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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 63-year-old woman contacts her GP with 3 weeks of progressively worsening mid-thoracic back pain. It is now disturbing her sleep, is worse when she coughs and when rising from a chair, and has not responded to paracetamol or ibuprofen. She completed treatment for breast cancer 6 years ago and has had no known recurrence. She has no leg pain, sensory symptoms, weakness, gait disturbance, bladder or bowel dysfunction, fever or recent trauma. Examination shows localised mid-thoracic tenderness. Lower-limb power, reflexes, sensation and gait are normal. What is the most appropriate next referral and imaging plan?

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

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Correct answer: C — Seek advice through the MSCC coordinator within 24 hours and arrange local MRI of the spine within 1 week

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

This woman has a previous cancer diagnosis plus several pain characteristics suggesting spinal metastases: progressive pain, night pain, mechanical pain and pain aggravated by straining. This warrants advice through the metastatic spinal cord compression (MSCC) coordinator within 24 hours and spinal MRI within 1 week to guide treatment. She does not currently have symptoms or signs of cord compression: there is no gait disturbance, limb weakness, sensory loss, radicular pain or bladder/bowel dysfunction, and neurological examination is normal. Therefore, she does not meet the threshold for suspected MSCC requiring MRI as soon as possible and always within 24 hours (option C). A is inappropriate because suspected serious spinal pathology overrides routine non-specialist back-pain management. B is incorrect because plain spinal radiographs should not be used to diagnose or exclude spinal metastases or MSCC, and coordinator advice should not await imaging. D delays the required spinal assessment; staging investigations may follow, but do not replace timely MRI when spinal metastases are clinically suspected.

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 — Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations NICE NG234: Spinal metastases and metastatic spinal cord compression — Recommendations (2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations