Spinal Cord Compression (Adult)

Quick Reference Card

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Overview

Spinal cord compression (SCC) is a neurological emergency characterised by compression of the spinal cord or cauda equina by an extrinsic mass, resulting in motor, sensory, and autonomic dysfunction. The condition requires urgent diagnosis and treatment to prevent irreversible neurological damage.

Metastatic spinal cord compression (MSCC) is the most common cause in adults, affecting 5-10% of all cancer patients and representing up to 5% of all cancer-related deaths. [1] It may be the first presentation of malignancy in approximately 20% of cases. [5] The thoracic spine is most commonly affected (60-70%), followed by the lumbosacral region (20-30%) and cervical spine (10%). [6]

The prognosis is critically dependent on neurological status at the time of treatment initiation. Patients who are ambulatory at diagnosis have a 75-90% chance of remaining ambulatory after treatment, whereas only 10-30% of non-ambulatory patients regain the ability to walk. [3] This underscores the importance of early recognition and urgent intervention.

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Epidemiology

Incidence and Prevalence

Demographics

MSCC incidence increases with age, reflecting the higher prevalence of malignancy in older populations. The median age at presentation is 55-65 years. Male predominance exists due to higher rates of lung and prostate cancer.

Primary Tumour Distribution

[1,6,7]

Spinal Level Distribution

[4,6]

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Aetiology and Pathophysiology

Causes of Spinal Cord Compression

Exam Detail: #### 1. Neoplastic Causes (Most Common in Adults)

Metastatic Disease (85-90% of neoplastic SCC)

• Mechanism: Haematogenous spread to vertebral body, with posterior extension into epidural space
• Route: Batson's venous plexus provides valveless communication between pelvic/abdominal organs and vertebral column
• Pattern: Vertebral body involvement in 85%, paraspinal/epidural direct extension in 10-15%, intradural metastases in less than 5%

Primary Spinal Tumours (5-10%)

• Extradural: Chordoma, chondrosarcoma, osteosarcoma, Ewing sarcoma
• Intradural extramedullary: Meningioma, schwannoma, neurofibroma
• Intramedullary: Ependymoma, astrocytoma (rare)

2. Infective Causes

Spinal Epidural Abscess

• Incidence: 0.2-2 per 10,000 hospital admissions [8]
• Risk factors: IVDU, diabetes, immunosuppression, spinal procedures
• Organisms: Staphylococcus aureus (60-70%), Gram-negative bacilli, Mycobacterium tuberculosis
• Classic triad: Fever, back pain, neurological deficit (present in only 10-15%)

Vertebral Osteomyelitis with Extension

• Discitis spreading to epidural space
• TB spine (Pott's disease) - thoracolumbar junction predilection

3. Degenerative Causes

Acute Disc Herniation

• Large central disc prolapse causing cauda equina syndrome or conus compression
• Thoracic disc herniation rare but may cause cord compression
• Cervical disc causing myelopathy

Cervical Spondylotic Myelopathy

• Chronic compression from degenerative changes
• Osteophytes, ligamentum flavum hypertrophy, disc bulge

Spinal Stenosis

• Central canal narrowing from multilevel degenerative disease
• May acutely decompensate with minor trauma

4. Traumatic Causes

Vertebral Fractures

• Burst fractures with retropulsion of bone fragments
• Fracture-dislocations
• Pathological fractures through metastatic/osteoporotic bone

5. Vascular Causes

Spinal Epidural Haematoma

• Spontaneous: Anticoagulation, coagulopathy, vascular malformations
• Iatrogenic: Post-spinal anaesthesia, epidural procedures
• Traumatic: Following spinal surgery or trauma

Spinal Subdural Haematoma

• Rare, similar risk factors to epidural

6. Other Causes

• Extramedullary haematopoiesis (myeloproliferative disorders)
• Epidural lipomatosis (chronic steroid use, obesity)
• Sarcoidosis
• Paget's disease

Pathophysiology of Cord Injury

The mechanism of spinal cord damage in compression involves a cascade of events:

Epidural Mass Effect
        ↓
Venous Congestion and Obstruction
        ↓
Vasogenic Oedema
        ↓
Increased Tissue Pressure
        ↓
Arterial Compromise and Ischaemia
        ↓
Cytotoxic Oedema and Demyelination
        ↓
Axonal Injury and Infarction
        ↓
Irreversible Neurological Deficit

Key Points:

• Venous compression precedes arterial compromise
• Oedema propagates proximally and distally from compression site
• White matter (long tracts) more susceptible than grey matter
• Corticosteroids reduce vasogenic oedema, explaining their efficacy [2]

Why Time is Critical

Clinical Pearl: The Golden Window: Neurological function at the time of treatment initiation is the single most important prognostic factor.

• Ambulatory patients: 75-90% remain ambulatory [3]
• Paraparetic (weak but some movement): 50% regain ambulation
• Paraplegic > 24-48 hours: less than 10% functional recovery [9]

This creates an urgent imperative for rapid diagnosis and treatment. Every hour of delay with progressive deficit worsens outcome.

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Clinical Presentation

Natural History and Symptom Progression

The typical progression of MSCC occurs over days to weeks:

[10]

Symptoms

Pain (90-95% of patients)

Clinical Pearl: Key Pain Features in MSCC:

• Pain precedes neurological deficit by a median of 7 weeks
• Night pain relieved by sitting up is highly suggestive
• Pain may be the ONLY symptom initially - maintain high index of suspicion in cancer patients

Motor Symptoms (60-85%)

• Progressive leg weakness (bilateral > unilateral)
• Difficulty walking, unsteady gait
• Leg "heaviness" or "giving way"
• Difficulty climbing stairs
• Upper limb weakness if cervical involvement

Sensory Symptoms (40-90%)

• Numbness, tingling, paraesthesias
• Sensory level (key localising finding)
• Band-like numbness around trunk
• Loss of proprioception (posterior columns)
• Dysaesthesia (abnormal, unpleasant sensation)

Autonomic Symptoms (40-60%)

⚠️ Red Flag: Bladder and bowel dysfunction indicates advanced compression:

• Urinary retention (most common) - painless, overflow incontinence
• Urinary urgency, frequency, hesitancy
• Faecal incontinence (late sign)
• Constipation
• Erectile dysfunction

Physical Examination Findings

Motor Examination

Exam Detail: Grading Motor Function (Frankel/ASIA Scale)

The Frankel grade at presentation strongly predicts outcome. [3]

Sensory Examination

Key Findings:

• Sensory level: Level of sensory loss localises the lesion (remember: sensory level may be 1-2 segments below actual compression)
• Spinothalamic tract: Test pain and temperature
• Posterior columns: Test vibration and proprioception
• Saddle anaesthesia: Perianal numbness (cauda equina involvement)

Spine Examination

• Tenderness over affected vertebral level
• Palpable step deformity (if vertebral collapse/dislocation)
• Gibbus deformity (angular kyphosis - Pott's disease)
• Paraspinal muscle spasm

Rectal Examination

⚠️ Red Flag: Essential in all suspected cord compression:

• Reduced anal sphincter tone indicates sacral involvement
• Assess perianal sensation (S2-S4 dermatomes)
• Loss of bulbocavernosus reflex (S2-S4)

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Red Flags and Urgent Features

Symptoms Requiring Immediate Investigation

"Cannot Miss" Clinical Scenarios

1. Cancer patient with new-onset back pain - MSCC until proven otherwise
2. Back pain with bilateral leg symptoms - Urgent whole-spine MRI
3. Back pain with bladder disturbance - Emergency imaging
4. Thoracic back pain (any cause) - Higher index of suspicion (rare for mechanical causes)
5. Progressive neurological deficit - Emergency treatment required

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Differential Diagnosis

Spinal Cord Compression vs Other Myelopathies

Cord Compression vs Cauda Equina Syndrome

Clinical Pearl: Mixed Picture: Compression at T12-L2 may involve both conus medullaris (cord) and cauda equina (roots), giving mixed UMN and LMN findings.

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Investigations

Imaging

MRI Entire Spine with Gadolinium (Gold Standard)

Exam Detail: Protocol:

• T1-weighted, T2-weighted, and STIR sequences
• Sagittal images of entire spine
• Axial images through abnormal levels
• Gadolinium enhancement for tumour characterisation

Rationale for Whole-Spine Imaging:

• Multiple levels of compression in 10-38% of patients [4]
• Skip lesions may be present
• Guides radiation field planning
• May identify primary tumour

MRI Findings in MSCC:

Sensitivity and Specificity:

• Sensitivity: 93% (95% CI 89-96%)
• Specificity: 97% (95% CI 93-99%)
• Positive predictive value: 95% [4]

Urgent vs Emergency MRI:

• Emergency (within hours): Rapidly progressive deficit, suspected epidural abscess
• Urgent (within 24h): Stable deficit, known malignancy with concerning symptoms
• Routine: Mild symptoms, chronic presentation

Plain Radiographs

• Low sensitivity (60-70%) for vertebral involvement
• May show: vertebral collapse, pedicle erosion ("winking owl" sign), paraspinal mass
• Cannot visualise cord or soft tissue
• Useful only if MRI delayed or unavailable

CT Spine

• Better bony detail than MRI
• Used for surgical planning (pedicle screw placement)
• CT myelography if MRI contraindicated (pacemaker, severe claustrophobia)

CT Myelography

• Alternative when MRI not available or contraindicated
• Invasive (requires lumbar puncture)
• Shows subarachnoid block
• Limited soft tissue detail compared to MRI

Laboratory Investigations

Biopsy

Indications:

• Unknown primary malignancy requiring histological diagnosis
• Suspected primary spinal tumour
• Atypical features raising diagnostic uncertainty
• Consideration of targeted therapy

Approach:

• CT-guided percutaneous needle biopsy
• Open surgical biopsy (at time of decompression)

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Classification and Staging

Bilsky Epidural Spinal Cord Compression Scale

Exam Detail: | Grade | Description | Management Implication | |-------|-------------|----------------------| | 0 | Bone disease only, no epidural involvement | Systemic therapy, surveillance | | 1a | Epidural disease without cord abutment | May observe, consider RT | | 1b | Epidural disease with cord abutment, no compression | Consider RT | | 1c | Epidural disease with cord compression, CSF visible | RT or surgery | | 2 | Cord compression, CSF not visible | Surgery preferred | | 3 | Cord compression with cord displacement | Surgery if feasible |

[11]

Tokuhashi Score (Prognosis)

Used to guide surgical decision-making based on expected survival:

Interpretation:

• 0-8: Expected survival less than 6 months (conservative/palliative RT)
• 9-11: Expected survival ≥6 months (consider surgery)
• 12-15: Expected survival ≥12 months (excisional surgery)

[12]

Spinal Instability Neoplastic Score (SINS)

Assesses mechanical stability for surgical planning:

Interpretation:

• 0-6: Stable
• 7-12: Potentially unstable (surgical consultation)
• 13-18: Unstable (surgical stabilisation indicated)

[13]

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Management

Immediate Management (First 24 Hours)

Step 1: Dexamethasone

Exam Detail: Evidence Base: The use of corticosteroids in MSCC is supported by a landmark randomised controlled trial by Sorensen et al. [2] which demonstrated improved ambulatory outcomes with high-dose dexamethasone.

Recommended Regimen:

• Loading dose: Dexamethasone 16mg IV (or 10mg if lower risk)
• Maintenance: 16mg daily in divided doses (4mg QDS or 8mg BD)
• Duration: Continue through radiotherapy/surgery, then taper over 2-4 weeks
• Gastroprotection: PPI for all patients on high-dose steroids

Mechanism:

• Reduces vasogenic oedema around tumour
• Decreases cord swelling
• May have direct oncolytic effect in some tumours (lymphoma)

Controversies:

• High-dose (96mg) vs standard-dose (16mg): Meta-analysis shows no significant benefit of very high doses with increased adverse effects [14]
• Current consensus favours 16mg as optimal balance

Side Effects to Monitor:

• Hyperglycaemia (check blood glucose)
• GI bleeding (add PPI)
• Infection risk
• Proximal myopathy (with prolonged use)
• Psychiatric disturbance

Step 2: Analgesia

• Pain is often severe and undertreated
• Paracetamol + weak opioids as first line
• Strong opioids (morphine, oxycodone) frequently required
• Consider neuropathic agents (gabapentin, pregabalin) for radicular pain
• Avoid NSAIDs in renal impairment or if surgery planned

Step 3: Bladder Care

• Assess for urinary retention (post-void residual)
• Catheterise if retention present (often painless)
• Monitor fluid balance

Step 4: VTE Prophylaxis

• High risk: malignancy + immobility
• LMWH prophylaxis unless contraindicated
• Mechanical prophylaxis (TEDs, pneumatic compression)

Step 5: Urgent Referral

• Contact oncology, radiation oncology, and spinal surgery within 24 hours
• Multidisciplinary team discussion essential
• Treatment should commence within 24-48 hours

Definitive Treatment Options

Radiotherapy

Indications:

• Radiosensitive tumours (lymphoma, myeloma, small cell lung cancer, seminoma)
• Multilevel disease
• Poor surgical candidates (performance status, comorbidities)
• Limited life expectancy (less than 3 months)
• Stable, ambulatory patients with mild compression

Regimens:

[15]

Outcomes:

• Ambulatory patients: 70-80% remain ambulatory
• Non-ambulatory: 30-40% regain ambulation
• Pain relief: 70-80%

Surgery + Radiotherapy

Landmark Evidence:

Evidence Debate: Patchell Trial (2005) [16]

This landmark RCT compared surgery (decompressive laminectomy + stabilisation) followed by radiotherapy versus radiotherapy alone in patients with MSCC.

Design:

• n = 101 patients with single-level MSCC
• Exclusion: Radiosensitive tumours, multiple areas compression, paraplegia > 48h
• Primary outcome: Ability to walk

Results:

Conclusion: Surgery + RT is superior to RT alone for motor outcomes in selected patients.

Criticisms:

• Selected population (excluded radiosensitive tumours)
• Old surgical techniques (pre-modern instrumentation)
• May not apply to all MSCC patients

Surgical Indications:

1. Single area of compression
2. Radioresistant tumour (renal cell, melanoma, sarcoma)
3. Spinal instability (SINS ≥7)
4. Progressive neurological deficit during/after radiotherapy
5. Unknown histology requiring tissue diagnosis
6. Life expectancy > 3 months
7. Reasonable performance status

Surgical Techniques:

Management of Specific Aetiologies

Epidural Abscess:

• Emergency surgical drainage AND IV antibiotics
• Empirical: Flucloxacillin + gentamicin (or vancomycin if MRSA risk) + metronidazole
• Duration: 6-8 weeks IV, then oral step-down
• Non-operative: Only if no neurological deficit, small abscess, improving on antibiotics

Disc Herniation:

• Urgent surgical discectomy
• Approach based on level (anterior for cervical, posterior for lumbar)
• Decompression ± fusion

Epidural Haematoma:

• Reverse anticoagulation (vitamin K, PCC, protamine)
• Emergency surgical evacuation
• Laminectomy and haematoma drainage

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Prognosis

Factors Affecting Outcome

[3,9,12]

Survival Data

Functional Outcomes

Clinical Pearl: The Critical Prognostic Rule:

• Ambulatory at treatment initiation: 75-90% remain ambulatory
• Paraparetic with some power: 50% regain ambulation
• Paraplegic less than 48 hours: 35% regain ambulation
• Paraplegic > 48 hours: less than 10% regain ambulation [3,9]

This evidence forms the basis for treating MSCC as a neurological emergency.

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Monitoring and Follow-up

Inpatient Monitoring

Post-Treatment Follow-up

Oncology:

• Restaging imaging at 3 months
• Ongoing systemic therapy review
• Further spinal surveillance

Rehabilitation:

• Physiotherapy for mobility
• Occupational therapy for ADLs
• Spasticity management
• Bladder/bowel rehabilitation

Spinal Surgery:

• Wound review at 2 weeks
• Stability assessment at 6 weeks
• Instrumentation check at 3-6 months

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Special Populations

Unknown Primary Malignancy

• MSCC is first presentation of cancer in 20% of cases [5]
• Urgent CT chest/abdomen/pelvis for staging
• Tumour markers: PSA, CEA, AFP, beta-HCG, CA125, CA19-9
• Tissue diagnosis essential for treatment planning
• Consider biopsy during surgical decompression

Lymphoma and Myeloma

• Exquisitely radiosensitive
• Often dramatic response to steroids (lymphoma may "melt")
• Systemic chemotherapy important
• Surgery rarely needed unless instability

Breast and Prostate Cancer

• May be hormone-sensitive
• Consider hormonal manipulation
• Relatively good prognosis with treatment
• May present years after primary diagnosis

Patients on Anticoagulation

• Consider epidural haematoma in differential
• May need reversal for surgery
• Higher surgical risk
• Restart anticoagulation as soon as safe

End-Stage Cancer

• Goals of care discussion essential
• Palliative radiotherapy for pain relief
• Surgery generally inappropriate if life expectancy less than 3 months
• Focus on comfort, symptom control, dignity

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Viva Questions and Model Answers

Opening Statement

Viva Point: "Tell me about spinal cord compression"

"Spinal cord compression is a neurological emergency characterised by compression of the spinal cord or cauda equina by an extrinsic mass. In adults, metastatic cancer is the most common cause, affecting 5-10% of cancer patients, with lung, breast, and prostate being the most common primaries. It represents an oncological emergency because neurological outcomes are critically dependent on neurological function at the time of treatment - 75-90% of patients ambulatory at diagnosis remain ambulatory, whereas less than 10% of those paraplegic for more than 48 hours regain ambulation."

Common Viva Questions

Q1: What are the causes of spinal cord compression?

"The causes can be classified as:

Neoplastic (most common in adults):

• Metastatic disease - lung, breast, prostate, renal, myeloma, lymphoma
• Primary spinal tumours - chordoma, nerve sheath tumours

Infective:

• Epidural abscess (Staph aureus most common)
• TB spine (Pott's disease)

Degenerative:

• Disc herniation
• Cervical spondylotic myelopathy

Traumatic:

• Vertebral fracture with retropulsion
• Fracture-dislocation

Vascular:

• Epidural haematoma (anticoagulation, post-procedure)"

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Q2: How would you differentiate cord compression from cauda equina syndrome?

"The key differences relate to the anatomy - the spinal cord ends at L1-L2, so compression above this causes upper motor neuron signs, while compression below involves nerve roots and causes lower motor neuron signs:

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Q3: What is your management of suspected MSCC?

"My immediate management follows a systematic approach:

Step 1: Dexamethasone - 16mg IV immediately if MSCC suspected, before imaging. This reduces vasogenic oedema and improves outcomes.

Step 2: MRI entire spine - Gold standard imaging, must include whole spine as 10-38% have multiple levels.

Step 3: Analgesia and supportive care - Often requires opioids. Catheterise if retention.

Step 4: VTE prophylaxis - LMWH as these patients are high risk.

Step 5: Urgent MDT referral - Oncology, radiation oncology, and spinal surgery within 24 hours.

Definitive treatment depends on tumour type, extent, and patient factors:

• Radioresistant, single level, good PS, life expectancy > 3 months: Surgery + RT (Patchell trial evidence)"

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Q4: What is the evidence for surgery in MSCC?

"The landmark evidence comes from the Patchell trial published in The Lancet in 2005. This was a randomised controlled trial of 101 patients with single-level MSCC comparing surgery plus radiotherapy versus radiotherapy alone.

The primary outcome was ability to walk after treatment:

• Surgery + RT: 84% ambulatory
• RT alone: 57% ambulatory (p=0.001)

Patients in the surgical group maintained ambulation longer (122 vs 13 days, p=0.003) and had improved survival (126 vs 100 days, p=0.033).

However, this trial has limitations - it excluded radiosensitive tumours and multilevel disease, and used older surgical techniques. Current practice involves more selective use of surgery based on tumour biology, SINS score, and life expectancy."

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Common Mistakes in Exams

⚠️ Red Flag: What Gets You Failed:

1. Missing the diagnosis - Not considering MSCC in cancer patient with back pain
2. Delayed imaging - Not recognising urgency of MRI
3. Wrong investigation - Ordering X-rays when MRI is required
4. Missing steroids - Not giving dexamethasone early
5. Not imaging whole spine - Missing additional levels of compression
6. Confusing UMN/LMN signs - Incorrect localisation
7. Not knowing prognosis - Failing to mention that ambulatory status at treatment predicts outcome
8. Outdated management - Not knowing Patchell trial evidence
9. Missing red flags - Not recognising bladder dysfunction as late sign

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Key Clinical Pearls

Diagnostic Pearls

1. Cancer + back pain = MRI until proven otherwise
2. Night pain relieved by sitting up is classic for spinal metastases
3. Sensory level is the key localising finding - examine carefully
4. MRI entire spine - 10-38% have multiple levels
5. MSCC is the first presentation of cancer in 20% of cases

Treatment Pearls

1. Dexamethasone 16mg immediately - before imaging if high suspicion
2. Time is function - delays cost neurological recovery
3. Surgery + RT > RT alone for selected single-level MSCC (Patchell trial)
4. Paraplegic > 48 hours rarely recover ambulation
5. Radiosensitive tumours (lymphoma, myeloma) may respond dramatically to RT alone

Prognostic Pearls

1. Ambulatory at treatment = 75-90% remain ambulatory
2. Paraplegic > 48 hours = less than 10% regain ambulation
3. Functional outcome is the most important predictor - more than tumour type
4. Life expectancy guides treatment - surgery if > 3 months expected survival

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Quality Metrics and Documentation

Performance Indicators

Documentation Checklist

• Time of symptom onset
• Detailed motor examination with MRC grades
• Sensory level documented
• Bladder function assessed
• Rectal tone examined
• Dexamethasone timing and dose
• MRI findings with levels documented
• MDT discussion documented
• Treatment plan with rationale
• Goals of care discussion (if applicable)
• VTE prophylaxis prescribed

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Patient Education

Understanding Spinal Cord Compression

For patients and families:

"A growth (tumour) is pressing on your spinal cord, which is the bundle of nerves that runs through your spine. This pressure is causing weakness and numbness in your legs. We need to treat this urgently because the longer the pressure continues, the harder it is to recover your function.

What we're doing:

1. Giving you steroids to reduce swelling around your spine
2. Getting an MRI scan to see exactly where the pressure is
3. Arranging for specialists to decide the best treatment - this might be radiotherapy (X-ray treatment), surgery, or both

What you might notice:

• Your legs may feel weak or numb
• You may have difficulty controlling your bladder
• The steroids may affect your blood sugar and mood

Warning signs to tell us immediately:

• Any worsening weakness
• New numbness
• Difficulty passing urine
• Increasing back pain"

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Guidelines and Recommendations

Key Guidelines

1. NICE CG75 (2008, updated 2014): Metastatic spinal cord compression in adults [17]

   • MRI within 24 hours of clinical suspicion
   • Dexamethasone for all patients with MSCC
   • Definitive treatment within 24 hours if neurologically unstable

2. SIGN 137 (2014): Diagnosis and management of MSCC [18]

   • Whole-spine MRI recommended
   • Surgery + RT for appropriate candidates
   • Single-fraction RT acceptable for poor prognosis

3. ESMO Clinical Practice Guidelines (2020): Bone metastases [19]

   • Multidisciplinary approach
   • SBRT for oligometastases
   • Bisphosphonates/denosumab for bone health

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References

1. Loblaw DA, Perry J, Chambers A, Laperriere NJ. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. J Clin Oncol. 2005;23(9):2028-2037. doi:10.1200/JCO.2005.00.067

2. Sorensen S, Helweg-Larsen S, Mouridsen H, Hansen HH. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer. 1994;30A(1):22-27. doi:10.1016/s0959-8049(05)80011-5

3. Rades D, Heidenreich F, Karstens JH. Final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression. Int J Radiat Oncol Biol Phys. 2002;53(4):975-979. doi:10.1016/s0360-3016(02)02819-5

4. Li KC, Poon PY. Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae. Magn Reson Imaging. 1988;6(5):547-556. doi:10.1016/0730-725x(88)90129-4

5. Husband DJ, Grant KA, Romaniuk CS. MRI in the diagnosis and treatment of suspected malignant spinal cord compression. Br J Radiol. 2001;74(877):15-23. doi:10.1259/bjr.74.877.740015

6. Klimo P Jr, Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol. 2005;7(1):64-76. doi:10.1215/S1152851704000262

7. Cole JS, Patchell RA. Metastatic epidural spinal cord compression. Lancet Neurol. 2008;7(5):459-466. doi:10.1016/S1474-4422(08)70089-9

8. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012-2020. doi:10.1056/NEJMra055111

9. Rades D, Stalpers LJ, Veninga T, et al. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol. 2005;23(15):3366-3375. doi:10.1200/JCO.2005.04.754

10. Helweg-Larsen S, Sorensen PS. Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients. Eur J Cancer. 1994;30A(3):396-398. doi:10.1016/0959-8049(94)90263-1

11. Bilsky MH, Laufer I, Fourney DR, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324-328. doi:10.3171/2010.3.SPINE09459

12. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine. 2005;30(19):2186-2191. doi:10.1097/01.brs.0000180401.06919.a5

13. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 2010;35(22):E1221-E1229. doi:10.1097/BRS.0b013e3181e16ae2

14. George R, Jeba J, Ramkumar G, Chacko AG, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015;(9):CD006716. doi:10.1002/14651858.CD006716.pub3

15. Rades D, Fehlauer F, Schulte R, et al. Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression. J Clin Oncol. 2006;24(21):3388-3393. doi:10.1200/JCO.2005.05.0542

16. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643-648. doi:10.1016/S0140-6736(05)66954-1

17. National Institute for Health and Care Excellence. Metastatic spinal cord compression in adults: risk assessment, diagnosis and management. NICE guideline CG75. 2008 (updated 2014). https://www.nice.org.uk/guidance/cg75

18. Scottish Intercollegiate Guidelines Network. SIGN 137: Diagnosis and management of metastatic malignant disease of unknown primary origin. 2014. https://www.sign.ac.uk

19. Coleman R, Hadji P, Body JJ, et al. Bone health in cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2020;31(12):1650-1663. doi:10.1016/j.annonc.2020.07.019

20. Maranzano E, Latini P. Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial. Int J Radiat Oncol Biol Phys. 1995;32(4):959-967. doi:10.1016/0360-3016(95)00572-g

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