Suspected metastatic spinal cord compression

NICE NG234 (2023); NICE QS56

Whole-spine MRI within 24 hours, and the word that carries the clinical weight is whole. Multilevel and skip metastatic disease is common, so imaging only the symptomatic level treats the level that hurts and misses the one that will paralyse.

A patient with known or suspected malignancy who develops new or progressive spinal pain, limb weakness, a sensory level, gait disturbance or sphincter dysfunction.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Time since onset

Decides thrombolysis and thrombectomy windows, testicular salvage, and whether an ischaemic limb is still salvageable.

Focal neurological deficit

Red flags

These accumulate rather than exclude. Back pain with one of these is a different question from back pain.

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

MRI Whole Spine — suspected metastatic cord compression

MRI Whole Spine

What we'd amend, and why

Only MRI shows the epidural soft-tissue component and the cord itself, which is the finding that defines compression — bony destruction on CT correlates poorly with whether the cord is actually being compressed. The coverage is whole spine rather than the symptomatic level for a specific reason: metastatic deposits are frequently multilevel and non-contiguous, referred pain localises poorly, and a second unimaged level determines both the radiotherapy field and whether surgical stabilisation will work. Imaging only where the patient points is the characteristic failure of this pathway.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults
rulerule-mr-device-screening — MR safety screening for implants and foreign bodies; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(1)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

MR safety screening for implants and foreign bodies
Complete the MR safety questionnaire, verify implant labelling and its stated conditions of use against this scanner and this protocol, and ensure no ferromagnetic object enters Zone IV.
Radiographer at the scannerBefore the scan
Flags back if: An implant or retained foreign body that is MR Unsafe, unlabelled, or cannot be identified; or an MR Conditional device whose stated conditions this scanner or the requested protocol cannot satisfy; or a credible unexcluded intraocular metallic foreign body history.
Time-critical: device screening runs alongside transfer and preparation, never as a queue in front of the scan. Where an implant cannot be identified quickly, escalate to the on-call radiologist and the MR safety expert in parallel rather than deferring the appointment — a delay measured in days here is measured in permanent neurological function.

Worth asking the referrer (1)

None of these hold the request up. They sharpen the protocol or the plan that follows.

Is there weakness, a sensory level, gait disturbance or sphincter dysfunction, and how quickly is it progressing?
It determines the urgency band rather than the study, and it is what the treating team needs recorded before treatment starts. It never delays the request being accepted.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Deficit progressing over hours — image now, not within 24 hours

Role	Study & protocol	Why this answers the question
First line	MRI Whole Spine MRI Whole Spine — suspected metastatic cord compression usually appropriate	Same study, same coverage, different clock. The deficit present when treatment starts is broadly the deficit the patient keeps, so in a deficit that is measurably worse than it was this morning the 24-hour standard is a maximum and not a plan — this is a scan tonight, ahead of the elective list, with the radiotherapy or surgical team told before the images are cold. Whole spine remains non-negotiable: multilevel and non-contiguous deposits are common, referred pain localises poorly, and the level that determines the radiotherapy field or the surgical construct is regularly not the level that hurts. Corticosteroids are started on suspicion and do not wait for the scan.
Second line	CT Thoracic Spine CT Thoracic Spine — Unenhanced, Thin Section	Only where MRI is genuinely impossible, and the limits are sharper the faster the patient is deteriorating: CT shows bone destruction and retropulsion and cannot show the cord or an epidural mass, so a reassuring CT in a patient losing power by the hour is actively misleading. If the local scanner cannot deliver the MRI tonight, transfer is the answer rather than substitution.

Adults

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	MRI Whole Spine MRI Whole Spine — suspected metastatic cord compression usually appropriate	Only MRI shows the epidural soft-tissue component and the cord itself, which is the finding that defines compression — bony destruction on CT correlates poorly with whether the cord is actually being compressed. The coverage is whole spine rather than the symptomatic level for a specific reason: metastatic deposits are frequently multilevel and non-contiguous, referred pain localises poorly, and a second unimaged level determines both the radiotherapy field and whether surgical stabilisation will work. Imaging only where the patient points is the characteristic failure of this pathway.
Second line	CT Thoracic Spine CT Thoracic Spine — Unenhanced, Thin Section	Only where MRI is genuinely impossible, and with its limits stated plainly: CT shows bony destruction, vertebral body collapse and the retropulsion that suggests canal compromise, but it cannot show the cord or an epidural soft-tissue mass. It is also the study that plans instrumentation once compression has been confirmed by MRI.

Corticosteroids and oncology referral are started on clinical suspicion. The scan confirms and maps; it does not gate treatment.

Pitfalls

Restricting the study to the symptomatic level. Multilevel disease is common and the unimaged level is the one that presents as the next emergency.
Accepting a CT request as equivalent. CT cannot demonstrate cord compression, and a reassuring CT in this setting is actively misleading.
Attributing collapse to osteoporosis without looking for a soft-tissue component, marrow replacement or posterior element involvement.
Allowing routine safety or transport logistics to push a same-day scan into the next day. Neurological function at treatment is what the patient keeps.
Overlooking the conus and cauda equina, where a lesion produces a very different clinical syndrome and a different surgical approach.

Priors — what to pull first

Recent staging CT or PET frequently already shows the vertebral deposits and can be reviewed while the MRI is being arranged.
Compare with any previous spinal imaging to distinguish a pathological collapse from an old osteoporotic one, which is the commonest source of confusion in this group.

What makes a good request

NICE places whole-spine MRI within 24 hours of the suspected diagnosis for adults with neurological symptoms or signs, and identifies the study as central to diagnosis, staging and treatment planning rather than as confirmation of a clinical impression.
Neurological function at the time of treatment is the strongest predictor of function afterwards. That is why this is an hours question rather than a days question: the deficit present when treatment starts is broadly the deficit the patient keeps.
Severe progressive spinal pain in a patient with known malignancy, even without neurology, is an indication in its own right, because impending compression is what treatment is trying to get ahead of. NG234 separates the two timescales explicitly: whole-spine MRI within one week for suspected spinal metastases, and within 24 hours where there are neurological signs or symptoms suggesting cord or cauda equina compression. Neither is a target to aim at — both are ceilings.
A single symptomatic level is not the disease. The whole-spine survey defines the radiotherapy field and identifies the additional levels that would otherwise present as a second emergency weeks later.

Scoring this once it is done

The classification and risk tools this question ends in.

SINS (Spinal Instability Neoplastic Score)ASIA Impairment Scale (AIS) with Frankel Mapping

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

MRI Whole Spine — suspected metastatic cord compression CT Thoracic Spine — Unenhanced, Thin Section

Confirm locally

MRI Whole Spine — suspected metastatic cord compression: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.