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ukmla 2026

Spinal Cord Compression

Compression of the spinal cord causing progressive motor weakness, sensory level, and sphincter dysfunction — a surgical/oncological emergency requiring urgent MRI and treatment

Review date
reviewed 2026-04-05
Reading time
6 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Neurologyless-commonacute
On this page
Condition details
Neurology
less-common
6 min read
reviewed 2026-04-05
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About This Page

This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.

Key points

  • Spinal cord compression is a SURGICAL/ONCOLOGICAL EMERGENCY — delays cause irreversible neurological damage
  • Metastatic spinal cord compression (MSCC) is the most common cause in adults — lung, breast, prostate, renal, myeloma
  • Classic triad: progressive motor weakness (UMN pattern), sensory level, sphincter dysfunction (urinary retention)
  • Urgent MRI whole spine within 24 hours (or sooner if acute deterioration)
  • Dexamethasone 16 mg IV/PO immediately if MSCC suspected — reduces spinal oedema

Overview

Spinal cord compression (SCC) occurs when the spinal cord is compressed by an extrinsic mass, causing progressive myelopathy. In adults, metastatic spinal cord compression (MSCC) is the most common cause, occurring in approximately 5–10% of cancer patients. The thoracic spine is the most commonly affected site (~60%). Other causes include disc prolapse (cervical/thoracic), epidural abscess, epidural haematoma, vertebral fracture, primary spinal tumour, and rarely spondylotic myelopathy (chronic). Prompt diagnosis and treatment are essential — neurological function at the time of treatment is the strongest predictor of outcome.

Epidemiology

MSCC affects approximately 4,000 people per year in England and Wales. The most common primary cancers causing MSCC are lung, breast, prostate, renal, and myeloma. Non-malignant SCC from disc prolapse or epidural abscess is less common but equally urgent. Median age at presentation for MSCC is ~65 years.

Clinical Features

Symptoms
Progressive back pain — often the earliest symptom. Worse lying down (unlike mechanical back pain), worse at night, radicular pattern
Progressive limb weakness (bilateral) — upper motor neurone pattern below the level of compression
Sensory changes: numbness, paraesthesiae, band-like sensation at the level of compression (sensory level)
Urinary retention or incontinence (late feature — poor prognostic sign if present at diagnosis)
Bowel dysfunction: constipation or faecal incontinence
Known history of cancer (in MSCC)
Signs
UMN signs below the level of compression: spasticity, hyperreflexia, clonus, upgoing plantars (Babinski)
Sensory level: loss of sensation below a dermatome — identifies level of compression
Spinous process tenderness (localised to level of compression)
LMN signs at the level of compression (anterior horn cell involvement)
Palpable bladder (urinary retention)
Reduced anal tone (S2-4 involvement)

Investigations

First-line
MRI whole spine (with gadolinium)Gold standard investigation — URGENT. Within 24 hours of clinical suspicion, or within 4 hours if acute neurological deterioration. Shows level, extent, and nature of compression. Image entire spine — multiple levels of compression in ~30% of MSCC
Second-line
BloodsFBC, U&Es, calcium (hypercalcaemia in malignancy), ALP (bone metastases), PSA, myeloma screen (protein electrophoresis, Bence Jones protein), inflammatory markers (epidural abscess)
CT spineIf MRI contraindicated or unavailable urgently — shows bony anatomy, fractures, and extent of vertebral destruction
Specialist
CT-guided biopsyIf tissue diagnosis needed and primary unknown
Bone scanIdentifies other skeletal metastases — staging in known malignancy

Management

NICE NG234 (Spinal metastases and MSCC), 2023
1
Immediate management of MSCC
  • Dexamethasone 16 mg IV/PO immediately — reduces peritumoral oedema and buys time. Start PPI
  • Flat bed rest with neutral spinal alignment until stability assessed
  • Urgent referral to MSCC coordinator and spinal oncology MDT
  • Contact MSCC coordinator if cancer patient develops new back pain, neurological symptoms, or bladder dysfunction
2
Definitive treatment (MSCC)
  • Surgical decompression ± stabilisation: if fit for surgery, single-level compression, expected survival >3 months, and ideally operated within 24 hours
  • Radiotherapy: for radiosensitive tumours (myeloma, lymphoma, breast, prostate), or if unfit for surgery
  • Surgery + postoperative radiotherapy gives best outcomes for appropriate patients
3
Non-malignant SCC
  • Disc prolapse: urgent surgical decompression (especially if progressive neurology or sphincter dysfunction)
  • Epidural abscess: IV antibiotics + urgent surgical drainage
  • Epidural haematoma: urgent surgical evacuation
4
Rehabilitation and support
  • MDT rehabilitation from day of diagnosis: physiotherapy, OT, continence service, psychology
  • Ongoing cancer treatment: systemic therapy, bisphosphonates/denosumab for bone metastases
  • Advance care planning — prognosis discussion with patient and family

Complications

  • Irreversible paraplegia: If treatment is delayed — neurological function at time of treatment predicts outcome. Patients who are walking when treated are most likely to remain walking
  • Urinary retention and catheterisation: May become permanent
  • Pressure ulcers: Immobility and sensory loss
  • DVT/PE: Immobility and malignancy — thromboprophylaxis essential
  • Spinal instability: May require surgical stabilisation
UKMLA Exam Tips
  • 1Cancer patient with new back pain + limb weakness = MSCC until proven otherwise
  • 2UMN signs below the level + sensory level + sphincter dysfunction = spinal cord compression
  • 3MRI WHOLE spine urgently — multiple levels in ~30% of MSCC
  • 4Dexamethasone 16 mg immediately — do NOT wait for MRI
  • 5Thoracic spine most commonly affected in MSCC (~60%)
  • 6Neurological function at time of treatment is the strongest predictor of outcome — hence urgency
  • 7Cauda equina (below L1/L2) = LMN signs, saddle anaesthesia. Cord compression = UMN signs, sensory level

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Verified Sources & References

NICE NG234 — Spinal metastases and MSCC
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