Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Suspect MSCC in cancer patients with back pain/neurologic symptoms; start dexamethasone immediately.
- Obtain MRI whole spine; consult oncology, radiation oncology, and spine surgery.
- Decide surgery vs RT vs combined based on stability, histology, and deficits.
- Begin DVT prophylaxis and bowel/bladder management; rehab planning after stabilization.
Clinical Synopsis & Reasoning
Back pain with neurologic deficits in cancer patients is an emergency. Give dexamethasone promptly, obtain MRI whole spine, and coordinate urgent surgical decompression and/or radiotherapy based on stability, radiosensitivity, and prognosis.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| MRI whole spine with contrast | Definitive imaging | Epidural mass, level(s) of compression | If unavailable, CT myelogram |
| Neurologic exam (serial) | Severity/progression | Motor/sensory/reflex/bowel‑bladder | Document baseline |
| Primary tumor workup | Oncologic planning | Histology, staging | Guides RT vs surgery |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Dexamethasone 10 mg IV load → 4 mg IV/PO q6h | Glucocorticoid | Hours | Reduce edema and pain; preserve function | Taper after definitive therapy |
| Urgent radiotherapy (radiosensitive) | Local control | Hours‑days | Preferred for many solid tumors/lymphoma | Coordinate with oncology |
| Surgical decompression/stabilization | Definitive | Immediate‑hours | Indicated with instability, radioresistance, or rapid progression | Requires spine surgery |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- NICE/ASCO guidance on metastatic spinal cord compression — Link