Metastatic spinal cord compression: warning signs, emergency action and treatment

The spinal cord is a bundle of nerves running from the brain down the back, protected by the bones of the spine (vertebrae). Macmillan explains that it connects the brain to the rest of the body and is important for movement, bowel and bladder function and the sensations of touch, pain and temperature.

Some cancers spread to the bones of the spine or to tissues around the cord. Macmillan says that metastatic spinal cord compression happens when cancer grows and presses on the spinal cord, stopping the nerves from working properly. Cancer Research UK adds that pressure causes the nerves to swell and slows or blocks their blood supply, and that malignant spinal cord compression refers to cancer that started in the spine, while metastatic means cancer cells have spread into the spinal bones from elsewhere.

NICE guideline NG234 covers the recognition, referral, investigation and management of spinal metastases and MSCC, and aims to improve early diagnosis and treatment to prevent neurological injury and improve prognosis.

Macmillan says back pain is the most common symptom of cancer in the spine, and symptoms of MSCC depend on which part of the spine is affected. Signs to tell your team about straight away include the following.

• Back or neck pain that is new, severe or getting worse, worse with movement, coughing, sneezing or straining, disturbing sleep, or feeling like a band around the chest or tummy.

• Pain made worse by lying flat on your back, or by standing or moving, according to Cancer Research UK.

• Weakness in the legs, legs giving way or difficulty walking.

• Weakness in the arms and hands or difficulty gripping.

• Numbness or pins and needles that are new or quickly getting worse.

• Bowel problems: loss of control or new or worsening constipation.

• Bladder problems: loss of control, passing only small amounts or none at all, or, according to Cancer Research UK, erection problems.

Macmillan says that if you develop any symptoms of MSCC you should get medical advice immediately, even at the weekend or on a holiday. Contact the hospital team where you usually have cancer treatment, and make sure you know who to phone in the evenings and at weekends. If you cannot get in touch with anyone, go to the nearest emergency department straight away.

Cancer Research UK adds that you might be asked to go to your nearest hospital, which may not be your usual hospital, and that it is important to follow instructions so you are seen quickly. Tell staff that you have cancer and are worried about spinal cord compression, and show any MSCC alert card or leaflet. Macmillan notes that the symptoms can also be caused by other conditions, but you should always get them checked, even if you have had MSCC before.

Cancer Research UK says around 3 to 5 in 100 people (3 to 5%) with advanced cancer develop spinal cord compression. You are at higher risk if you have cancer that has already spread to the bones, is at high risk of spreading to bones, such as prostate, breast, lung or myeloma, or started in the spine.

Macmillan says that sometimes MSCC is the first symptom of cancer, and that if you have not been diagnosed with cancer the doctor may recommend a biopsy of the spine to give an exact diagnosis. Cancer Research UK adds that spinal cord compression can also happen in people who do not have cancer.

A member of your healthcare team will examine you, and Macmillan says they may ask you to lie flat on your back and keep still to avoid further damage to the spine, arrange an urgent scan and prescribe steroids to reduce swelling and pressure on the nerves. The scan is usually an MRI scan of the spine, or a CT scan if you cannot have an MRI.

Cancer Research UK says a biopsy is only done if knowing the type of cancer affects treatment and it does not delay urgent treatment. During and after treatment your team will examine your range of movement, muscle strength, coordination and sensation to see how well treatment is working.

Macmillan says the aims of treatment are to minimise damage to the spinal cord and to treat symptoms, and that treatment depends on the type of cancer, the part of the spine affected and your general health. The most common treatment is radiotherapy.

Macmillan explains that damage from compression differs for each person: treatment may ease the pressure with no lasting damage, but sometimes the nerves are badly damaged, and some people have some paralysis or bladder and bowel problems that may be permanent. Treatment started early gives the best chance of preserving function.

Cancer Research UK acknowledges that resting flat in bed at first can be very difficult and frustrating, and that it is normal to feel upset and frightened. It suggests asking the team about changes to help independence and about your outlook, and using support from information nurses and organisations.

MSCC is managed through the NHS cancer team and emergency department. Macmillan says you should know who to phone in the evenings and at weekends, and Cancer Research UK says you should have an emergency number to call.

Private radiotherapy or surgery is possible for some, but because the condition is time-critical and depends on coordination between oncology, radiology and spinal teams, most people are treated through their existing NHS cancer team. Keep your alert card and out-of-hours number with you.