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Suspected metastatic spinal cord compression — MRCEM SBA MCQ

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EasyNeurological emergenciesSuspected metastatic spinal cord compressionMRCEM SBA

A 67-year-old woman receiving treatment for breast cancer presents with three days of worsening thoracic back pain and new difficulty walking. Examination shows bilateral leg weakness, brisk knee reflexes and reduced sensation below the umbilicus. She is haemodynamically stable, has no contraindication to MRI and has been positioned to minimise spinal loading. What is the most appropriate immediate management plan?

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Correct answer: D — Contact the MSCC coordinator, give dexamethasone 16 mg now and arrange MRI within 24 hours.

Cancer with progressive back pain, new gait difficulty, bilateral weakness and a sensory level raises suspicion of metastatic spinal cord compression (MSCC), rather than uncomplicated spinal metastases. This is an oncological emergency: the MSCC coordinator should be contacted immediately. Neurological signs warrant dexamethasone 16 mg as soon as possible, without waiting for confirmation, and MRI should be obtained as soon as possible and within 24 hours. Continue precautions to minimise spinal loading while stability and definitive treatment are assessed. ([nice.org.uk](https://www.nice.org.uk/guidance/ng234/chapter/recommendations)) A selects the right investigation but delays indicated corticosteroid treatment. B gives dexamethasone promptly, but the one-week MRI timeframe applies to suspected spinal metastases *without* suspected cord compression. C is reasonable if MRI is contraindicated; it is not the preferred investigation here. E anticipates a possible definitive treatment, but surgery or radiotherapy must be selected after imaging and specialist assessment, not before the site and extent of compression are established. Her ability to remain stable in the emergency department does not reduce the urgency created by the new neurological findings. ([nice.org.uk](https://www.nice.org.uk/guidance/ng234/chapter/Recommendations))

Reference: NICE NG234, recommendations 1.3.1–1.3.2: recognising MSCC (6 September 2023) — https://www.nice.org.uk/guidance/ng234/chapter/recommendations NICE NG234, recommendations 1.5.2–1.5.3: MRI assessment (6 September 2023) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations NICE NG234, recommendations 1.8.1–1.8.2: corticosteroid therapy (6 September 2023) — https://www.nice.org.uk/guidance/ng234/chapter/Recommendations