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Suspected spinal metastases without metastatic spinal cord compression — MSRA MCQ

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ModerateMRISuspected spinal metastases without metastatic spinal cord compressionMSRA

A 67-year-old woman consults her GP with 3 weeks of progressively worsening mid-thoracic back pain. The pain is severe, disturbs her sleep and is aggravated by sitting, standing and coughing. She completed treatment for oestrogen-receptor-positive breast cancer 6 years ago and remains under annual oncology follow-up. She has no leg weakness, gait disturbance, radicular pain, sensory change, bladder or bowel symptoms, fever or recent trauma. Examination shows localised thoracic vertebral tenderness; lower-limb power, reflexes, sensation and gait are normal. She has no contraindication to MRI. 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: A — Seek advice through the MSCC coordinator within 24 hours, provide analgesia and arrange MRI of the whole spine within 1 week.

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

This woman has a past history of cancer plus several pain features suggesting spinal metastases: progressive, severe unremitting thoracic pain, night pain, pain aggravated by movement and straining, and localised tenderness. However, she has no symptoms or signs suggesting metastatic spinal cord compression (MSCC): there is no radicular pain, limb weakness, sensory disturbance, gait impairment, or bladder or bowel dysfunction. NICE recommends seeking advice through the MSCC coordinator within 24 hours for a person with current or previous cancer and pain characteristics suggestive of spinal metastases. MRI to guide management should then be performed locally within 1 week where spinal metastases are suspected without MSCC. Analgesia should be provided while investigation proceeds. A is inappropriate because plain spinal radiographs should not be used to diagnose or exclude spinal metastases or MSCC. B risks an uncoordinated and insufficiently prompt pathway. C applies if cord compression is suspected, when MRI is required as soon as possible and within 24 hours; that threshold is not met here. E would delay the required MSCC-coordinator pathway and MRI; urgent oncology referral is principally relevant when cancer is suspected but not yet diagnosed.

Reference: NICE NG234: Spinal metastases and metastatic spinal cord compression — Recommendations (2023; current NICE guidance accessed August 2026) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations NICE NG234: Spinal metastases and metastatic spinal cord compression — PDF (2023; PDF current August 2026) — https://www.nice.org.uk/guidance/ng234/resources/spinal-metastases-and-metastatic-spinal-cord-compression-pdf-66143896133317