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Suspected spinal metastases without metastatic spinal cord compression — MSRA MCQ

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HardMRISuspected spinal metastases without metastatic spinal cord compressionMSRA

A 71-year-old woman contacts her GP with 3 weeks of progressively worsening mid-thoracic back pain. It is now waking her at night and is exacerbated by coughing. She had renal cell carcinoma treated by nephrectomy 5 years ago and was discharged from oncology follow-up 2 years ago. She has no history of trauma or fever. Examination shows localised thoracic spinal tenderness, but normal lower-limb power, tone, reflexes and sensation. She walks normally and has no radicular pain, saddle sensory disturbance, or bladder or bowel dysfunction. What is the most appropriate next management plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Seek advice through the MSCC coordinator within 24 hours and arrange whole-spine MRI within 1 week

Explanation lettering: C = shown as A · E = shown as B · D = shown as C · B = shown as D · A = shown as E

This presentation raises clinical suspicion of spinal metastases: she has a past history of cancer together with progressive, severe thoracic pain, nocturnal pain and pain aggravated by coughing. However, she has no symptoms or signs of spinal cord or cauda equina compression: there is no limb weakness, gait disturbance, sensory loss, radicular pain, or bladder or bowel dysfunction. NICE therefore advises seeking advice through the MSCC coordinator within 24 hours and performing MRI to guide treatment within 1 week. MRI should assess the whole spine, because spinal metastatic disease may be multifocal. B incorrectly treats pain characteristics alone as suspected MSCC requiring MRI within 24 hours; that urgency applies when neurological symptoms or signs suggest cord compression. C is insufficient because a regional thoracic MRI may miss non-contiguous spinal metastases, and routine musculoskeletal referral does not reflect the cancer-related red flags. D is inappropriate because plain radiography must not be used to diagnose or exclude spinal metastases or MSCC. E delays specialist coordination and imaging beyond the recommended timeframe; this is not asymptomatic surveillance imaging but investigation of symptomatic suspected spinal metastases.

Reference: NICE NG234: Spinal metastases and metastatic spinal cord compression — Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations NICE NG234: Spinal metastases and metastatic spinal cord compression — MRI assessment (2023) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations NICE NG234: Spinal metastases and metastatic spinal cord compression — Other imaging techniques (2023) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations