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Metastatic spinal cord compression — MSRA MCQ

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HardMRIMetastatic spinal cord compressionMSRA

A 68-year-old man with metastatic prostate cancer contacts his GP because of 5 days of progressively severe thoracic back pain, now worse on coughing and preventing sleep. Since this morning he has developed bilateral leg weakness, unsteady gait and difficulty initiating micturition. He has a legacy non-MR-conditional pacemaker; the local radiology department confirms that MRI is contraindicated. What is the most appropriate immediate investigation and referral plan?

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Correct answer: C — Immediately contact the MSCC coordinator and arrange urgent CT of the spine, with myelography considered after CT only if further information is needed

This presentation is metastatic spinal cord compression (MSCC) until proved otherwise: he has known cancer, progressive severe mechanical/night thoracic pain, new bilateral leg weakness and gait disturbance, and new bladder dysfunction. NICE classifies this as an oncological emergency requiring immediate contact with the MSCC coordinator. MRI of the whole spine is normally required as soon as possible and within 24 hours, but MRI is contraindicated here because of the non-MR-conditional pacemaker. NICE specifies CT as the alternative investigation when MRI is contraindicated. Myelography is not the first-line replacement for MRI: it is considered only rarely after CT if additional information is required to guide diagnosis or management, and should be undertaken in a neuroscience or spinal surgical centre. Plain radiographs must not be used to diagnose or exclude MSCC. A 1-week pathway applies to suspected spinal metastases without neurological signs or symptoms, not to this emergency presentation. Transferring solely to pursue MRI delays appropriate imaging when MRI is contraindicated.

Reference: NICE NG234: Spinal metastases and metastatic spinal cord compression — Recommendations (Published 6 September 2023; last reviewed 19 March 2026) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations