Malignant Spinal Cord Compression

The true incidence of malignant spinal cord compression (MSCC) and epidural disease is unknown. Approximately 5-10% of patients with cancer develop metastatic spinal cord compression. The majority of patients diagnosed with MSCC have an established diagnosis of cancer, but for some (10-20%), MSCC is the presenting feature of malignancy. Many people with cancer are at risk of MSCC but particularly those with lung, breast, prostate cancer or multiple myeloma, which account for approximately 60% of cases of MSCC.

About 90% of patients are over 50 years of age and nearly all MSCC patients have pain, usually severe spinal nerve root pain (80%) with or without local back pain. The site of pain and the site of compression do not always correlate and X-rays and bone scans may be misleading. MSCC is usually diagnosed late, by which timely treatment may well be ineffective – once paraplegia develops it is usually irreversible. MSCC should be dealt with as an oncological emergency.

All Scottish cancer networks have developed locally agreed MSCC pathways. More information is available via the Scottish Palliative Care Guidelines website.13

13 Scottish Palliative Care Guidelines https://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/malignant-spinal-cord-compression

Urgent suspicion of cancer referral for patients with known cancer (particularly prostate, breast, lung or multiple myeloma)

People with a history of cancer and any of the following symptoms:

  • significant localised back pain, especially thoracic
  • severe, progressive pain or poor response to medication
  • spinal pain aggravated by straining (for example, at stool, or coughing or sneezing)
  • nocturnal spinal pain, especially if preventing sleep
  • radicular pain (for example, around chest, down front or back of thighs)
  • limb weakness or difficulty in walking
  • sensory loss (including perineal or saddle paraesthesia)
  • bladder or bowel dysfunction

Good practice

  • A normal neurological examination does not preclude epidural disease or
    evolving MSCC
  • The definitive method of investigation is MRI of the whole spine
  • All patients with bone metastasis, or considered by their clinician to be at high risk of developing MSCC, should be given written guidance on early symptoms with advice to contact a health care professional promptly. This information should also be sent to the GP
  • Written information on early symptoms should also be given to patients
    following treatment for MSCC
Quick Reference Guideline