Spinal Metastases and Metastatic Spinal Cord Compression in Secondary Care

Overview

This specialist Guidelines summary covers investigation and management of spinal metastases and metastatic spinal cord compression (MSCC). The guidance is also relevant for direct malignant infiltration of the spine and associated cord compression. It aims to improve early diagnosis and treatment to prevent neurological injury and improve prognosis.

This summary is intended for oncologists working in a secondary care setting. 

Please refer to the full guideline for the complete set of recommendations, including organising and delivering services, recognising spinal metastases or MSCC, and rehabilitation and supportive care. 

Initial Assessment and Management

Please refer to the full guideline for a visual summary of the initial assessment and management of spinal metastases.

Figure 1: Metastatic Spinal Cord Compression: Initial Assessment and Management 

Information and Support

Supporting Decision Making

• Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers are given information and support that is tailored to their needs and preferences so that they are fully informed and supported to be involved in all decisions about their care. Follow the principles in NICE's guidelines on shared decision making and patient experience in adult NHS services
• Discuss with the person and their family or carers the reasons why investigations and treatments are being offered by the multidisciplinary team, and the risks and benefits of these, so that they fully understand their options and are involved in decisions about their care 
• Give opportunities to the person and their family or carers to discuss their concerns and ask questions about issues such as:
  • their diagnosis and what it might mean for them
  • initial treatment options
  • risks and benefits of treatment options
  • how the condition could affect them in the future, including the possibility of worsening symptoms and functional decline
  • ways to manage pain
  • when further treatment options could be considered 
• Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers know who to contact if they develop new symptoms or signs (see Box 1 in the full guideline) or if their existing symptoms worsen. 

Providing Support

• Carry out a holistic needs assessment with the person, and their family or carers if appropriate, as soon as possible after initial diagnosis, once the person is physically and emotionally able to be involved in the assessment, and revisit this when needs or preferences change
• Give advice on how to access support based on the holistic needs assessment, including help with psychological, emotional, spiritual, and financial needs
• Discuss with the person their needs and preferences and the support they receive, and aim to help them:
  • maintain their independence and quality of life
  • deal with uncertainty
  • adapt to potential changes in their level of function 
• Discuss with the person and their family or carers their experience of the service and explore whether changes can be made to better meet their needs. Ask about any concerns they may have, such as:
  • accessing the service and attending appointments
  • undergoing investigations
  • adhering to treatment
  • their social and practical circumstances
  • disabilities that may be relevant to their care
• Offer the person opportunities to discuss advance care planning (with support from family and carers if appropriate). For principles of advance care planning, see the section on Advance Care Planning in the NICE Guideline on Decision Making and Mental Capacity and the NICE Quick Guide on Advance Care Planning
• Offer the person end-of-life care, when appropriate, following NICE's guidelines on End of Life Care for Adults and Care of Dying Adults in the Last Days of Life
• When the person is approaching the end of their life, discuss the bereavement support available with their family or carers and provide written information. Give advice on how to access bereavement support according to their wishes and preferences. 

Support from Healthcare Services Including Discharge from Hospital

• Ensure that all people with spinal metastases or MSCC, and their families or carers, if appropriate:
  • have access to support and advice from the full range of healthcare services needed
  • are supported by healthcare services to adapt to changes and to maintain their independence and quality of life 
• Ensure that people with spinal metastases or MSCC and their families or carers have ongoing access to support and training on appropriate care techniques and use of equipment both in hospital and after they are discharged home. This may include:
  • manual handling
  • use of spinal braces
  • use of equipment (such as wheelchairs)
  • managing bladder and bowel problems. 

Immobilisation

• Start immobilisation without delay (including for transfer to hospital) for people with:
  • suspected or confirmed MSCC, and
  • neurological symptoms or signs suggesting spinal instability (see the recommendations in the full guideline on Tools for Assessing Spinal Stability and Prognosis)
• Consider immobilisation for people with:
  • suspected or confirmed spinal metastases or MSCC, and
  • moderate to severe pain associated with movement
• Nurse people who are immobilised in a supine position to minimise weight bearing by the spine (lying flat or with partial elevation). If they cannot tolerate the supine position, for example, because of pain or breathlessness, try adjusting their position to reduce these symptoms
• Seek early advice (within 24 hours) from an expert clinician (for example, a specialist physiotherapist, oncologist, or spinal surgeon) and start assessment of spinal stability to minimise the duration of immobilisation, if appropriate. 

Imaging Investigations

Radiologist Involvement

• Radiological imaging of the spine in people with suspected spinal metastases or MSCC should be overseen by a radiologist to ensure:
  • appropriate and complete imaging is performed, and
  • they report the results urgently. 

Magnetic Resonance Imaging Assessment

• Offer a magnetic resonance imaging (MRI) scan to people with suspected MSCC (see recommendation 1.3.2 in the full guideline) to be performed:
  • as soon as possible (and always within 24 hours)
  • at the local hospital or appropriate centre with direct access to imaging facilities.
    Transfer to a tertiary centre for MRI should only be undertaken if local MRI is not possible  
• Offer an MRI scan to guide treatment options for people with clinical suspicion of spinal metastases but without suspicion of MSCC (see recommendation 1.3.3 in the full guideline), to be performed:
  • within 1 week
  • at the local hospital
• Offer overnight MRI only in clinical circumstances in which urgent diagnosis is needed to enable treatment to start immediately 
• MRI of the spine should include:
  • sagittal T1 and/or short TI inversion recovery sequences of the whole spine, to identify spinal metastases
  • sagittal T2-weighted sequences, to show the level and degree of compression of the cord or cauda equina by a soft tissue mass, and to assess possible MSCC and detect lesions within the cord itself
  • supplementary axial imaging through any significant abnormality noted on the sagittal scan 
• In people with an existing diagnosis of spinal metastases without symptoms or signs of cord compression, do not perform MRI of the spine solely for the early radiological detection of cord compression. 

Other Imaging Techniques for Diagnosis and Management

• If MRI is contraindicated, carry out a computerised tomography (CT) scan for people with suspected spinal metastases or MSCC. Rarely, if more information is needed for diagnosis and to guide management, carry out myelography after CT scanning 
• If myelography is indicated, only perform it at a neuroscience or spinal surgical centre 
• Do not perform plain X-ray of the spine to diagnose or rule out spinal metastases or MSCC
• Consider multiplanar viewing or 3-plane reconstruction of recent or new CT images for people with spinal metastases or MSCC to:
  • assess spinal stability, and
  • plan vertebroplasty, kyphoplasty, or spinal surgery. 

Mobilisation and Assessment of Spinal Stability

• If assessment, including imaging, suggests spinal stability is likely (before or after treatment), start testing this by graded sitting followed by weight bearing
• Monitor neurological symptoms and pain continuously during mobilisation 
• Continue to unsupported sitting, transfers and mobilisation if, during graded sitting and weight bearing, there is:
  • no evidence of orthostatic hypotension, and
  • no significant increase in pain, and
  • no deterioration in neurological symptoms 
• If there is a significant increase in pain or neurological symptoms when the person begins graded sitting and mobilisation:
  • return them to a position where these changes reverse, and
  • reassess the stability of their spine
• For a person with MSCC for whom surgery, radiotherapy, or other oncology treatments are not appropriate, mobilisation should still be carried out if possible. 

Using Orthoses in Mobilisation

• Seek advice from a specialist (for example, a physiotherapist) on the use of orthoses to promote mobility and to prevent loss of range of limb movement. 

Pain Management

Individualised Pain Assessment and Management Plan

• Ensure adequate pain relief is provided promptly for people with suspected or confirmed spinal metastases or MSCC, including while the person is waiting for investigations or treatment 
• Carry out an individualised pain assessment for people presenting with pain related to suspected or confirmed spinal metastases or MSCC. This should include assessing:
  • the severity, location and characteristics of the pain
  • the underlying cause of the pain and whether this has deteriorated
  • the impact of pain on lifestyle, daily activities (including sleep) and participation in work, education, training or recreation
• Discuss and agree a pain management plan with the person based on their individualised pain assessment and taking into account any previous strategies tried, as well as their concerns and expectations. Discussions may include:
  • why a particular management plan is being suggested
  • the psychological impact of pain, including the effect on emotional wellbeing
  • pharmacological analgesic treatment options, with individualised information and advice, including possible risks and benefits, and dosage titration
  • individualised coping strategies for pain
  • other treatment options, if suitable, for example:
    • physical therapy
    • immobilisation (for example, bracing)
    • psychological therapies
    • systemic anticancer treatments
    • bisphosphonates (see the section on Bisphosphonates)
    • denosumab (see the section on Denosumab)
    • corticosteroids (see the section on Corticosteroid Therapy)
    • radiotherapy (see the section on Radiotherapy)
    • surgery (see the section on Invasive Interventions)
  • when and how to seek further advice if pain persists, progresses, or changes in character.
    For more information about involving people in decisions and supporting adherence, see the NICE guidelines on shared decision making and medicines adherence.  
• After starting or changing a pain management plan, carry out a clinical review to assess the effectiveness of the chosen treatment
• Consider referring the person to a specialist pain service (or, if appropriate, a palliative care service) if pain is difficult to manage at any stage, including at initial presentation, and if:
  • they have severe pain, or
  • their pain significantly limits their lifestyle, daily activities (including sleep) and participation in work, education, training, or recreation. 

Analgesic Medication

• When deciding on analgesic medication, discuss with the person and take into account:
  • the possible side effects
  • the possible effects on existing comorbidities and new comorbidities that could arise from treatment
  • concurrent medications (including over-the-counter medicines) and possible drug interactions
• Offer non-opioid or opioid analgesic medication, individually or in combination, to people with pain associated with suspected or confirmed spinal metastases or MSCC. The choice of medicine should be based on the ongoing individualised pain assessment and agreed in the pain management plan 
• At each review, discuss analgesic drug dosage, titration, tolerability, and adverse effects, and agree to continue or update the pain management plan where necessary 
• For people with pain that has neuropathic features or is unresponsive to opioid analgesia, consider managing pain according to the NICE Guideline on Neurpathic Pain in Adults
• For people having strong opioids in palliative care, follow the recommendations on starting and titrating opioid analgesia and managing side effects in the NICE guideline on palliative care for adults
• When using strong opioids, follow the processes for their safe use and management in the NICE Guideline on controlled drugs. 

Bisphosphonates

In September 2023, the following were off-label uses of some bisphosphonates. See  NICE's information on prescribing medicines. 

• For people with spinal involvement from myeloma or breast cancer, offer bisphosphonates to reduce pain and the risk of vertebral fracture or collapse
• For people with spinal metastases from prostate cancer, offer bisphosphonates to reduce pain only if conventional analgesia fails to control pain
• Do not use bisphosphonates to treat spinal pain in people:
  • with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer (if conventional analgesia fails), or
  • with the intention of preventing MSCC, except as part of a randomised controlled trial.

Denosumab

• For people with bone metastases from breast cancer and from solid tumours other than prostate, follow the NICE technology appraisal guidance on denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. 

Corticosteroid Therapy

• For people with neurological symptoms or signs of MSCC:
  • offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible
  • after the initial dose, continue 16 mg of oral dexamethasone (or equivalent parenteral dose) daily for people awaiting surgery or radiotherapy
  • after surgery or at the start of radiotherapy, reduce the dose gradually until stopped
• If dexamethasone is given before imaging and spinal metastases and MSCC are subsequently ruled out, discontinue it 
• Consider giving corticosteroids as part of initial management to people with spinal metastases or MSCC who do not have neurological symptoms or signs, if they have:
  • severe pain, or
  • a haematological malignancy (see the recommendation below for people with confirmed haematological malignancy with spinal metastases [with or without neurological symptoms or signs]) 
• For people with spinal metastases or MSCC without other effective treatment options, reduce dexamethasone gradually until stopped. Only continue dexamethasone if the person's symptoms return or worsen as dexamethasone is reduced
• For people with confirmed haematological malignancy with spinal metastases (with or without neurological symptoms or signs):
  • offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible
  • after the initial dose, offer further corticosteroid treatment in discussion with the haematology multidisciplinary team
• Seek specialist haematological advice before starting corticosteroid treatment for people presenting with radiologically suspected lymphoma or myeloma with spinal metastases without neurological symptoms or signs
• Do not routinely offer corticosteroids as part of initial management for people with spinal metastases or MSCC who do not have neurological symptoms or signs, except where this is part of a radiotherapy regimen 
• For people taking corticosteroid treatment:
  • monitor blood glucose levels, and
  • offer proton pump inhibitor acid suppression. 

Tools for Assessing Spinal Stability and Prognosis

• Consider using a validated spinal stability scoring system with good evidence of accuracy (for example, the Spinal Instability Neoplastic Score) alongside clinical assessment of risk of spinal instability to inform treatment decisions
• Consider using a validated prognostic scoring system with good evidence of accuracy (for example, the revised Tokuhashi scoring system) alongside recognised prognostic factors (such as comorbidities) to inform treatment decisions 
• Only use a scoring system as part of a full clinical assessment (including general health, pain, and information from imaging) to support clinical decision making and inform discussions with the person with spinal metastases or MSCC and their family or carers. 

Radiotherapy

Figure 3: Metastatic Spinal Cord Compression Radiotherapy and Invasive Interventions

Radiotherapy and Fertility

• When considering radiotherapy as a treatment option, explain the impact of the cancer and its treatment on future fertility. Explore the person's priorities for fertility and offer referral to a fertility specialist if suitable, but do not delay urgent treatment for spinal metastases or MSCC. See also the section on People with Cancer Who Wish to Preserve Fertility in the NICE Guideline on Fertility Problems.

Radiotherapy to Treat Painful Spinal Metastases and Prevent Metastatic Spinal Cord Compression

• For people with spinal metastases without MSCC who have non-mechanical spinal pain:
  • offer 8 Gy single fraction radiotherapy, even if they are paralysed, or
  • consider stereotactic ablative body radiotherapy for people with a good overall prognosis (see the section on Tools for Assessing Spinal Stability and Prognosis in the full guideline) or oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement 
• Be aware that radiotherapy for haematological malignancy with spinal metastases may reduce the success of stem cell harvest. If stem cell harvest is being considered, discuss the use of radiotherapy with the relevant haematology multidisciplinary team. 

Radiotherapy to Treat Metastatic Spinal Cord Compression

• Offer urgent radiotherapy (to be given as soon as possible and within 24 hours) to people with MSCC that is not suitable for spinal surgery, unless:
  • they have had complete tetraplegia or paraplegia for 2 weeks or longer and their pain is well controlled, or
  • their overall prognosis is considered to be poor (see also the section on Tools for Assessing Spinal Stability and Prognosis in the full guideline) 
• Use 8 Gy single fraction radiotherapy for people with MSCC having radiotherapy unless they are at high risk of side effects 
• Consider multiple fraction radiotherapy for people at high risk of side effects from radiation, for example, if they have:
  • disease requiring a large treatment field or fields
  • had previous radiotherapy treatments. 

Radiotherapy for Asymptomatic Spinal Metastases

• For people with asymptomatic spinal metastases, consider radiotherapy only:
  • as part of a randomised controlled trial with the intention of preventing MSCC, or
  • as part of a treatment strategy for oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement, or
  • if there are radiological signs of impending cord compression by an epidural or intradural tumour. 

Postoperative Radiotherapy

• Offer postoperative radiotherapy after the person has recovered from surgery for spinal metastases or MSCC. For information on surgery, see the section below on Invasive Interventions.

Further Radiotherapy Treatment

• Consider further radiotherapy for people with spinal metastases or MSCC who have:
  • had a good response to previous radiotherapy, and
  • developed recurrent symptoms at least 3 months after initial radiotherapy
• If further radiotherapy is being considered, discuss the possible benefits and risks with the person, and take into account the following factors before agreeing a treatment plan:
  • total biological equivalent dose
  • the time since the previous treatment
  • volume of tissue to be irradiated. 

Invasive Interventions

Timing of Invasive Interventions

• Before an invasive intervention is offered, make a treatment plan in discussion with the appropriate specialists (such as an oncologist and spinal surgeon) within the MSCC service multidisciplinary team
• If the primary cancer has not been identified, carry out a radiologically guided biopsy if:
  • identifying the primary cancer may affect treatment decisions, and
  • there is no need for immediate treatment
• Offer surgical intervention intended to halt or reverse neurological decline as soon as possible after the onset of neurological symptoms or signs indicating MSCC
• Take into account the speed of onset and rate of progression of neurological symptoms and signs when determining the urgency of surgical intervention
• Do not use a time limit after complete tetraplegia or paraplegia as the only factor to decide whether to offer surgical intervention to restore neurological function. 

Options for Invasive Interventions

Interventions to Treat Spinal Metastases Without Metastatic Spinal Cord Compression

• For people with spinal metastases without MSCC who have suspected or confirmed spinal instability, or pain not controlled by analgesia, consider the following options alone or in combination:
  • vertebroplasty or kyphoplasty (see also NICE's interventional procedures guidance on percutaneous vertebroplasty and balloon kyphoplasty for vertebral compression fractures)
  • radiofrequency ablation (see also NICE's interventional procedures guidance on radiofrequency ablation for palliation of painful spinal metastases and radiofrequency ablation as an adjunct to balloon kyphoplasty or percutaneous vertebroplasty for palliation of painful spinal metastases)
  • surgical stabilisation of the spine
  • spinal surgery to prevent MSCC.

Interventions to Treat Spinal Metastases with Metastatic Spinal Cord Compression

• For people with spinal metastases with MSCC, consider the following options:
  • surgical decompression of the spinal cord
  • surgical stabilisation of the spine
• Offer spinal stabilisation surgery, even if there is a severe neurological deficit that may be irreversible, if a person with MSCC:
  • has suspected or confirmed spinal instability with mechanical pain that is not controlled by analgesia, and
  • is able to have surgery and it is suitable for them
• Offer external spinal support (for example, a halo vest or cervico-thoraco-lumbar orthosis) if a person with MSCC:
  • has suspected or confirmed spinal instability with mechanical pain that is not controlled by analgesia, and
  • surgery is not suitable for them.