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Suspected metastatic spinal cord compression — MSRA MCQ

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HardMRISuspected metastatic spinal cord compressionMSRA

A 69-year-old woman with metastatic breast cancer, currently receiving systemic treatment, contacts the out-of-hours GP service at 21:00. For 10 days she has had progressive mid-thoracic pain that wakes her from sleep and is worse on coughing. Since this afternoon, she has developed a band-like burning pain around the right lower chest and new tingling in both feet. She remains independently mobile and denies leg weakness, saddle sensory loss, or bladder or bowel disturbance. The local acute hospital can perform and report whole-spine MRI at 08:00 tomorrow; a tertiary centre 90 minutes away could perform MRI overnight. What is the most appropriate immediate management plan?

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

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Correct answer: C — Immediately contact the MSCC coordinator, give 16 mg oral dexamethasone, and arrange whole-spine MRI at the local hospital as soon as possible and within 24 hours

This is suspected metastatic spinal cord compression (MSCC), an oncological emergency. She has current cancer, pain characteristics suggesting spinal metastases (progressive night pain aggravated by coughing), and new neurological symptoms suggesting cord compression: thoracic radicular pain and bilateral distal paraesthesia. Preserved mobility, normal sphincter function and absent objective weakness do not downgrade this to uncomplicated spinal metastatic pain. NICE recommends immediate contact with the MSCC coordinator, 16 mg dexamethasone as soon as possible for neurological symptoms or signs of MSCC, and MRI as soon as possible, always within 24 hours. MRI should assess the whole spine, because metastatic disease and clinically important compression may occur away from the symptomatic level. The local scan at 08:00 meets the required timeframe; transfer to a tertiary centre solely to obtain an overnight MRI is not indicated when local timely MRI is available. Overnight MRI is reserved for circumstances in which an immediate diagnosis is needed to enable treatment to start immediately. A applies to suspected spinal metastases without symptoms or signs of cord compression. B uses CT despite no MRI contraindication. C inadequately limits imaging to the thoracic region. D creates an unnecessary transfer despite timely local MRI access.

Reference: NICE NG234: Spinal metastases and metastatic spinal cord compression (2023; guideline PDF current in 2026) — https://www.nice.org.uk/guidance/ng234/resources/spinal-metastases-and-metastatic-spinal-cord-compression-pdf-66143896133317 NICE NG234 recommendations: recognising MSCC and corticosteroid therapy (2023; last reviewed March 2026) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations