How should I prioritize imaging studies in a patient with suspected MSCC, and what are the recommended modalities?

Appropriate prioritization of imaging studies in suspected malignant spinal cord compression (MSCC): An MRI scan should be offered as soon as possible and always within 24 hours at the local hospital or an appropriate centre with direct access to imaging facilities. Transfer to a tertiary centre for MRI should only occur if local MRI is not possible.

Recommended imaging modalities: The first-line imaging modality is MRI of the spine, which should include sagittal T1 and/or short TI inversion recovery (STIR) sequences of the whole spine to identify spinal metastases, sagittal T2-weighted sequences to show the level and degree of cord or cauda equina compression and to assess possible MSCC, and supplementary axial imaging through any significant abnormality noted on sagittal scans.

If MRI is contraindicated, a CT scan should be performed. In rare cases where more diagnostic information is needed, myelography after CT scanning may be considered but only at a neuroscience or spinal surgical centre.

Plain X-rays should not be used to diagnose or rule out spinal metastases or MSCC.