Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

This guideline covers spinal metastases and metastatic spinal cord compression (MSCC). NICE has produced visual summaries of the recommendations on:

The guideline is also relevant to direct malignant infiltration of the spine and associated cord compression.

1.1 Organising and delivering services

These recommendations are for cancer alliances (or equivalent local partnerships), commissioners and service providers involved in planning, organising and delivering services.

Cancer alliances and commissioners

1.1.1 Service commissioners, working with their cancer alliance, should:

  • ensure clear care pathways for referral, diagnosis, treatment, rehabilitation and ongoing care of people with suspected or confirmed spinal metastases or MSCC

  • ensure appropriate services are commissioned and in place for efficient and effective implementation of the care pathways

  • monitor services regularly through prospective audit of the care pathways (for example, collecting outcome data for treatments). [2023]

1.1.2 The cancer alliance should appoint a lead for MSCC whose responsibilities include:

  • advising the cancer alliance, commissioners and providers about the provision and organisation of clinical services

  • ensuring that the local care pathways are documented, agreed and implemented consistently across the alliance

  • maintaining an alliance-wide audit of incidence, timeliness of management and outcomes using nationally agreed measures

  • arranging and chairing regular meetings of the MSCC steering group (at least twice a year), at which treatment outcomes will be reported and the local care pathways reviewed and amended if necessary (see also recommendation 1.1.4 for details of the steering group). [2023]

1.1.3 Services within the cancer alliance (including those in primary, community, secondary and tertiary care) should have an identified lead healthcare professional for MSCC whose responsibilities include:

  • representing their service at alliance level in the development of care pathways

  • implementing and disseminating information about the care pathways

  • ensuring timely and effective communication between all relevant healthcare professionals involved in the care pathways, including those in palliative care

  • raising and maintaining awareness and understanding of treatments among all clinical staff across the locality

  • contributing to regular alliance MSCC audits of care

  • attending and contributing to regular alliance MSCC steering group meetings. [2023]

1.1.4 Every cancer alliance should have a steering group for MSCC that:

  • includes people with lived experience and representatives from primary, community, secondary and tertiary care

  • includes an MSCC service representative, for example, the MSCC coordinator

  • has strong links to cancer alliance groups for primary tumours. [2023]

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on cancer alliances and commissioners.

Full details of the evidence and the committee's discussion are in evidence review B: service configuration and delivery (management and rehabilitation).

Providing a coordinated MSCC and spinal metastases service

1.1.5 Ensure that there is a designated local MSCC service with clear processes and referral pathways so that all people with suspected or confirmed spinal metastases or MSCC are referred to an MSCC service with an appropriate level of urgency (see recommendations 1.3.2 and 1.3.3 about when to contact the MSCC coordinator, and recommendations 1.5.2 and 1.5.3 about when to offer an MRI scan). [2023]

1.1.6 MSCC services should ensure that the first point of contact for people referred to the service is the MSCC coordinator. When the MSCC coordinator is not working, the role should be carried out by a designated clinician with appropriate expertise (for example, an on-call oncology registrar). [2023]

1.1.7 MSCC services should ensure that the role of MSCC coordinator is covered at all times (24 hours a day, 7 days a week) and is based in an oncology service. [2023]

1.1.8 MSCC services should have arrangements in place to coordinate care between different specialties and services, for example, by having:

  • clear referral criteria and processes

  • processes for information sharing

  • effective channels for communication between specialties. [2023]

1.1.9 MSCC services should operate through a multidisciplinary approach, with key members from relevant specialties, including:

  • acute oncology

  • haematology

  • histopathology

  • oncology

  • palliative care

  • physiotherapy

  • radiology

  • spinal surgery. [2023]

1.1.10 Specialties providing treatment within the MSCC service (for example, spinal surgery and radiotherapy) should designate a single point of contact to liaise with other services, provide advice and contribute to the coordination of care. [2023]

1.1.11 MSCC services should establish links and communication pathways with primary and community care and other relevant services (for example, palliative care and social services) so that information about the person's care and support needs is shared effectively to ensure safe discharge from hospital, continuity of care and appropriate follow up (see also the section on providing support and rehabilitation services). [2023]

1.1.12 MSCC services should have systems and processes in place for recording data, audit evaluation, and investigating and reporting incidents. [2023]

1.1.13 Be aware of the impact of health inequalities (for example, deprivation) on outcomes for people with spinal metastases or MSCC. Ensure that:

  • information is collected and analysed by local services to identify any health inequalities

  • education is provided within services on reducing local health inequalities

  • reasonable adjustments are made by local services to address any health inequalities, in line with the Equality Act 2010. [2023]

1.1.14 Hospital and community services should establish coordinated care pathways with each other, and with social services, to ensure that people with spinal metastases or MSCC:

  • are discharged in a safe and timely manner and

  • receive the support they need for themselves and their families and carers once home. [2023]

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on providing a coordinated MSCC and spinal metastases service.

Full details of the evidence and the committee's discussion are in:

Roles in a coordinated MSCC and spinal metastases service

1.1.15 The person in the role of MSCC coordinator should ensure that:

  • key information about each person is recorded; this includes information on:

    • clinical presentation

    • neurological assessment

    • performance status

    • frailty assessment

    • investigations, including imaging reports

    • oncology assessment and disease staging

    • individual needs, preferences and circumstances (for example, language and communication needs)

  • initial triage of information about the person's care is performed

  • appropriate information is shared with primary care and with the multidisciplinary team

  • discharge planning is coordinated. [2023]

1.1.16 The person in the role of MSCC coordinator should provide initial advice to referring healthcare professionals on:

1.1.17 A senior clinician from the multidisciplinary team with expertise in diagnosing and managing spinal metastases and MSCC should develop a personalised care plan with the person. This should take into account the person's needs and preferences, and advice from the multidisciplinary team (see recommendation 1.1.9) and other clinicians, if relevant, such as:

  • allied health professionals

  • pharmacists

  • the referring health professional. [2023]

1.1.18 Centres treating spinal metastases or MSCC should ensure that a senior clinician is available at all times to give advice and support to the MSCC service. [2023]

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on roles in a coordinated MSCC and spinal metastases service.

Full details of the evidence and the committee's discussion are in evidence review A: service configuration and delivery – investigations.

Providing urgent imaging and radiotherapy services

1.1.19 MSCC services should ensure that there is local access to urgent MRI scans (within 24 hours) for all people with suspected MSCC who have neurological signs and symptoms. MRI scans should be available outside normal working hours if needed to start immediate treatment (see recommendation 1.5.4). [2023]

1.1.20 Imaging departments should make provision for short-notice spinal scans, taking into account the relative urgency of scans investigating suspected spinal metastases or MSCC (see recommendations 1.5.2 and 1.5.4). [2023]

1.1.21 MSCC services should ensure that radiotherapy and simulator facilities are available for urgent (within 24 hours) daytime sessions, 7 days a week for people with MSCC so that radiotherapy can be given within 24 hours of a decision to treat (see recommendation 1.10.4). [2023]

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on providing urgent imaging and radiotherapy services.

Full details of the evidence and the committee's discussion are in:

Providing support and rehabilitation services

1.1.22 Ensure access to community-based nursing and rehabilitation services, and equipment and support to meet the needs of people with suspected or confirmed spinal metastases or MSCC, and their families and carers. [2023]

1.1.23 Ensure access for people with MSCC to appropriate specialist rehabilitation services (including to specialist rehabilitation units) if they are likely to benefit from it, based on an assessment of their circumstances, their level of function and the type of treatment they received. [2023]

1.1.24 Discharge planning should be led by a named individual from within the responsible clinical team and involve:

  • the person and their family and carers, if appropriate

  • the primary oncology site team

  • the rehabilitation team

  • a pharmacist

  • community support, including primary care and specialist palliative care, if needed. [2023]

1.1.25 MSCC services should establish clear pathways of care, linking hospital and community-based healthcare and social services to ensure that equipment and support for people with MSCC returning home, and their families and carers, are available and coordinated. [2023]

1.1.26 MSCC and rehabilitation services should provide support and training to the families and carers of people with MSCC before discharge from hospital (see the section on support and training for carers in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs). [2023]

1.1.27 MSCC and rehabilitation services should take account of the section on discharge from hospital in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs for hospital discharge planning. [2023]

1.1.28 MSCC and rehabilitation services should take account of the principles of rehabilitation in the NICE guideline on rehabilitation after critical illness in adults. [2023]

For a short explanation of why the committee made these recommendations and how they might affect services, see the rationale and impact section on providing support and rehabilitation services.

Full details of the evidence and the committee's discussion are in evidence review B: service configuration and delivery (management and rehabilitation).

1.2 Information and support

Supporting decision making

1.2.1 Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers are given information and support that is tailored to their needs and preferences so that they are fully informed and supported to be involved in all decisions about their care. Follow the principles in NICE's guidelines on shared decision making and patient experience in adult NHS services. [2023]

1.2.2 Discuss with the person and their family or carers the reasons why investigations and treatments are being offered by the multidisciplinary team, and the risks and benefits of these, so that they fully understand their options and are involved in decisions about their care. [2023]

1.2.3 Give opportunities to the person and their family or carers to discuss their concerns and ask questions about issues such as:

  • their diagnosis and what it might mean for them

  • initial treatment options

  • risks and benefits of treatment options

  • how the condition could affect them in the future, including the possibility of worsening symptoms and functional decline

  • ways to manage pain

  • when further treatment options could be considered. [2023]

1.2.4 Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers know who to contact if they develop new symptoms or signs (see box 1) or if their existing symptoms worsen. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on supporting decision making.

Full details of the evidence and the committee's discussion are in evidence review C: information and support.

Providing support

1.2.5 Carry out a holistic needs assessment with the person, and their family or carers if appropriate, as soon as possible after initial diagnosis, once the person is physically and emotionally able to be involved in the assessment, and revisit this when needs or preferences change. [2023]

1.2.6 Give advice on how to access support based on the holistic needs assessment, including help with psychological, emotional, spiritual and financial needs. [2023]

1.2.7 Discuss with the person their needs and preferences and the support they receive, and aim to help them:

  • maintain their independence and quality of life

  • deal with uncertainty

  • adapt to potential changes in their level of function. [2023]

1.2.8 Discuss with the person and their family or carers their experience of the service and explore whether changes can be made to better meet their needs. Ask about any concerns they may have, such as:

  • accessing the service and attending appointments

  • undergoing investigations

  • adhering to treatment

  • their social and practical circumstances

  • disabilities that may be relevant to their care. [2023]

1.2.9 Offer the person opportunities to discuss advance care planning (with support from family and carers if appropriate). For principles of advance care planning, see the section on advance care planning in the NICE guideline on decision making and mental capacity and the NICE quick guide on advance care planning. [2023]

1.2.10 Offer the person end-of-life care, when appropriate, following NICE's guidelines on end of life care for adults and care of dying adults in the last days of life. [2023]

1.2.11 When the person is approaching the end of their life, discuss the bereavement support available with their family or carers and provide written information. Give advice on how to access bereavement support according to their wishes and preferences. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on providing support.

Full details of the evidence and the committee's discussion are in:

Support from healthcare services including discharge from hospital

1.2.12 Ensure that all people with spinal metastases or MSCC, and their families or carers, if appropriate:

  • have access to support and advice from the full range of healthcare services needed

  • are supported by healthcare services to adapt to changes and to maintain their independence and quality of life. [2023]

1.2.13 Ensure that people with spinal metastases or MSCC and their families or carers have ongoing access to support and training on appropriate care techniques and use of equipment both in hospital and after they are discharged home. This may include:

  • manual handling

  • use of spinal braces

  • use of equipment (such as wheelchairs)

  • managing bladder and bowel problems. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on support from healthcare services including discharge from hospital.

Full details of the evidence and the committee's discussion are in evidence review C: information and support.

1.3 Recognising spinal metastases or MSCC

For information on assessing low back pain, including risk assessment and the use of risk stratification tools, see NICE's guideline on low back pain and sciatica in over 16s.

1.3.1 Think about the possibility of spinal metastases or MSCC in people with any of the factors in box 1. See recommendations 1.3.2 to 1.3.6 for people presenting with current, past or suspected cancer and symptoms or signs of spinal metastases or cord compression. [2023]

Box 1 Factors suggesting spinal metastases or MSCC

Cancer:

Pain characteristics suggesting spinal metastases:

  • severe unremitting back pain

  • progressive back pain

  • mechanical pain (aggravated by standing, sitting or moving)

  • back pain aggravated by straining (for example, coughing, sneezing or bowel movements)

  • night-time back pain disturbing sleep

  • localised tenderness

  • claudication (muscle pain or cramping in the legs when walking or exercising).

Symptoms and signs suggesting cord compression:

  • bladder or bowel dysfunction

  • gait disturbance or difficulty walking

  • limb weakness

  • neurological signs of spinal cord or cauda equina compression

  • numbness, paraesthesia or sensory loss

  • radicular pain.

1.3.2 Immediately contact the MSCC coordinator if a person with a past or current diagnosis of cancer presents with the symptoms or signs of cord compression listed in box 1. Treat this as an oncological emergency. [2023]

1.3.3 Seek advice through the MSCC coordinator (within 24 hours) if a person with a past or current diagnosis of cancer presents with pain with the characteristics suggesting spinal metastases listed in box 1. [2023]

1.3.4 Discuss initial care with the MSCC coordinator, including the advice in recommendation 1.1.16. [2023]

1.3.5 If a person without a past or current diagnosis of cancer has any of the pain characteristics listed in box 1 and cancer is suspected, refer them for urgent oncology assessment (see also the NICE guideline on suspected cancer). [2023]

1.3.6 For people with a past or current diagnosis of cancer with low back pain but no clinical evidence of spinal metastases or MSCC (for example, previous imaging investigations), explain:

  • what changes in their symptoms they should look out for (see box 1)

  • that they should contact their healthcare professional urgently if their symptoms change or worsen. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on recognising spinal metastases or MSCC.

Full details of the evidence and the committee's discussion are in:

1.4 Immobilisation

1.4.1 Start immobilisation without delay (including for transfer to hospital) for people with:

1.4.2 Consider immobilisation for people with:

  • suspected or confirmed spinal metastases or MSCC and

  • moderate to severe pain associated with movement. [2023]

1.4.3 Nurse people who are immobilised in a supine position to minimise weight bearing by the spine (lying flat or with partial elevation). If they cannot tolerate the supine position, for example, because of pain or breathlessness, try adjusting their position to reduce these symptoms. [2023]

1.4.4 Seek early advice (within 24 hours) from an expert clinician (for example, a specialist physiotherapist, oncologist or spinal surgeon) and start assessment of spinal stability to minimise the duration of immobilisation, if appropriate. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on immobilisation.

Full details of the evidence and the committee's discussion are in evidence review H: immobilisation.

1.5 Imaging investigations

Radiologist involvement

1.5.1 Radiological imaging of the spine in people with suspected spinal metastases or MSCC should be overseen by a radiologist to ensure:

  • appropriate and complete imaging is performed and

  • they report the results urgently. [2023]

MRI assessment

1.5.2 Offer an MRI scan to people with suspected MSCC (see recommendation 1.3.2), to be performed:

  • as soon as possible (and always within 24 hours)

  • at the local hospital or appropriate centre with direct access to imaging facilities.

    Transfer to a tertiary centre for MRI should only be undertaken if local MRI is not possible. [2023]

1.5.3 Offer an MRI scan to guide treatment options for people with clinical suspicion of spinal metastases but without suspicion of MSCC (see recommendation 1.3.3), to be performed:

  • within 1 week

  • at the local hospital. [2023]

1.5.4 Offer overnight MRI only in clinical circumstances in which urgent diagnosis is needed to enable treatment to start immediately. [2023]

1.5.5 MRI of the spine 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 compression of the cord or cauda equina by a soft tissue mass and to assess possible MSCC and detect lesions within the cord itself

  • supplementary axial imaging through any significant abnormality noted on the sagittal scan. [2023]

1.5.6 In people with an existing diagnosis of spinal metastases without symptoms or signs of cord compression, do not perform MRI of the spine solely for the early radiological detection of cord compression. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on imaging investigations – radiologist involvement and MRI assessment.

Full details of the evidence and the committee's discussion are in:

Other imaging techniques for diagnosis and management

1.5.7 If MRI is contraindicated, carry out a CT scan for people with suspected spinal metastases or MSCC. Rarely, if more information is needed for diagnosis and to guide management, carry out myelography after CT scanning. [2023]

1.5.8 If myelography is indicated, only perform it at a neuroscience or spinal surgical centre. [2023]

1.5.9 Do not perform plain X-ray of the spine to diagnose or rule out spinal metastases or MSCC. [2023]

1.5.10 Consider multiplanar viewing or 3-plane reconstruction of recent or new CT images for people with spinal metastases or MSCC to:

  • assess spinal stability and

  • plan vertebroplasty, kyphoplasty or spinal surgery. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on imaging investigations – other imaging techniques for diagnosis and management.

Full details of the evidence and the committee's discussion are in:

1.6 Mobilisation and assessment of spinal stability

1.6.1 If assessment, including imaging, suggests spinal stability is likely (before or after treatment), start testing this by graded sitting followed by weight bearing. [2023]

1.6.2 Monitor neurological symptoms and pain continuously during mobilisation. [2023]

1.6.3 Continue to unsupported sitting, transfers and mobilisation if, during graded sitting and weight bearing, there is:

  • no evidence of orthostatic hypotension and

  • no significant increase in pain and

  • no deterioration in neurological symptoms. [2023]

1.6.4 If there is a significant increase in pain or neurological symptoms when the person begins graded sitting and mobilisation:

  • return them to a position where these changes reverse and

  • reassess the stability of their spine. [2023]

1.6.5 For a person with MSCC for whom surgery, radiotherapy or other oncology treatments are not appropriate, mobilisation should still be carried out if possible. [2023]

Using orthoses in mobilisation

1.6.6 Seek advice from a specialist (for example, a physiotherapist) on the use of orthoses to promote mobility and to prevent loss of range of limb movement. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on mobilisation and assessment of spinal stability.

Full details of the evidence and the committee's discussion are in evidence review H: immobilisation.

1.7 Pain management

Individualised pain assessment and management plan

1.7.1 Ensure adequate pain relief is provided promptly for people with suspected or confirmed spinal metastases or MSCC, including while the person is waiting for investigations or treatment. [2023]

1.7.2 Carry out an individualised pain assessment for people presenting with pain related to suspected or confirmed spinal metastases or MSCC. This should include assessing:

  • the severity, location and characteristics of the pain

  • the underlying cause of the pain and whether this has deteriorated

  • the impact of pain on lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

1.7.3 Discuss and agree a pain management plan with the person based on their individualised pain assessment and taking into account any previous strategies tried, as well as their concerns and expectations. Discussions may include:

  • why a particular management plan is being suggested

  • the psychological impact of pain, including the effect on emotional wellbeing

  • pharmacological analgesic treatment options, with individualised information and advice, including possible risks and benefits, and dosage titration

  • individualised coping strategies for pain

  • other treatment options, if suitable, for example:

  • when and how to seek further advice if pain persists, progresses or changes in character.

    For more information about involving people in decisions and supporting adherence, see the NICE guidelines on shared decision making and medicines adherence. [2023]

1.7.4 After starting or changing a pain management plan, carry out a clinical review to assess the effectiveness of the chosen treatment. [2023]

1.7.5 Consider referring the person to a specialist pain service (or, if appropriate, a palliative care service) if pain is difficult to manage at any stage, including at initial presentation, and if:

  • they have severe pain or

  • their pain significantly limits their lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on individualised pain assessment and management plan.

Full details of the evidence and the committee's discussion are in evidence review I: analgesic interventions.

Analgesic medication

1.7.6 When deciding on analgesic medication, discuss with the person and take into account:

  • the possible side effects

  • the possible effects on existing comorbidities and new comorbidities that could arise from treatment

  • concurrent medications (including over-the-counter medicines) and possible drug interactions. [2023]

1.7.7 Offer non-opioid or opioid analgesic medication, individually or in combination, to people with pain associated with suspected or confirmed spinal metastases or MSCC. The choice of medicine should be based on the ongoing individualised pain assessment and agreed in the pain management plan. [2023]

1.7.8 At each review, discuss analgesic drug dosage, titration, tolerability and adverse effects, and agree to continue or update the pain management plan where necessary. [2023]

1.7.9 For people with pain that has neuropathic features or is unresponsive to opioid analgesia, consider managing pain according to the NICE guideline on neuropathic pain in adults. [2023]

1.7.10 For people having strong opioids in palliative care, follow the recommendations on starting and titrating opioid analgesia and managing side effects in the NICE guideline on palliative care for adults. [2023]

1.7.11 When using strong opioids, follow the processes for their safe use and management in the NICE guideline on controlled drugs. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on analgesic medication.

Full details of the evidence and the committee's discussion are in evidence review I: analgesic interventions.

Bisphosphonates

In September 2023, the following were off-label uses of some bisphosphonates. See NICE's information on prescribing medicines.

1.7.12 For people with spinal involvement from myeloma or breast cancer, offer bisphosphonates to reduce pain and the risk of vertebral fracture or collapse. [2008]

1.7.13 For people with spinal metastases from prostate cancer, offer bisphosphonates to reduce pain only if conventional analgesia fails to control pain. [2008]

1.7.14 Do not use bisphosphonates to treat spinal pain in people:

  • with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer (if conventional analgesia fails) or

  • with the intention of preventing MSCC, except as part of a randomised controlled trial. [2008]

Denosumab

1.7.15 For people with bone metastases from breast cancer and from solid tumours other than prostate, follow the NICE technology appraisal guidance on denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on bisphosphonates and denosumab.

No evidence review was conducted in 2023. Full details of the evidence considered in the 2008 guideline and the committee's discussion are reported in the 2008 full guideline.

1.8 Corticosteroid therapy

1.8.1 For people with neurological symptoms or signs of MSCC:

  • Offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible.

  • After the initial dose, continue 16 mg of oral dexamethasone (or equivalent parenteral dose) daily for people awaiting surgery or radiotherapy.

  • After surgery or at the start of radiotherapy, reduce the dose gradually until stopped. [2023]

1.8.2 If dexamethasone is given before imaging, and spinal metastases and MSCC are subsequently ruled out, discontinue it. [2023]

1.8.3 Consider giving corticosteroids as part of initial management to people with spinal metastases or MSCC who do not have neurological symptoms or signs, if they have:

  • severe pain or

  • a haematological malignancy (see recommendation 1.8.5). [2023]

1.8.4 For people with spinal metastases or MSCC without other effective treatment options, reduce dexamethasone gradually until stopped. Only continue dexamethasone if the person's symptoms return or worsen as dexamethasone is reduced. [2023]

1.8.5 For people with confirmed haematological malignancy with spinal metastases (with or without neurological symptoms or signs):

  • Offer 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible.

  • After the initial dose, offer further corticosteroid treatment in discussion with the haematology multidisciplinary team. [2023]

1.8.6 Seek specialist haematological advice before starting corticosteroid treatment for people presenting with radiologically suspected lymphoma or myeloma with spinal metastases without neurological symptoms or signs. [2023]

1.8.7 Do not routinely offer corticosteroids as part of initial management for people with spinal metastases or MSCC who do not have neurological symptoms or signs, except where this is part of a radiotherapy regimen. [2023]

1.8.8 For people taking corticosteroid treatment:

  • monitor blood glucose levels and

  • offer proton pump inhibitor acid suppression. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on corticosteroid therapy.

Full details of the evidence and the committee's discussion are in evidence review J: corticosteroids.

1.9 Tools for assessing spinal stability and prognosis

1.9.1 Consider using a validated spinal stability scoring system with good evidence of accuracy (for example, the Spinal Instability Neoplastic Score) alongside clinical assessment of risk of spinal instability to inform treatment decisions. [2023]

1.9.2 Consider using a validated prognostic scoring system with good evidence of accuracy (for example, the revised Tokuhashi scoring system) alongside recognised prognostic factors (such as comorbidities) to inform treatment decisions. [2023]

1.9.3 Only use a scoring system as part of a full clinical assessment (including general health, pain and information from imaging) to support clinical decision making and inform discussions with the person with spinal metastases or MSCC and their family or carers. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on tools for assessing spinal stability and prognosis.

Full details of the evidence and the committee's discussion are in:

1.10 Radiotherapy

Radiotherapy and fertility

1.10.1 When considering radiotherapy as a treatment option, explain the impact of the cancer and its treatment on future fertility. Explore the person's priorities for fertility and offer referral to a fertility specialist if suitable, but do not delay urgent treatment for spinal metastases or MSCC. See also the section on people with cancer who wish to preserve fertility in the NICE guideline on fertility problems. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on radiotherapy and fertility.

Full details of the evidence and the committee's discussion are in evidence review M: radiotherapy.

Radiotherapy to treat painful spinal metastases and prevent MSCC

1.10.2 For people with spinal metastases without MSCC who have non-mechanical spinal pain:

  • offer 8 Gy single fraction radiotherapy, even if they are paralysed or

  • consider stereotactic ablative body radiotherapy for people with a good overall prognosis (see the section on tools for assessing spinal stability and prognosis) or oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement. [2023]

1.10.3 Be aware that radiotherapy for haematological malignancy with spinal metastases may reduce the success of stem cell harvest. If stem cell harvest is being considered, discuss the use of radiotherapy with the relevant haematology multidisciplinary team. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on radiotherapy to treat painful spinal metastases and prevent MSCC.

Full details of the evidence and the committee's discussion are in evidence review M: radiotherapy.

Radiotherapy to treat MSCC

1.10.4 Offer urgent radiotherapy (to be given as soon as possible and within 24 hours) to people with MSCC that is not suitable for spinal surgery, unless:

1.10.5 Use 8 Gy single fraction radiotherapy for people with MSCC having radiotherapy unless they are at high risk of side effects. [2023]

1.10.6 Consider multiple fraction radiotherapy for people at high risk of side effects from radiation, for example, if they have:

  • disease requiring a large treatment field or fields

  • had previous radiotherapy treatments. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on radiotherapy to treat MSCC.

Full details of the evidence and the committee's discussion are in evidence review M: radiotherapy.

Radiotherapy for asymptomatic spinal metastases

1.10.7 For people with asymptomatic spinal metastases, consider radiotherapy only:

  • as part of a randomised controlled trial with the intention of preventing MSCC or

  • as part of a treatment strategy for oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement or

  • if there are radiological signs of impending cord compression by an epidural or intradural tumour. [2023]

For a short explanation of why the committee made this recommendation and how it might affect practice, see the rationale and impact section on radiotherapy for asymptomatic spinal metastases.

Full details of the evidence and the committee's discussion are in evidence review M: radiotherapy.

Postoperative radiotherapy

1.10.8 Offer postoperative radiotherapy after the person has recovered from surgery for spinal metastases or MSCC. For information on surgery, see the section on invasive interventions. [2023]

Further radiotherapy treatment

1.10.9 Consider further radiotherapy for people with spinal metastases or MSCC who have:

  • had a good response to previous radiotherapy and

  • developed recurrent symptoms at least 3 months after initial radiotherapy. [2023]

1.10.10 If further radiotherapy is being considered, discuss the possible benefits and risks with the person and take into account the following factors before agreeing a treatment plan:

  • total biological equivalent dose

  • the time since the previous treatment

  • volume of tissue to be irradiated. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on postoperative radiotherapy and further radiotherapy treatment.

Full details of the evidence and the committee's discussion are in:

1.11 Invasive interventions

Timing of invasive interventions

1.11.1 Before an invasive intervention is offered, make a treatment plan in discussion with the appropriate specialists (such as an oncologist and spinal surgeon) within the MSCC service multidisciplinary team. [2023]

1.11.2 If the primary cancer has not been identified, carry out a radiologically guided biopsy if:

  • identifying the primary cancer may affect treatment decisions and

  • there is no need for immediate treatment. [2023]

1.11.3 Offer surgical intervention intended to halt or reverse neurological decline as soon as possible after the onset of neurological symptoms or signs indicating MSCC. [2023]

1.11.4 Take into account the speed of onset and rate of progression of neurological symptoms and signs when determining the urgency of surgical intervention. [2023]

1.11.5 Do not use a time limit after complete tetraplegia or paraplegia as the only factor to decide whether to offer surgical intervention to restore neurological function. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on timing of invasive interventions.

Full details of the evidence and the committee's discussion are in evidence review N: invasive interventions.

Options for invasive interventions

Interventions to treat spinal metastases without MSCC

1.11.6 For people with spinal metastases without MSCC who have suspected or confirmed spinal instability, or pain not controlled by analgesia, consider the following options alone or in combination:

Interventions to treat spinal metastases with MSCC

1.11.7 For people with spinal metastases with MSCC, consider the following options:

  • surgical decompression of the spinal cord

  • surgical stabilisation of the spine. [2023]

1.11.8 Offer spinal stabilisation surgery, even if there is a severe neurological deficit that may be irreversible, if a person with MSCC:

  • has suspected or confirmed spinal instability with mechanical pain that is not controlled by analgesia and

  • is able to have surgery and it is suitable for them. [2023]

1.11.9 Offer external spinal support (for example, a halo vest or cervico-thoraco-lumbar orthosis) if a person with MSCC:

  • has suspected or confirmed spinal instability with mechanical pain that is not controlled by analgesia and

  • surgery is not suitable for them. [2023]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on options for invasive interventions.

Full details of the evidence and the committee's discussion are in evidence review N: invasive interventions.

1.12 Rehabilitation and supportive care

See also the recommendations on providing support, and support from healthcare services, in the sections on information and support and providing support and rehabilitation services.

1.12.1 From diagnosis onwards, offer people with spinal metastases or MSCC support and rehabilitation from healthcare professionals and allied healthcare professionals, based on ongoing review of their management plan and holistic needs. [2023]

1.12.2 Focus rehabilitation on the person's priorities and goals as outlined in the section on setting rehabilitation goals in the NICE guideline on rehabilitation after traumatic injury. These could include:

  • improving functional independence

  • participation in activities of daily life

  • improving quality of life. [2023]

1.12.3 Start planning for discharge and ongoing care, including rehabilitation, on admission to hospital. [2023]

1.12.4 Offer specialist rehabilitation (including admission to a specialist rehabilitation unit if appropriate) to people with MSCC who are likely to benefit from it, based on an assessment of their circumstances, level of function and the type of treatment they received. [2023]

1.12.5 Offer supportive care to prevent and manage complications both during hospital stays and after discharge. If relevant, follow NICE guidance on:

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on rehabilitation and supportive care.

Full details of the evidence and the committee's discussion are in evidence review B: service configuration and delivery (management and rehabilitation).

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline. For other definitions, see the NICE glossary and the Think Local, Act Personal Care and Support Jargon Buster.

Cancer alliances

Cancer alliances bring together clinical and managerial leaders from different hospital trusts and other health and social care organisations, to transform the diagnosis, treatment and care for cancer patients in their local area. These partnerships enable care to be more effectively planned across local cancer pathways. For more information, see NHS England Cancer Alliances – improving care locally.

Direct malignant infiltration of the spine

Cancer that has spread beyond the layer of tissue in which it developed and is growing into the spinal column.

Holistic needs assessment

An assessment that considers all aspects of a person's wellbeing, their spiritual, cultural, and health and social care needs. Undertaking a holistic needs assessment ensures that the person's concerns and problems are identified so that support can be provided to address them.

  • National Institute for Health and Care Excellence (NICE)