Patient handout

Metastatic Spinal Cord Compression (MSCC)

PRODUCTION

1. Your condition

This handout is for metastatic spinal cord compression (mscc). Your care team identified this based on: new / worsening back pain in a cancer patient — presenting symptom in ≈95% of mscc (cole-patchell lancet neurol 2008 pmid 18420159); often nocturnal + worsens recumbent + worsens with valsalva.

Other reasons your team may use this plan: new motor weakness in cancer patient — second most common feature after back pain (loblaw 2012 pmid 22420969); sensory level on trunk or saddle anesthesia — late finding; localizes spinal level (patchell lancet 2005 pmid 16112300); urinary retention / incontinence / bowel dysfunction — late + ominous (cole-patchell pmid 18420159).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
dexamethasone (high-dose, severe deficit)	96 mg IV bolus, then 96 mg PO daily × 3 days, then taper over 10 days	IV→PO	bolus then daily taper	Sørensen Eur J Cancer 1994 (PMID 8142159) — high-dose dexamethasone improves 6-mo ambulation 59% vs 33% in severe deficit; PPI cover; glucose watch
dexamethasone (standard-dose, mild-moderate deficit)	10 mg IV bolus, then 16 mg/day in divided doses (4 mg q6h or 8 mg q12h) for 48-72 h, then taper over 1-2 wk concurrent with RT	IV→PO	q6-12h taper	Loblaw 2012 PMID 22420969 — standard-dose taper avoids high-dose toxicity (peptic ulcer, GI bleed, hyperglycaemia, mood) while preserving benefit

Plan: MSCC acute care bundle — dexamethasone + RT/surgery + anti-resorptive + analgesia (Loblaw 2012 PMID 22420969; Patchell Lancet 2005 PMID 16112300; Hoskin SCORAD JAMA 2019 PMID 31794625; Sørensen Eur J Cancer 1994 PMID 8142159)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent / new back pain → STAT MRI
Any new neurological deficit → ED + STAT MRI
New bone-pain elsewhere → restaging
PHQ-9 ≥15 OR suicidal ideation → psych urgent
Hypercalcaemia symptoms → ED
ONJ symptoms → dental + hold anti-resorptive

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

New or worsening motor deficit (MRC drop ≥1 grade within hours-to-days) in cancer patient with back pain — emergent MSCC pivot (Loblaw 2012 PMID 22420969; Cole-Patchell PMID 18420159)(life-threatening)
Saddle anesthesia + bilateral leg weakness + urinary retention / sphincter loss in cancer patient — STAT decompression within hours (NICE NG41)(life-threatening)
Definable sensory level on trunk OR complete motor + sensory + autonomic loss below a spinal level — late + ominous finding (Cole-Patchell PMID 18420159)
SINS ≥7 (Fisher Spine 2010 PMID 20562730) — pain on movement, kyphosis, posterior-element involvement, vertebral-body collapse >50% → mechanical instability axis of NOMS (Laufer Oncologist 2013 PMID 23709750); calc.sins is schema-blocked
NSCLC / RCC / melanoma / sarcoma / colorectal / hepatocellular primary with epidural compression — radioresistant tumour (NOMS-O axis); separation surgery + SBRT preferred over conventional RT alone (Laufer J Neurosurg Spine 2013 PMID 23339593)
Cervical spine MSCC with potential respiratory compromise — risk of diaphragmatic involvement at C3-C5; FVC + NIF monitoring; ICU watch (Cole-Patchell PMID 18420159)(life-threatening)
MRI shows compression at >1 vertebral level (≈30% of MSCC presentations) — never image only the symptomatic level (Loblaw 2012 PMID 22420969; NICE CG75)
MSCC as initial cancer presentation — biopsy of accessible site (vertebral or other) for histology; restaging CT/PET; treat empirically with steroid + RT while histology pending (Loblaw 2012 PMID 22420969)
Patient has received prior conventional RT to the same vertebral level — re-irradiation tolerance limited; favours SBRT / separation surgery + SBRT (Laufer J Neurosurg Spine 2013 PMID 23339593)
Fever + IVDU + CRP >100 + risk factors for bacteraemia / endocarditis + epidural enhancement on MRI — pivot to id.spinal-epidural-abscess.v1 (NOT MSCC)(life-threatening)

5. Follow-up

Outpatient oncology + radiation oncology + neurosurgery (if operated) + rehab; PHQ-9 depression screen (post-MSCC depression high); bowel/bladder management; recurrence-symptom education; anti-resorptive therapy ongoing; advance-care-planning discussion (life-expectancy is the dominant prognostic factor)

6. Sources

Guideline: Loblaw IJROBP 2012 Cancer Care Ontario MESCC practice guideline (PMID 22420969) + NICE NG41 metastatic spinal cord compression + Patchell Lancet 2005 surgery RCT (PMID 16112300) + Hoskin SCORAD JAMA 2019 (PMID 31794625) + Laufer NOMS Oncologist 2013 (PMID 23709750)