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Practice Guidelines

Diagnosis and management of patients at risk of or with metastatic spinal cord compression: summary of NICE guidance

BMJ 2008; 337 doi: (Published 27 November 2008) Cite this as: BMJ 2008;337:a2538
  1. B D White, consultant neurosurgeon1,
  2. A J Stirling, consultant orthopaedic spinal surgeon2,
  3. E Paterson, general medical practitioner3,
  4. K Asquith-Coe, project manager4,
  5. A Melder, senior researcher 4
  6. on behalf of the Guideline Development Group
  1. 1Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham NG7 2UH
  2. 2Royal Orthopaedic Hospital NHS Foundation Trust, Department of Spinal Surgery, Northfield, Birmingham B31 2AP
  3. 3Govan Health Centre, Glasgow G51 4BJ
  4. 4National Collaborating Centre for Cancer, Cardiff CF10 3AF
  1. Correspondence to: B White barrie.white{at}

    Why read this summary?

    Metastatic spinal cord compression is thought to affect more than 4000 people each year in the United Kingdom.1 2 Treatment before paralysis is clinically effective and cost effective. Despite the fact that spinal pain is often present for three months and neurological symptoms for two months before paraplegia, almost 50% of patients are unable to walk by the time of diagnosis.1 3

    Recognition is difficult as non-specific back pain is common in both the general population and patients with cancer.4 5 In addition, 23% of patients with spinal metastases have no prior cancer diagnosis.1 The added distress and disability caused by paralysis affecting someone already living with cancer cannot be overestimated.6

    This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on how to diagnose and manage patients at risk of or with metastatic spinal cord compression.7 The algorithm outlines the management of patients with suspected metastatic spinal cord compression (figure).

    Management of patients with suspected metastatic spinal cord compression


    NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Early recognition and diagnosis

    • For patients who have cancer and bone metastases or a high risk of developing bone metastases, and for patients with cancer who present with spinal pain, offer information on the symptoms of spinal metastases and metastatic spinal cord compression and what to do and whom to contact if symptoms develop or worsen while waiting for investigation or treatment. [Based on the experience of the Guideline Development Group]

    • In patients with cancer, the following suggest spinal metastases: pain in the thoracic or …

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