Summary

Metastatic Spinal Cord Compression (MSCC) is an Oncological Emergency occurring in 5-10% of all cancer patients. It is defined as compression of the spinal cord or cauda equina by direct metastasis or vertebral collapse. The most common primaries are Breast, Lung, Prostate, Kidney, and Thyroid ("BLT with a Kosher Pickle"). The cardinal sign is Pain (often preceding neurology by weeks), which is characteristically Nocturnal and Mechanical. Early diagnosis is critical: ambulatory status at diagnosis is the strongest predictor of post-treatment prognosis. Management involves immediate Dexamethasone, flat bed rest (Log Roll), and urgent MRI (Whole Spine). Treatment is a choice between Surgery (Separation surgery + Stabilization) or Radiotherapy, guided by the NOMS Framework. [1,2,3]

Key Facts

• The "Golden 24 Hours": NICE Guidelines (CG75) mandate MRI within 24 hours of suspicion.
• The "BLT with a Pickle": Primary sources: Breast, Lung, Thyroid, (K)idney, Prostate.
• SINS Score: The "Spinal Instability Neoplastic Score". Asserts whether the spine is mechanically stable. Unstable spines need metal (fixation), not just radiation.

Clinical Pearls

"Pain is the warning shot": 90% of patients have back pain for weeks before they get paralyzed. In a cancer patient, new back pain is a met until proven otherwise.

"The Night Watch": Degenerative back pain gets better when you lie down. Metastatic pain gets WORSE at night (venous engorgement / biological activity). "I have to sleep in a chair".

"Assume Instability": Until the MRI is reviewed, keep the patient flat and log-rolled. Handling an unstable spine can cause irreversible paraplegia.

                 SUSPECTED MSCC
          (Cancer Hx + Pain/Neurology)
                        ↓
             DO NOT WAIT FOR PLAIN X-RAY
             ┌──────────┴──────────┐
         IMMOBILISE           DEXAMETHASONE
    (Flat Bed / Log Roll)   (16mg PO/IV Stat)
             ↓                     ↓
         URGENT MRI           PPI COVER
       (Whole Spine)        (Gastric protection)
         <24 Hours
             ↓
       COMPRESSION CONFIRMED?
             ↓
       IS SPINE STABLE? (SINS Score)
       ┌─────┴─────┐
    STABLE      UNSTABLE
      ↓            ↓
   RADIOSENSITIVE? SURGERY (Stabilisation)
   (Lymphoma/Myeloma)      ↓
      ↓               RADIOTHERAPY
   RADIOTHERAPY       (Post-op)

1. Medical (Immediate)

• Dexamethasone: 16mg stat, then 8mg BD (morning/lunch to avoid insomnia). Reduces vasogenic edema around the cord. "Buys time".
• Immobilisation: Flat bed rest until stability confirmed.

2. Decision Making (NOMS)

• Neurology: High grade compression (Bilsky 3)? -> Decompress.
• Oncology: Radiosensitive (Myeloma/Lymphoma/Small Cell) -> Bedside Radiotherapy. Radioresistant (Renal/Melanoma) -> Surgery.
• Mechanical: Unstable (SINS >13)? -> Surgery (Fixation).
• Systemic: Is patient fit? Prognosis >3 months?

3. Surgical options

• Decompression + Stabilisation: Remove tumor (laminectomy/corpectomy) + Screws/Rods.
• Kyphoplasty: Cement injection for painful fractures without cord compression.

4. Radiotherapy

• External Beam (EBRT): Standard. 20Gy in 5 fractions.
• SBRT (Stereotactic): High dose, precision. For radioresistant solitary mets.

Scores based on: Performance status, Number of bone mets, Number of visceral mets, Primary site, Palsy severity.

• Score 0-8: Prognosis <6 months. Palliative Radiotherapy.
• Score 9-11: Prognosis >6 months. Palliative Surgery.
• Score 12-15: Prognosis >1 year. Excisional Surgery.

Patchell's Study (Lancet 2005)

• Comparison: Surgery + Radiotherapy vs Radiotherapy alone.
• Finding: Surgery group retained ability to walk significantly longer (122 days vs 13 days).
• Practice Change: Established surgery (decompression + fixation) as standard of care for single level MSCC in fit patients.

NICE CG75 (2008)

• Coordinates the "MSCC Coordinator" role.
• Mandates MRI <24h.
• Mandates Treatment <24h after MRI.

What is MSCC?

The cancer has spread to the bones of your back. A piece of the bone or tumor is pressing on the spinal cord.

Why the rapid treatment?

The spinal cord is fragile. Pressure cuts off its blood supply. If we don't relieve that pressure quickly (with steroids or surgery or radiation), the damage becomes permanent (paralysis).

Why lie flat?

The cancer has weakened the bone like a crumbling brick. If you stand up, the bone might collapse completely, severing the cord. We keep you flat to protect it until we can fix it with metal or radiation.

Q1: What are the primary tumours that commonly metastasize to bone? A: Breast, Lung, Thyroid, Kidney, Prostate. ("BLT with a Kosher Pickle").

Q2: Describe the Patchell Trial and its impact. A: A landmark RCT (Lancet 2005) comparing Surgery+Radiotherapy vs Radiotherapy alone for MSCC. It was stopped early because the Surgery arm was vastly superior in maintaining ambulation and survival. It shifted practice towards aggressive surgical decompression for suitable candidates.

Q3: What determines if a patient gets Surgery or Radiotherapy? A: Use the NOMS framework.

• Surgery if: Unstable spine (Mechanical), Radioresistant tumor (Oncology), or High grade compression needing immediate clearance.
• Radiotherapy if: Stable spine, Radiosensitive tumor (Lymphoma/Myeloma), or Patient unfit for surgery.

(End of Topic)