Metastatic Spinal Cord Compression (MSCC)

Algorithm Steps

1. ▶

   Start

   Suspected MSCC

   Cancer patient with new back pain ± neurological symptoms

   1. ●

      Action

      Identify Warning Features

      Red flags for MSCC

      • Severe mechanical back pain
      • Radicular pain (band-like)
      • Lower limb weakness
      • Sensory level/changes
      • Bladder/bowel dysfunction
      • Known cancer history
      1. ●

         Action

         Urgent Neurological Examination

         Document baseline function

         • Motor strength (MRC scale)
         • Sensory level
         • Reflexes (may be brisk or absent)
         • Rectal tone, perianal sensation
         • Gait assessment if ambulatory
         1. ◆

            Decision

            Ambulatory Status?

            Critical prognostic factor

            • Ambulatory: can walk with/without aids
            • Non-ambulatory: unable to walk
            • Paraplegia: complete loss of function
            1. ●

               Action

               Immediate Dexamethasone

               Start before imaging if high suspicion

               • Dexamethasone 16 mg IV/PO STAT
               • Continue 16 mg daily until surgery/RT
               • PPI for GI protection
               • Taper after treatment initiated
               • Do NOT delay for imaging
               1. ●

                  Action

                  Urgent MRI Whole Spine

                  Within 24 hours (ideally same day)

                  • MRI entire spine (multiple levels common)
                  • With gadolinium contrast
                  • If MRI unavailable: CT myelogram
                  • Do NOT delay for plain XR
                  1. ◆

                     Decision

                     MSCC Confirmed?

                     MRI findings

                     • Epidural disease with cord compression
                     • Degree of canal narrowing
                     • Number of levels involved
                     • Stability assessment
                     1. ●

                        Action

                        No MSCC on MRI

                        Alternative diagnosis

                        • Consider: nerve root compression
                        • Bone-only metastases
                        • Other causes of myelopathy
                        • May still need intervention
                     2. ●

                        Action

                        MDT Discussion

                        Oncology, spine surgery, radiation oncology

                        • Tumor type and radiosensitivity
                        • Life expectancy (prognosis)
                        • Neurological status
                        • Spinal stability
                        • Patient performance status
                        1. ◆

                           Decision

                           Treatment Selection

                           Surgery vs Radiation vs Supportive

                           • Surgery: rapid onset, single level, radioresistant tumor
                           • Radiation: multiple levels, radiosensitive, poor surgical candidate
                           • Supportive: complete paraplegia ≥2 weeks, very poor prognosis
                           1. ●

                              Action

                              Surgical Decompression

                              ± Stabilization

                              • Ideally within 24-48 hours
                              • Posterior decompression common
                              • May need instrumentation
                              • Followed by radiation usually
                              1. ●

                                 Action

                                 Radiotherapy

                                 External beam radiation

                                 • Start within 24 hours if not surgical
                                 • Fractionation based on prognosis
                                 • Single fraction 8 Gy if poor prognosis
                                 • Multi-fraction if good prognosis
                                 1. ●

                                    Action

                                    Rehabilitation

                                    Maximize function

                                    • Early mobilization if safe
                                    • PT/OT assessment
                                    • Spinal precautions if unstable
                                    • Adaptive equipment
                                    1. ✓

                                       Outcome

                                       Ongoing Oncology Care

                                       Systemic treatment, monitoring

                                       • Continue steroids taper
                                       • Systemic anticancer therapy
                                       • Monitor for recurrence
                                       • Bone-targeted agents
                           2. ●

                              Action

                              Supportive Care

                              Best supportive care

                              • Pain management
                              • Steroids (may taper)
                              • DVT prophylaxis
                              • Bowel/bladder care
                              • Palliative care involvement