with MSCC.
It is important to note that having some of these symptoms does not necessarily mean a diagnosis of MSCC, however reporting of symptoms and investigations are essential to come to a diagnosis.
Metastatic spinal cord compression (MSCC) key red flags
- Past medical history of cancer (note 25% of patients do not have a diagnosed primary)
- Early diagnosis is essential – as the prognosis is severely impaired once paralysis occurs
- A combination of red flags increases suspicion – the more red flags the higher the risk and the greater the urgency
Credit: The above information has been produced by The Christie NHS Foundation Trust. The Greater Manchester and Cheshire MSCC guidelines can be accessed on The Christie NHS Foundation Trust website.
Early warning signs of MSCC
The following has been produced by Greenhalgh S, Turnpenny J, Richards L, Selfe J (2010)
- R– Referred back pain is multi-segmental or band-like
- E– Escalating pain which is poorly responsive to treatment (including medication)
- D – Different character or site to previous symptoms
- F – Funny feelings, odd sensations or heavy legs (mult-segmental)
- L – Lying flat increases back pain
- A – Agonising pain causing anguish and despair
- G – Gait disturbance, unsteadiness, especially on stairs (not just a limp)
- S – Sleep grossly disturbed due to pain being worse at night
NB – established motor, sensory, bladder, bowel disturbances = late signs
Low Level of clinical suspicion = suspect metastases or impending MSCC
- Cancer diagnosis*
- New and persistent localised back pain, chest wall pain or other unexplained atypical pain
- Unilateral nerve root pain (radiates in dermatomal distribution)
- Pain on movement
- No abnormal neurological signs on examination
Action required:
- Keep possibility of evolving cord compression in mind
- Arrange MR whole spine to rule out / confirm this within the 7 day OP pathway (NICE 2023)
- Warn the patient to report any significant change in pain or neurology (safety net red flags) immediately to GP, CNS, Hotline, etc, or attend accident and emergency
- Arrange early review of patient by yourself or another professional
Further considerations:
- Reassess if symptoms worsen/progress
High level of clinical suspicion = Suspect MSCC
- Cancer diagnosis* with or without documented bone metastases or myeloma
- Bilateral nerve root pain, tingling, burning, shooting and band-like pain around chest
- Acute escalation of severe spinal pain
- Unsteadiness/heaviness in legs
- Pain aggravated by movement, coughing, sneezing, straining and lying flat
- Neurological signs may be equivocal
Action required:
- Urgent referral (same day) to local hospital for MRI scan (CT scan if MRI contra-indicated)
- Assume spine unstable until proven otherwise, advice flat bed rest and log roll
- Contact the on-call oncology consultant/registrar on 01642 850850 for advice on treatment
- Start dexamethasone 16 mg daily with PPI
Further considerations:
- Do not delay
Definite clinical diagnosis = Definite MSCC Diagnosis
- Weakness in limbs
- Altered sensation with a sensory level
- Urinary retention
- Upper motor neurone signs or sudden flaccid paralysis
- Saddle anaesthesia and sphincter disturbance (cauda equina lesions) (definite neurological signs)
Action required:
- Urgent referral for MRI scan (CT scan if MRI contra-indicated): MRI scan via local hospital
- Contact the on-call oncology consultant/registrar on 01642 850850 for advice on treatment
- Spinal surgery opinion -the referring team are responsible for contacting the spinal team after discussion with the clinical oncology registrar on call.
- If not for surgery, urgent radiotherapy within 24 hours.
- Start dexamethasone 16 mg daily with PPI
Further considerations:
- Do not delay
Important contacts for radiotherapy/oncology
Sophie Burns: Advanced practitioner in palliative radiotherapy
- Mobile- 07442824652
- Available: Monday to Friday, 9am to 5pm.
- (Outside these hours, please contact the on-call consultant/registrar).
On-call oncologist, consultant or registrar
- Phone The James Cook University Hospital switchboard, 01642 850850, and ask for the oncology consultant or registrar on-call.
- (For after hours Monday-Friday and including weekends and bank holidays)
Acute oncology service (AOS) The James Cook University Hospital
- Mobile: 07741616475
- Tel: phone 01642 850850 and enter extension 57982 or 57983
- Email: [email protected]
- Available: Monday to Friday, 9am to 5pm.