01Approach to the Critical Patient/attcp38

Immediate priorities

›Oncologic emergency recognition

›MSCC is a time-sensitive neurologic emergency requiring immediate action

›Neurologic outcome is directly linked to ambulatory status at presentation

›Paraplegic >24 hours before treatment — surgical benefit diminishes significantly

›Activate oncology/neurosurgery/radiation oncology pathway immediately

›Notify spine surgery for emergent surgical evaluation

›Neurosurgery or orthopedic spine on-call paged within 30 minutes of diagnosis

›Initiate dexamethasone without waiting for MRI confirmation if high clinical suspicion

›Class I recommendation based on NCCN guidelines

›Dexamethasone 10–16 mg IV bolus immediately upon clinical suspicion

Neurological stabilization

›Airway threat from high cervical lesions

›Diaphragmatic compromise with C3–C5 lesions

›Respiratory failure may develop acutely

›Anesthesia and critical care involvement for airway planning

›SpO2 target 94–98%

›Supplemental O2 titrated to target

›If unable to protect airway, rapid sequence intubation

›Spinal shock from cervical or upper thoracic lesions

›Hypotension with paradoxical bradycardia

›SBP <90 mmHg with HR <60 — neurogenic shock pattern

›Vasopressors: norepinephrine 0.01–0.5 mcg/kg/min, titrate to MAP >85 mmHg

›Avoid hypotension — cord ischemia worsens with MAP <85 mmHg in acute SCI

›Target MAP 85–90 mmHg for first 7 days per spinal cord injury guidelines

›Immobilization

›Spinal precautions until imaging confirms stability

›Log roll for repositioning

02History/hx41

Presenting symptoms

›Pain characteristics

›Back pain in 83–96% of patients; may precede neurologic deficits by weeks

›Local axial pain over affected vertebra — most common

›Radicular pain in dermatomal band-like distribution

›Referred pain patterns: cervical lesions to midscapular; thoracic to hip; lumbosacral to thoracic

›Pain worse when supine with nocturnal awakening — distinguishing from degenerative disease

›Exacerbated by Valsalva, coughing, sneezing, or straining — suggests epidural involvement

›Pain unrelenting, progressive, and unresponsive to analgesics — alarm feature

Neurologic symptoms

›Motor deficits

›Progressive weakness in extremities

›Upper extremity weakness — cervical lesion

›Lower extremity weakness — thoracic or lumbar lesion

›Gait difficulty — early ambulatory compromise

›Inability to ambulate — advanced motor deficit; strongest prognostic indicator

›Sensory changes

›Numbness or paresthesias below a dermatomal level

›Saddle anesthesia — cauda equina involvement

›Autonomic dysfunction

›Urinary retention with overflow incontinence — pathognomonic for cauda equina

›90% sensitivity, 95% specificity for cauda equina syndrome

›Constipation or bowel incontinence — neurogenic bowel

›Autonomic dysreflexia in cervical or upper thoracic lesions

Cancer history

›Known malignancy

›Tumor type and stage — prostate, breast, lung account for 15–20% each

›Lymphoma, renal cell carcinoma, myeloma each 5–10%

03Physical Exam/exam39

Vital signs

›Hemodynamic assessment

›Hypotension with bradycardia — neurogenic shock from cervical or upper thoracic lesion

›Tachycardia — may reflect autonomic dysfunction or PE (high VTE risk in MSCC)

›Temperature — fever suggests concurrent infection or epidural abscess

Spine examination

›Focal spinal tenderness

›Percussion tenderness over affected vertebra — sensitivity 66–90% for MSCC

›Palpable step-off or vertebral deformity — pathologic fracture

›Paraspinal muscle spasm

›Range of motion limitation

›Cervical extension restriction

›Lumbar flexion limitation with radiation into legs

Neurological examination

›Motor assessment

›Systematic myotomal strength testing 0–5 scale all extremities

›Document motor level: most caudal level with normal strength bilaterally

›Gait evaluation if ambulation possible

›Tandem gait — early myelopathy sign

›Sensory assessment

›Sensory level to pinprick and light touch

›Maps to cord level: sensory level typically 1–2 segments below cord lesion

›Proprioception and vibration — posterior column involvement

›Saddle anesthesia to perianal pinprick — cauda equina

›Reflexes

›Hyperreflexia and Babinski sign — upper motor neuron; lesion above conus

›Hyporeflexia or areflexia — lower motor neuron; cauda equina syndrome

›Clonus — sustained clonus indicates significant myelopathy

04Differential Diagnosis/ddx38

Epidural causes

›Malignant epidural spinal cord compression

›ICD-10: G99.2; C79.51 (secondary malignant neoplasm of vertebrae)

›Known malignancy; MRI shows epidural mass with cord compression

›Most common at thoracic level (60%)

›Epidural abscess

›ICD-10: G06.1

›Fever, elevated ESR/CRP, elevated WBC, recent procedure or immunosuppression

›MRI with ring-enhancing epidural collection; gadolinium-enhancing rim

Vertebral causes

›Pathologic vertebral compression fracture without cord compression

›ICD-10: M48.50

›Pain without neurologic deficit; MRI shows marrow replacement without epidural extension

›Osteoporotic compression fracture

›ICD-10: M80.08XA

›Elderly patient; low bone density; no malignancy history; benign-appearing MRI signal

Intramedullary causes

›Intramedullary spinal cord metastasis

›ICD-10: G99.2; C79.49

›Rare; central cord syndrome pattern; lung cancer most common primary

›MRI shows intramedullary T2 signal change with enhancing lesion

›Transverse myelitis

›ICD-10: G37.3

›Inflammatory; often post-infectious or autoimmune; no cancer history

›MRI shows central cord T2 hyperintensity; CSF pleocytosis

Leptomeningeal causes

›Leptomeningeal carcinomatosis

›ICD-10: C79.32

05Laboratory Tests/lt31

Hematologic studies

›Complete blood count

›Anemia of chronic disease — common with advanced malignancy

›Hb <80 g/L may affect surgical candidacy

›Leukocytosis — infection vs. steroid effect; differentiate from epidural abscess

›Thrombocytopenia — affects surgical and anticoagulation planning

Metabolic studies

›Comprehensive metabolic panel

›Creatinine and eGFR — MRI with gadolinium; contrast planning; NSF risk

›Gadolinium contraindicated if eGFR <30 mL/min/1.73m2

›Calcium — hypercalcemia of malignancy in 10–20% of cases

›Corrected calcium >2.75 mmol/L — treat hypercalcemia concurrently

›Glucose — steroid-induced hyperglycemia common with dexamethasone

›Monitor glucose every 4–6 hours after dexamethasone initiation

›LFTs — liver metastases; drug metabolism for opioids and steroids

Coagulation studies

›Preoperative coagulation

›PT/INR — anticoagulant status; INR >1.5 increases surgical bleeding risk

›PTT — heparin effect

›Platelet count — surgical threshold typically >80 x 10^9/L

›Type and screen

›Vascular tumors (renal cell carcinoma, thyroid) can bleed significantly at surgery

›Cross-match 2–4 units pRBC if renal cell or thyroid primary

Tumor markers and special studies

›Tumor-specific markers

›PSA — prostate cancer (most common male primary)

›SPEP/UPEP with free light chains — multiple myeloma

›LDH — lymphoma (elevated LDH suggests high-grade disease)

06Diagnostic Tests/dt89

Scoring Systems

›Frankel grading scale

›Standard functional classification for MSCC severity

›Frankel A: complete motor and sensory loss below lesion

›Frankel B: sensory preservation only

›Frankel C: non-functional motor preservation

›Frankel D: functional motor preservation; ambulatory

›Frankel E: neurologically intact

›SINS (Spinal Instability Neoplastic Score)

›18-point score guiding surgical stabilization decisions

›Location: 0–3 points (junctional spine highest risk)

›Pain relief with recumbency: 0–3 points

›Lesion type: 0–2 points (lytic worst, blastic best)

›Radiographic spinal alignment: 0–4 points

›Vertebral body involvement: 0–3 points

›Posterior element involvement: 0–3 points

›SINS 0–6: stable — no surgery required for instability

›SINS 7–12: potentially unstable — surgical consultation recommended

›SINS 13–18: unstable — surgical stabilization indicated

›Tokuhashi score

›15-point prognostic score predicting survival

›General condition (KPS): 0–2 points

›Number of extraspinal bone metastases: 0–2 points

›Number of vertebral metastases: 0–2 points

›Number of internal organ metastases: 0–2 points

›Primary cancer type: 0–5 points

›Palsy: 0–2 points

›Score 0–8: predicted survival <6 months — palliative treatment

›Score 9–11: predicted survival 6–12 months — palliative or excisional surgery

›Score 12–15: predicted survival >12 months — excisional surgery may be considered

›NOMS framework (Neurologic, Oncologic, Mechanical, Systemic)

›Structured decision framework integrating tumor biology and mechanical stability

›Neurologic: degree and rate of deficit

›Oncologic: tumor radiosensitivity (radiosensitive vs. radioresistant)

›Mechanical: SINS score for stability

›Systemic: overall cancer burden and treatment tolerance

MRI

›MRI entire spine with and without gadolinium

›Gold standard for MSCC diagnosis

›Sensitivity 44–93%, specificity 90–98% for epidural cord compression

›NCCN recommends entire spine imaging regardless of clinical level

›Must image entire spine — 15–20% have additional lesions at other levels

›Up to one-third of patients have multiple noncontiguous levels of involvement

›Urgency: obtain within 24 hours of symptom onset; emergent if acute deficit

›MRI sequences and interpretation

›T1 — vertebral body marrow signal: hypointense in tumor infiltration

›Loss of normal fatty marrow signal

›T2 — cord signal: hyperintensity indicates edema or myelomalacia

›T2 cord signal change correlates with severity and prognosis

›STIR — highly sensitive for marrow edema and tumor infiltration

›Useful when gadolinium is contraindicated

›Post-gadolinium T1 — differentiates tumor from abscess (ring enhancement vs. homogeneous)

›Leptomeningeal disease: linear enhancement over cord surface

›Epidural Spinal Cord Compression Scale (ESCC)

›Six-point grading of epidural disease on axial MRI

›Grade 0: bone only, no epidural disease

›Grade 1a: epidural impingement without thecal sac deformation

›Grade 1b: thecal sac deformation without cord contact

›Grade 1c: cord contact without cord compression

›Grade 2: cord compression with CSF visible around cord

›Grade 3: cord compression, no CSF visible; ESCC 3 = highest risk

CT

›CT spine

›Indications and role

›MRI contraindicated (pacemaker, ferromagnetic implants) — CT myelogram alternative

›Superior bone detail: pathologic fracture assessment, cortical destruction

›Surgical planning: pedicle screw placement, vertebral body integrity

›CT chest/abdomen/pelvis

›Staging and unknown primary workup

›Lung cancer — most common unknown primary to present with MSCC

›CT myelogram

›Sensitivity and specificity equivalent to MRI when MRI contraindicated

›Intrathecal contrast injection; invasive; risk of post-procedure headache

›Bone windows interpretation

›Lytic lesion — bone destruction; renal, thyroid, lung, breast cancer

›Greatest instability risk with >50% vertebral body involvement

›Blastic lesion — bone formation; prostate cancer, carcinoid

›More mechanically stable than lytic lesions

›Mixed pattern — lung, breast cancer

Ultrasound

›Ultrasound in MSCC evaluation

›Limited direct role for spinal cord assessment

›Spinal cord not accessible to ultrasound in adults beyond neonatal period

›Bladder ultrasound — essential

›Postvoid residual measurement to assess for neurogenic bladder

›PVR >150 mL indicates retention requiring catheterization

›Intraoperative ultrasound

›Used during laminectomy to confirm adequacy of cord decompression

›Real-time guidance for tumor resection margins

›FAST and point-of-care ultrasound

›Not a primary diagnostic modality for MSCC

›Useful to evaluate hemodynamically unstable patients for concurrent pathology

›DVT assessment in lower extremities — high VTE risk in immobilized MSCC patients

07Disposition/dispo29

Admission criteria

›All patients with confirmed or suspected MSCC

›Mandatory inpatient admission for all symptomatic patients

›New or progressive neurologic deficit — emergent admission

›Intractable pain — urgent admission

›ICU or high-dependency unit for

›Cervical lesions with respiratory compromise

›Neurogenic shock requiring vasopressors

›Rapidly deteriorating neurologic status

Surgical candidacy evaluation

›Factors favoring surgical decompression

›Good performance status (KPS >70, ECOG 0–2)

›Expected survival >3–6 months

›SINS score 7–18 (unstable or potentially unstable)

›Radioresistant tumor histology (renal cell, sarcoma, melanoma, thyroid)

›Neurologic deficit from single-level compression

›Prior radiation to same site (reirradiation not feasible)

›Factors against surgery

›Poor performance status (KPS <40)

›Complete paraplegia >48 hours

›Multiple levels of compression with widespread systemic disease

›Patient preference for non-operative management

Transfer criteria

›Transfer to spine surgery center

›Surgical candidate but no spine surgery capability at presenting facility

›Transfer within 24 hours for non-ambulatory patients

›Emergent transfer for deteriorating ambulatory patients

›Dexamethasone loading dose given before transfer

08Treatment/t78

Corticosteroids

›Dexamethasone — initiate immediately upon clinical suspicion

›NCCN recommended standard dose: 4 mg IV every 6 hours (16 mg/day total)

›Initiate before MRI confirmation if high clinical suspicion

›NCCN CNS Cancers Guidelines v1.2026

›High-dose protocol: 96 mg IV bolus

›Supported by randomized trial for improved ambulatory outcomes

›Higher adverse effect rate: 14% serious AEs vs. 0% with standard dosing

›Cochrane 2015 Systematic Review — no clear superiority for neurologic recovery

›Taper strategy

›Begin taper over 1–2 weeks once definitive treatment (RT or surgery) initiated

›If no radiotherapy planned, longer taper guided by symptom response

›Concurrent protective medications

›PPI or H2 blocker — GI prophylaxis, especially perioperative or with NSAIDs

›PJP prophylaxis if steroids anticipated >4 weeks at dexamethasone >3 mg/day equivalent

›Blood glucose monitoring every 4–6 hours; insulin sliding scale as needed

Radiation therapy

›Conventional external beam radiation therapy (cEBRT)

›Indications

›Radiosensitive tumors (lymphoma, myeloma, prostate, breast)

›Non-surgical candidates or patient declines surgery

›Post-surgical adjuvant RT to residual or adjacent disease

›Typical regimens

›30 Gy in 10 fractions — most common palliative regimen

›20 Gy in 5 fractions — shorter course for poor performance status

›8 Gy in 1 fraction — single fraction for very short prognosis

›ASTRO Bone Metastasis Guidelines 2024

›Initiation timing

›Begin within 24 hours of diagnosis in non-surgical candidates with deficit

›Stereotactic body radiotherapy (SBRT)

›Indications

›Radioresistant tumors (renal cell, sarcoma, melanoma, thyroid)

›Reirradiation of previously treated sites

›Post-operative consolidation after separation surgery

›Dose fractionation

›18–24 Gy in 1 fraction for radioresistant histologies

›24–27 Gy in 3 fractions for post-operative treatment

›ESCC score <2 required before SBRT to avoid radiation myelopathy

›Requires surgical separation if ESCC grade 2–3 before SBRT delivery

Surgery

›Separation surgery with adjuvant SBRT

›Current standard of care for surgical candidates with MSCC

›Goals: decompress cord, stabilize spine, create 2–3 mm separation from cord for SBRT

›Not aimed at complete tumor removal — reduces morbidity

›Preferred approach: posterior decompression with instrumented fusion

›Posterolateral decompression with pedicle screw fixation

›Anterior approach for anterior column disease with good prognosis and kyphosis

›Patchell RCT (2005) — landmark trial showing surgery + RT superior to RT alone

›84% vs. 57% maintained or regained ability to walk

›122 days vs. 13 days median ambulatory duration

›Lancet Oncol 2005

›Percutaneous vertebroplasty and kyphoplasty

›Indications: pain control for vertebral compression fractures without significant cord compression

›Not for patients with posterior cortex destruction or epidural tumor

›Cement augmentation stabilizes pathologic fracture

›Pain relief in 70–90% within 48 hours

›Minimally invasive spine stabilization

›MIS techniques reduce blood loss and complication rates vs. open surgery

›Particularly beneficial for multilevel disease and high surgical risk patients

Analgesics and symptom management

›Pain management

›Opioid analgesics — first-line for moderate to severe pain

›Morphine oral: 5–10 mg every 4 hours (opioid-naive)

›IV morphine: 2–4 mg every 3–4 hours titrate to comfort

›Patient-controlled analgesia for severe intractable pain

›NSAIDs — adjunct with caution; avoid with concurrent steroids (GI risk)

›Gabapentin — neuropathic pain adjunct

›100–300 mg orally three times daily; titrate to 900–1800 mg/day

›Bowel and bladder management

›Urinary catheterization for retention — Foley catheter

›Stool softeners: docusate sodium 100–200 mg twice daily

›Stimulant laxatives for opioid-induced constipation: senna 8.6 mg twice daily

VTE prophylaxis

›Anticoagulation — mandatory for immobilized MSCC patients

›High VTE risk: spinal cord injury + immobility + malignancy

›10–50% incidence of DVT in untreated SCI patients

›Pharmacologic prophylaxis

›Low molecular weight heparin: enoxaparin 40 mg SC daily (CrCl >30 mL/min)

›Unfractionated heparin 5000 units SC every 8 hours if CrCl <30 mL/min

›Initiate 24–48 hours post-surgery once surgical bleeding risk acceptable

›Mechanical prophylaxis

›Sequential compression devices — initiate immediately on admission

›Continue mechanical until pharmacologic VTE prophylaxis initiated

09Special Populations/sp55

Pregnancy

›MSCC in pregnancy — rare but oncologic emergency

›MRI without gadolinium preferred

›Gadolinium crosses placenta — avoid in first trimester; use only if essential

›Non-gadolinium MRI maintains high sensitivity for cord compression

›Dexamethasone

›Generally safe across all trimesters at standard doses

›Increased risk of gestational diabetes with steroid use — monitor glucose

›Betamethasone may be preferred for fetal lung maturity if preterm delivery anticipated

›Radiation therapy considerations

›Fetal shielding essential; quantify fetal dose before RT

›SBRT with fetal shielding may be feasible for lumbar/lumbosacral lesions

›Thoracic RT carries lower fetal exposure risk than lumbar

›Surgical decompression

›Feasible in all trimesters if maternal neurologic status mandates

›Fetal monitoring throughout procedure

›Obstetrics and maternal-fetal medicine co-management required

Geriatric

›Frailty and performance status

›Standard performance status tools may underestimate frailty

›Comprehensive geriatric assessment before major surgical intervention

›Karnofsky Performance Status <50 — high surgical risk; favor RT

›Comorbidity burden affects treatment tolerance

›Cardiac and pulmonary disease — increased perioperative risk

›Renal impairment — affects contrast use and LMWH dosing

›Dexamethasone considerations in elderly

›Higher risk of steroid-induced hyperglycemia in diabetics and pre-diabetics

›More frequent glucose monitoring; earlier insulin initiation

10Background/b61

Epidemiology

›Incidence and prevalence

›MSCC affects approximately 2–5% of all cancer patients

›Estimated 20,000–25,000 cases per year in the United States

›Thoracic spine involved in 60% of cases

›Lumbar spine 25%

›Cervical spine 15%

›Multiple noncontiguous levels in up to one-third of patients

›Primary tumor distribution

›Prostate cancer: 15–20% of MSCC cases

›Breast cancer: 15–20%

›Lung cancer: 15–20%

›Lymphoma: 5–10%

›Renal cell carcinoma: 5–10%

›Multiple myeloma: 5–10%

›Unknown primary in approximately 7% of MSCC presentations

›Prognosis

›Median survival overall: 3–6 months

›Longer with favorable histology (breast, prostate, lymphoma, myeloma)

›Shorter with lung, renal, or colorectal primary

›Ambulatory patients at treatment: 75% remain ambulatory at 6 months

›Non-ambulatory patients at treatment: 10–30% recover ambulation

Pathophysiology

›Mechanisms of spinal cord compression

›Hematogenous spread to vertebral body — most common route

›Batson venous plexus: valveless epidural venous system allows retrograde tumor spread

›Preferential thoracic involvement due to vertebral volume and rich blood supply

›Direct tumor extension from paravertebral lymph nodes

›Intervertebral foramina entry — lymphoma and lung cancer common

›Leptomeningeal carcinomatosis — diffuse tumor in subarachnoid space

›Pathophysiology of cord injury

›Mechanical compression causing direct ischemia of cord parenchyma

›Epidural venous plexus congestion exacerbates ischemia

›Inflammatory cascade — VEGF release, edema formation

›Dexamethasone works primarily by reducing vasogenic edema

›Progressive cord ischemia leads to irreversible myelomalacia if untreated

›Time-dependent: neurologic injury accelerates as compression worsens

›Vertebral instability mechanisms

›Lytic destruction of >50% vertebral body — pathologic fracture risk

›Pedicle erosion — loss of posterior column integrity

›Junctional spine (cervicothoracic, thoracolumbar, lumbosacral) — highest instability risk

Therapeutic Considerations

›Treatment decision framework

›NOMS framework guides individualized management

›Neurologic deficit severity and progression rate

›Oncologic: tumor radiosensitivity stratification

›Mechanical: SINS instability scoring

›Systemic: overall tumor burden and treatment tolerance

›Radiosensitive tumors — cEBRT alone or after decompressive surgery

›Lymphoma, myeloma, small cell lung, prostate, breast, seminoma

›Radioresistant tumors — SBRT required with or without surgery first

›Renal cell carcinoma, sarcoma, melanoma, thyroid, non-small cell lung

›Surgery vs. radiation evidence base

›Patchell RCT (2005) — decompressive surgery + RT vs. RT alone

›84% vs. 57% ability to walk post-treatment

›Surgery group walked longer (median 122 vs. 13 days)

›NNT 3.7 patients treated to preserve one patient's ambulation

›Cochrane 2015 — no high-quality evidence favoring high-dose over standard-dose dexamethasone

›High-dose carries significantly higher adverse effect rate

›Emerging therapies

›Targeted therapy and immunotherapy reducing need for emergent intervention in some histologies

›BRAF inhibitors for melanoma; EGFR/ALK inhibitors for lung; anti-androgens for prostate

›Pre-emptive screening MRI for high-risk patients (PROMPTS trial, Lancet Oncol 2022)

›Screening castration-resistant prostate cancer patients with vertebral mets for early MSCC detection

11Patient Discharge Instructions/pdi36

copy discharge instructions

›Spinal cord compression from cancer — what to know

›Your cancer has caused pressure on your spinal cord or the nerves near your spine

›You were treated with steroids (dexamethasone) to reduce swelling

›You may be scheduled for radiation therapy, surgery, or both

›Take all prescribed medications as directed

›Dexamethasone — do not stop suddenly; taper only as directed by your doctor

›Stomach protection medication (antacid) — take with steroids to protect your stomach

›Pain medications — take as prescribed; do not drive while using opioids

›Monitor your blood sugar if you are diabetic or are prescribed steroids

›Steroids can raise your blood sugar significantly

›Activity restrictions

›Follow all mobility restrictions given by your care team

›Do not lift heavy objects unless cleared by spine surgery

›Use all mobility aids (walker, brace) as prescribed

›Prevent falls

›Your balance and leg strength may be affected

›Bathroom safety: grab bars, non-slip mats

›Ask for help getting up from bed or chairs

›Bowel and bladder care

›If you have a urinary catheter, keep the catheter clean and the bag below bladder level

›High-fiber diet and stool softeners to prevent constipation

›Report inability to urinate or bowel incontinence immediately

›Return to emergency department immediately for

›New weakness or worsening weakness in your arms or legs

›New or worsening numbness or tingling anywhere in the body

›Loss of bladder or bowel control (new incontinence or inability to urinate)

›Worsening or new back pain that is not relieved by your medications

12References/r39

Guidelines and key sources

›NCCN Clinical Practice Guidelines in Oncology — Central Nervous System Cancers v1.2026

›National Comprehensive Cancer Network; updated April 23, 2026

›SPINE-1 algorithm: workup and management of metastatic spine tumors

›Dexamethasone dosing, surgical, and RT recommendations

›Patchell RA et al. — Lancet Oncology 2005

›Landmark RCT: direct decompressive surgery vs. radiation therapy for MSCC

›Surgery + RT superior: 84% vs. 57% ambulatory post-treatment

›Foundation for surgical decompression recommendation

›ASTRO Clinical Practice Guideline — Bone Metastases — Practical Radiation Oncology 2024

›External beam RT fractionation guidance including single fraction regimens

›Supports 8 Gy x1, 20 Gy x5, 30 Gy x10 as equivalent for pain palliation

Supporting studies

›Ropper AE, Ropper AH — NEJM 2017

›Acute Spinal Cord Compression — comprehensive review

›Clinical assessment, MRI interpretation, management algorithm

›Cole JS, Patchell RA — Lancet Neurology 2008

›Metastatic epidural spinal cord compression review

›Pathophysiology, clinical features, management principles

›George R et al. — Cochrane Database of Systematic Reviews 2015

›Interventions for treatment of metastatic extradural MSCC

›No clear superiority of high-dose over standard-dose corticosteroids

›High-dose steroids: 14% serious adverse events vs. 0%

›Singer E et al. — Annals of Medicine 2025

›Initial management and disposition of MSCC in the ED

›Practical emergency medicine guidance for MSCC workup

›Lawton AJ et al. — Journal of Clinical Oncology 2019

›Multidisciplinary review of MSCC assessment and management

Evidence & Review

Evidence & Review