Initial management and disposition of metastatic spinal cord compression in the emergency department: a review of the literature.

Background

Metastatic spinal cord compression (MSCC) is a serious condition that can complicate the course of various malignancies. While spinal cord compression lacks a standardized definition, MSCC usually presents with several neoplastic deposits in the vertebral column or the epidural space that cause pressure on the spinal cord. Prostate, breast, and pulmonary malignancies are well known for their predilection for spinal involvement and together constitute 45%-60% of MSCC instances [ 1 ]. Less common tumor types associated with MSCC encompass multiple myeloma, renal cell carcinoma, sarcoma, non-Hodgkin lymphoma, colorectal neoplasms, and malignancies of unknown origin [ 2 ]. Managing MSCC in the emergency room is particularly challenging due to the need for rapid diagnosis, multi-specialties coordination, and urgent intervention to prevent irreversible neurological damage.

Given the complexity of MSCC management in the emergency room, the appropriate disposition of patients with MSCC is essential for timely and comprehensive care. The disposition depends on the severity of a patient’s clinical presentation. Stable patients with strong home support can opt for outpatient care with follow-up. Some may need up to 24 h of clinic observation. Severe cases require urgent inpatient admission and potential surgery. Consultative services from radiation oncology or neurosurgery may be appropriate to determine the best treatment pathway between radiotherapy, surgical de-compression, or a combined treatment approach. Dexamethasone can also aid in the acute setting by decreasing spinal cord oedema and associated symptoms, improving patient comfort and quality of life.

The degree of involvement within the epidural space and the extent of spinal cord displacement exhibit variability, and these considerations significantly influence treatment choices [ 3 ]. In this review, we aim to cover the multidisciplinary approaches for managing MSCC in its various manifestations in the emergency setting.

Incidence

The prevalence of MSCC among cancer patients varies between 0.2% and 7.9%, depending on the cancer type [ 1 , 2 , 4 ]. MSCC involves the thoracic vertebrae in 65% of cases, followed by the lumbosacral region in 25% and the cervical region in 10%, with a notable proportion of patients (20%–35%) presenting with MSCC in multiple sites [ 1 , 2 , 4 ]. In more recent literature, the overall prevalence of clinically overt spinal metastatic lesions in patients with solid cancers was 15.7% [ 5 ]. However, postmortem studies show that 30% of decedents have spinal metastatic lesions, suggesting an underdiagnosis [ 5 ]. Meanwhile, 10% of patients with spinal metastasis will go on to develop metastatic extradural spinal cord compression, while another 12.6% will have pathological vertebral body compression fractures [ 5 ].

Etiology and pathophysiology

MSCC transpires due to hematogenous dissemination, initially affecting the vertebral body and subsequently encroaching upon the epidural space. This mechanism accounts for up to 85% of MSCC cases [ 1 , 6 ]. Less frequently, MSCC results from tumour infiltration of paravertebral tissue or sudden collapse of a vertebral body, resulting in the displacement of bone fragments into the epidural space [ 1 , 7 , 8 ]. These events are often, but not always, secondary to metastases or direct extensions of a primary tumour. Intramedullary and leptomeningeal metastases can also provide occasional sources of MSCC [ 9 ].

The pathophysiology of MSCC is based on mechanical compression of the spinal cord, which triggers a sequence of secondary events. First, this compression raises venous hypertension and causes oedema in the white matter. These processes further compromise the arterial blood supply, eventually progressing to infarction of the cord parenchyma, leading to cellular death [ 1 , 7 ]. The early use of steroids, which work by reducing oedema, is hypothesized to help protect the spinal cord from infarction. Steroids may also have direct and specific tumoricidal effects in tumours such as leukaemias and lymphomas [ 1 ].

Medical history

The earliest possible intervention is crucial for a positive outcome for MSCC and requires an understanding of the range of presentations. Acute spinal cord compression caused by metastases has a variable and non-specific presentation, and patients might have atypical symptoms such as radicular pain, motor weakness, sensory disturbance, and autonomic dysfunction [ 10 , 11 ]. If left untreated, symptoms can progress rapidly, and patients can develop debilitating and permanent neurological deficits [ 10 , 11 ]. A detailed history is the first step in making an accurate diagnosis.

Spinal cord metastases often present insidiously, with non-specific axial stiffness and pain, especially in patients with an underlying malignancy history. Progressive back pain, particularly at night or with recumbency, could be suggestive of vertebral metastasis. Radicular pain might suggest nerve root impingement by a metastatic tumour [ 10 , 11 ]. Pain that is exacerbated by being supine or recumbent should raise suspicion for vertebral involvement. Additionally, any motor or sensory deficits, such as weakness in the limbs, paresthesia, or urinary and bowel dysfunctions, also warrant attention to the possibility of spinal cord compromise [ 10 , 11 ]. Difficulty climbing stairs, muscular stiffness or urinary retention, and constipation merit emergent evaluation for possible spinal cord decompression to stop the progression of irreversible neurological damage [ 10 , 11 ].

Physical examination

Although a thorough physical examination is integral to the initial evaluation of spinal cord compression, clinical findings can be nonspecific or absent, particularly in early or acute presentations. Combining physical examination with a high index of clinical suspicion and timely imaging is essential to ensure prompt diagnosis and management. Findings such as radicular pain, percussion tenderness, motor asymmetry, or sensory deficits and abnormalities, although not specific, are commonly seen in MSCC [ 12 ]. Sensory testing and muscle strength testing might allow localization of the neurological level of the injury [ 12 ]. Upper motor neuron signs such as hyperreflexia, spasticity, variable reflex activity, and the Babinski sign may also be present, though their presence is inconsistent and they may not be detectable in the initial stages, especially during acute or rapidly progressing cases.

The American Spinal Injury Association (ASIA) impairment scale (AIS) provides a structured framework for classifying spinal cord injuries based on detailed sensory and motor neurologic examination [ 13 , 14 ]. It is widely used to assess neurologic deficits in patients with MSCC, including those who present to the ED. The scale assigns grades from A (complete loss of function) to E (normal neurologic function) [ 13 , 14 ]. Grade A is characterized by a total absence of motor and sensory activity in the sacral S4–S5 region as assessed by light touch, pinprick testing, and anal sphincter control. Grade B applies when sensation is preserved, but motor control is lost at spinal levels below the lesion. Grade C includes present but impaired motor function below the spinal level of the injury, though most key muscles are nonfunctional (strength <3). In Grade D, more robust motor functions are observed with more than half of key muscle functions at strength ≥3. Grade E represents full function or no clinical manifestation [ 13 , 14 ].

In the ED, AIS can support rapid neurologic assessment and triage, determine the extent of spinal compromise and track any deterioration or change in the neurologic status. The ASIA scale is incorporated within the neurologic component of the NOMS framework, which helps to personalize MSCC treatment by integrating neurologic impairment with tumour behaviour, spinal stability, and overall health. Together, AIS and NOMS support evidence-based triage and care planning in the ED [ 15–19 ], which, alongside diagnostic imaging and other clinical findings, can provide a comprehensive approach to MSCC care in the emergency setting, guiding consultations, multidisciplinary care coordination, glucocorticoid use, and the proper disposition of the patient [ 17 , 19–23 ].

Diagnostic imaging

Urgent imaging is crucial when MSCC is suspected. Magnetic resonance imaging (MRI) of the entire spine is the gold standard [ 24 ], as it enables comprehensive evaluation of tumor location, grade, and extent of involvement [ 1 , 25 , 26 ]. According to the American College of Radiology, MRI of the spine with and without intravenous contrast (gadolinium) is the recommended first imaging study for suspected MSCC, provided there are no contraindications to contrast use [ 27 , 28 ]. The 6-point MRI-based grading system developed by Bilsky et al. ( Table 1 ) offers a reliable and reproducible framework for assessing epidural spinal cord compression, with the highest consistency observed using T2-weighted axial images [ 3 ]. Moreover, MRI is particularly valuable given that MSCC frequently involves multiple spinal levels/sites. It also helps differentiate between benign and malignant cord compression causes [ 7 ].

When MRI is not feasible due to specific patient factors, alternatives such as X-ray myelography or computed tomography of the spine with contrast can be considered [ 29 ]. These methods have lower soft-tissue resolution than MRI but can assess spinal stability. Studies comparing MRI and myelography for the detection of MSCC show that MRI has varying sensitivity (44%–93%) and high specificity (90%-98%), while myelography has a sensitivity (71%-95%) and specificity (88%–100%) [ 30–33 ]. Myelography is less common due to the need for specialized expertise, invasiveness, potential risks, and the time-consuming nature [ 30 ].

Initial management and emergency disposition

Patients diagnosed with MSCC should be broadly categorized into distinct sub-groups, each demanding a tailored approach to patient disposition. Some cases necessitate immediate surgical decompression to alleviate spinal cord compression and prevent further neurological deterioration. In contrast, others might benefit significantly from prompt initiation of radiotherapy to mitigate tumour burden and relieve associated symptoms. For those with stable neurological function and adequate home support, safe discharge with diligent outpatient follow-up and palliative care support can be appropriate, ensuring continued monitoring of symptoms and treatment response. Additionally, certain patients might warrant placement in a clinical observation unit for 24 h, allowing for close surveillance of their neurological status and response to initial therapeutic interventions, thereby facilitating timely adjustment of the management plan based on emerging clinical insights. Stratifying these patients into distinct subgroups is crucial for optimizing outcomes and ensuring the timely delivery of appropriate interventions tailored to their unique clinical needs. Figure 1 illustrates our workflow for emergency management of suspected MSCC in accordance with current practice and available evidence from different guidelines that are summarized in Table 2 .

MSCC is a medical emergency that requires immediate intervention to mitigate the risk of advancing neurological impairments. The urgency of intervention in cases of spinal cord compression is directly related to the rate of motor deficit development. When motor deficits evolve gradually over 7 days, it presents a more favourable scenario for retaining ambulatory function, and radiotherapy becomes a viable treatment option [ 34 ]. In such instances, the slower progression provides an opportunity to intervene effectively [ 34 ]. Conversely, when motor deficits present rapidly, over 24–48 h, the situation becomes more critical: early diagnosis and treatment planning are necessary to maintain the integrity of the spinal cord and minimize the risk of permanent neurological damage [ 34 ].

Ideally, a tissue diagnosis will be established before steroid treatment begins because steroid therapy can alter cellular morphology, particularly in haematological malignancies [ 35 ]. A rapid, comprehensive assessment should include a thorough history, a detailed physical and neurological examination, an evaluation of performance status, and screening for malignancies that commonly affect the spine (including a myeloma screen and serum prostate-specific antigen level) [ 35 ]. Based on the clinical findings, specific tumour markers to assist diagnosis and treatment planning should be requested [ 35 ].

In general, glucocorticoids should be started for MSCC as early as possible, unless there are clear contraindications or there is diagnosis uncertainty. Following the completion of diagnostic procedures, glucocorticoids should be promptly initiated and not be postponed till after consultations, given that timely treatment can prevent functional decline, cord edema, and irreversible neurologic injury [ 20 , 21 , 36 , 37 ]. Glucocorticoids can be initiated when MSCC is clinically suspected prior to the completion of the diagnostic workup, particularly in cancer patients with progressive neurologic symptoms [ 19 , 20 , 36–38 ], with heightened urgency in EDs where access to MRI or specialist/neurosurgery is limited [ 19 , 36 , 37 , 39 ]. A study conducted in this context compared high-dose steroids to no steroids and showed significantly greater probability for continued or regained ambulation at 3 and 6 months after steroid treatment [ 40 ]. The consensus recommendation is to commence treatment with a loading dose of 10 to 20 mg of intravenous dexamethasone, followed by 16 mg per day (4 mg q6h) with a subsequent tapering regimen [ 40–42 ]. A proton pump inhibitor for gastric protection is advisable, especially if the patient is concurrently using nonsteroidal anti-inflammatory drugs (NSAIDs) [ 43 ].

Pain control related to MSCC often follows a stepwise pathway, starting with non-opioid analgesics (i.e. NSAIDs and paracetamol), mild opioids (codeine, tramadol) for mild to moderate breakthrough pain, and strong opioids (morphine, oxycodone, hydromorphone, transdermal fentanyl) for severe breakthrough pain [ 44 ]. It is imperative to initiate these medications cautiously, gradually titrate their doses, and rotate them as necessary to achieve adequate analgesia while mitigating the risk of opioid-related adverse events [ 44 ]. Furthermore, complementary agents can be incorporated into the pain management regimen based on the specific nature of the pain [ 44 ]. For instance, gabapentin or pregabalin can be considered for neuropathic pain, steroids for inflammatory pain, and bisphosphonates for bone-related pain [ 44 ]. By tailoring the pain management strategy to the patient’s needs and the characteristics of their pain, it is possible to improve their comfort and quality of life while they undergo treatment for their MSCC.

Frameworks for treatment decisions

The NOMS (Neurologic, Oncologic, Mechanical, and Systemic) framework, mostly used in clinical practice, categorizes patients based on neurological criteria, distinguishing between low-grade (Grades 0–1) and high-grade (Grades 2–3) spinal cord compression [ 3 , 17 ]. High-grade MSCC is determined by neurological symptoms (e.g. motor or sphincter dysfunction) or radiographic evidence of cord compression or displacement, assessed using a 6-point MSCC scale. Patients with low-grade epidural spinal cord compression (ESCC) typically do not benefit from surgery unless mechanical instability is present, making RT the preferred treatment. In contrast, symptomatic high-grade ESCC often requires urgent surgical intervention to prevent permanent neurological damage [ 45 , 46 ]. However, surgery is generally not beneficial for patients with prolonged paraplegia due to irreversible neurological injury, and RT alone is recommended [ 45 , 46 ]. Many studies exclude patients with complete paraplegia lasting >24–72 h from surgical consideration, as the likelihood of neurological recovery diminishes over time [ 47–49 ].

In addition to NOMS, the Spine Instability Neoplastic Score (SINS) criteria were established through expert consensus and incorporated six clinical and radiographic parameters, yielding a total score of 18. This scoring system aids in identifying patients with spinal instability, defined by a score exceeding 12, who are likely to benefit from surgical intervention [ 50 ].

Role of radiotherapy and surgery

Historically, surgical decompressive laminectomy was not found to be superior to RT alone for pain management and ambulation improvement in patients with MSCC [ 51–53 ]. However, contemporary surgical techniques that include decompression and spinal stabilization have shown better outcomes, especially when the tumor affects the anterior aspect of the spinal cord [ 54 ]. These interventions, if administered within 48 h of the patient’s acute presentation, are associated with better outcomes [ 55 ]. A randomized trial demonstrated that surgery followed by radiotherapy was more effective in preserving ambulation status compared to radiotherapy alone, leading to an early trial termination [ 49 ]. Of note is that the study was conducted at a single centre with accrual spanning over a decade, so the findings might have limited generalizability to routine, real-world practice and broader clinical settings. In conclusion, while radiotherapy is commonly used for MSCC, surgical techniques, such as decompression and stabilization, often yield better outcomes.

Prognosis

Failure to promptly identify and treat MSCC can result in debilitating consequences, such as paraplegia, quadriplegia, sensory neuropathies, and impairments in bladder and bowel function, whose severity depends on the extent of spinal cord involvement. Early diagnosis and treatment are crucial for patients with acute MSCC, as delays can lead to permanent neurological damage with a low chance of recovery. The overall prognosis of MSCC is poor, with median survival ranging between 2.4 to 30 months and a one-year survival rate ranging between 12%-58% [ 56 ]. The type of cancer leading to MSCC is an important prognostic factor, with lung cancer being the worst, with overall survival of 50% in one month, compared to breast and prostate cancer, which have better prognoses [ 56 ]. While treatments have not significantly improved life expectancy, managing pain and preserving neurological function can improve quality of life. Comprehensive supportive care, rehabilitation, and symptom management are essential. Therefore, time spent in a rehabilitation unit should be reduced to allow patients to spend more time with loved ones, possibly with the assistance of palliative/hospice care. The prognosis depends on the severity and duration of initial impairment, with sphincter dysfunction indicating a poor outlook. Education about symptoms and risks is vital, especially for patients with prostate, breast, or lung cancer, to prevent neurological complications [ 57 , 58 ]. Prompt reporting of changes in back pain is vital to prevent neurological deficits.

Future directions

While progress has been made in identifying optimal treatments for MSCC, unresolved questions remain, particularly for asymptomatic patients with intermediate- (Grades 1c-2) or high-grade (Grades 2–3) compression from less radiosensitive tumors. Current classification systems often categorize ESCC as low (Grades 0–1) or high grade, though some studies propose an intermediate category [ 45 , 59 ]. Previous literature on MSCC has notable limitations that need to be addressed, including the inclusion of mixed tumor radiosensitivity and reliance on traditional RT techniques such as 3D conformal RT [ 45 , 59 ]. These factors may have obscured the potential benefits of surgical intervention or advanced RT modalities like SBRT. Future research should incorporate modern RT technologies and stratify patients by tumor radiosensitivity to refine treatment paradigms. Multidisciplinary collaboration among neurosurgeons, neuro-oncologists, and radiation oncologists is essential for tailoring individualized treatment strategies, as demonstrated by our framework in Figure 1 .

Conclusion

Metastatic spinal cord compression poses a significant challenge in the context of cancer care, demanding immediate clinical attention and precise management. Early detection and a multidisciplinary approach are the cornerstones of successful management. A prompt clinical assessment, urgent imaging, and, if necessary, tissue diagnosis play pivotal roles in shaping the course of treatment. The administration of steroids, the initiation of surgical interventions for specific cases, and the use of radiotherapy in conjunction with surgical decompression and stabilization contribute to improving patient outcomes. While the approach to treatment varies based on individual patient characteristics, the overarching goal remains preserving spinal cord function and alleviating neurological deficits.

Acknowledgments

The authors thank Sarah Bronson, ELS, of the Research Medical Library at the University of Texas MD Anderson Cancer Center for editing this manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

References

1 Cole JS , Patchell RA. Metastatic epidural spinal cord compression . Lancet Neurol . 2008 ; 7 ( 5 ): 459 – 466 . doi: 10.1016/S1474-4422(08)70089-9 . 18420159

2 Kim JM , Losina E , Bono CM , et al. Clinical outcome of metastatic spinal cord compression treated with surgical excision ± radiation versus radiation therapy alone: a systematic review of literature . Spine (Phila Pa 1976) . 2012 ; 37 ( 1 ): 78 – 84 . doi: 10.1097/BRS.0b013e318223b9b6 . 21629164 PMC3876411

3 Bilsky MH , Laufer I , Fourney DR , et al. Reliability analysis of the epidural spinal cord compression scale . J Neurosurg Spine . 2010 ; 13 ( 3 ): 324 – 328 . doi: 10.3171/2010.3.SPINE09459 . 20809724

4 Loblaw DA , Laperriere NJ , Mackillop WJ. A population-based study of malignant spinal cord compression in Ontario . Clin Oncol (R Coll Radiol) . 2003 ; 15 ( 4 ): 211 – 217 . doi: 10.1016/s0936-6555(02)00400-4 . 12846501

5 Van den Brande R , Cornips EM , Peeters M , et al. Epidemiology of spinal metastases, metastatic epidural spinal cord compression and pathologic vertebral compression fractures in patients with solid tumors: a systematic review . J Bone Oncol . 2022 ; 35 : 100446 . doi: 10.1016/j.jbo.2022.100446 . 35860387 PMC9289863

6 Pigott KH , Baddeley H , Maher EJ. Pattern of disease in spinal cord compression on MRI scan and implications for treatment . Clin Oncol (R Coll Radiol) . 1994 ; 6 ( 1 ): 7 – 10 . doi: 10.1016/s0936-6555(05)80361-9 . 8172840

7 Prasad D , Schiff D. Malignant spinal-cord compression . Lancet Oncol . 2005 ; 6 ( 1 ): 15 – 24 . doi: 10.1016/S1470-2045(04)01709-7 . 15629272

8 Oldenburger E , Brown S , Willmann J , et al. ESTRO ACROP guidelines for external beam radiotherapy of patients with complicated bone metastases . Radiother Oncol . 2022 ; 173 : 240 – 253 . doi: 10.1016/j.radonc.2022.06.002 . 35688398

9 Loblaw DA , Laperriere NJ. Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline . J Clin Oncol . 1998 ; 16 ( 4 ): 1613 – 1624 . doi: 10.1200/JCO.1998.16.4.1613 . 9552073

10 Jarvis C , Eckhardt AL. Physical examination and health assessment E-book . St. Louis, MO: Elsevier Health Sciences ; 2023 .

11 Cavalli F , Kaye SB , Hansen HH , et al. Textbook of medical oncology . London, UK: CRC Press ; 2009 .

12 Lee SS , Kim MK , Sym SJ , et al. Intramedullary spinal cord metastases: a single-institution experience . J Neurooncol . 2007 ; 84 ( 1 ): 85 – 89 . doi: 10.1007/s11060-007-9345-z . 17310265

13 Rajasekaran S , Jain AK , Shetty AP , et al. Spinal infections and trauma . New Delhi, India: Jaypee Brothers Publishers ; 2011 .

14 Kirshblum S , Snider B , Rupp R , et al. Updates of the International Standards for Neurologic Classification of Spinal Cord Injury: 2015 and 2019 . Phys Med Rehabil Clin N Am . 2020 ; 31 ( 3 ): 319 – 330 . doi: 10.1016/j.pmr.2020.03.005 . 32624097

15 Barzilai O , Laufer I , Yamada Y , et al. Integrating evidence-based medicine for treatment of spinal metastases into a decision framework: neurologic, oncologic, mechanicals stability, and systemic disease . J Clin Oncol . 2017 ; 35 ( 21 ): 2419 – 2427 . doi: 10.1200/JCO.2017.72.7362 . 28640703

16 Barzilai O , Versteeg AL , Goodwin CR , et al. Association of neurologic deficits with surgical outcomes and health-related quality of life after treatment for metastatic epidural spinal cord compression . Cancer . 2019 ; 125 ( 23 ): 4224 – 4231 . doi: 10.1002/cncr.32420 . 31410854

17 Laufer I , Rubin DG , Lis E , et al. The NOMS framework: approach to the treatment of spinal metastatic tumors . Oncologist . 2013 ; 18 ( 6 ): 744 – 751 . doi: 10.1634/theoncologist.2012-0293 . 23709750 PMC4063402

18 MacLean MA , Touchette CJ , Georgiopoulos M , Tumor AOSKF ., et al. Systemic considerations for the surgical treatment of spinal metastatic disease: a scoping literature review . Lancet Oncol . 2022 ; 23 ( 7 ): e321 – e33 . doi: 10.1016/S1470-2045(22)00126-7 . 35772464 PMC9844540

19 Ropper AE , Ropper AH. Acute spinal cord compression . N Engl J Med . 2017 ; 376 ( 14 ): 1358 – 1369 . doi: 10.1056/NEJMra1516539 . 28379788

20 Lawton AJ , Lee KA , Cheville AL , et al. Assessment and management of patients with metastatic spinal cord compression: a multidisciplinary review . J Clin Oncol . 2019 ; 37 ( 1 ): 61 – 71 . doi: 10.1200/JCO.2018.78.1211 . 30395488

21 Rispoli R , Reverberi C , Targato G , et al. Multidisciplinary approach to patients with metastatic spinal cord compression: a diagnostic therapeutic algorithm to improve the neurological outcome . Front Oncol . 2022 ; 12 : 902928 . doi: 10.3389/fonc.2022.902928 . 35747823 PMC9210572

22 Esperança-Martins M , Roque D , Barroso T , et al. Multidisciplinary approach to spinal metastases and metastatic spinal cord compression-a new integrative flowchart for patient management . Cancers (Basel) . 2023 ; 15 ( 6 ): 1796 .). doi: 10.3390/cancers15061796 . 36980681 PMC10046378

23 Barzilai O , Fisher CG , Bilsky MH. State of the art treatment of spinal metastatic disease . Neurosurgery . 2018 ; 82 ( 6 ): 757 – 769 . doi: 10.1093/neuros/nyx567 . 29481645

24 Gold M. Magnetic resonance imaging of spinal emergencies . Top Magn Reson Imaging . 2015 ; 24 ( 6 ): 325 – 330 . doi: 10.1097/RMR.0000000000000069 . 26636638

25 Colletti PM , Siegel HJ , Woo MY , et al. The impact on treatment planning of MRI of the spine in patients suspected of vertebral metastasis: an efficacy study . Comput Med Imaging Graph . 1996 ; 20 ( 3 ): 159 – 162 . doi: 10.1016/0895-6111(96)00009-2 . 8930468

26 Cook AM , Lau TN , Tomlinson MJ , et al. Magnetic resonance imaging of the whole spine in suspected malignant spinal cord compression: impact on management . Clin Oncol (R Coll Radiol) . 1998 ; 10 ( 1 ): 39 – 43 . doi: 10.1016/s0936-6555(98)80111-8 . 9543614

27 Eldaya RW , Parsons MS , Hutchins TA , et al. ACR Appropriateness Criteria ® ; Cervical Pain or Cervical Radiculopathy: 2024 Update . Journal of the American College of Radiology . 2025 ; 22 ( 5 ): S136 – S162 . doi: 10.1016/j.jacr.2025.02.035 . 40409873

28 Shah VN , Parsons MS , Boulter DJ , et al. ACR Appropriateness Criteria ® ; Thoracic Back Pain . Journal of the American College of Radiology . 2024 ; 21 ( 11 ): S504 – S517 . doi: 10.1016/j.jacr.2024.08.016 . 39488357

29 Patel DM , Weinberg BD , Hoch MJ. CT Myelography: clinical Indications and Imaging Findings . Radiographics . 2020 ; 40 ( 2 ): 470 – 484 . doi: 10.1148/rg.2020190135 . 32058837

30 Li KC , Poon PY. Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae . Magn Reson Imaging . 1988 ; 6 ( 5 ): 547 – 556 . doi: 10.1016/0730-725x(88)90129-4 . 3067022

31 Hagenau C , Grosh W , Currie M , et al. Comparison of spinal magnetic resonance imaging and myelography in cancer patients . J Clin Oncol . 1987 ; 5 ( 10 ): 1663 – 1669 . doi: 10.1200/JCO.1987.5.10.1663 . 3655863

32 Carmody RF , Yang PJ , Seeley GW , et al. Spinal cord compression due to metastatic disease: diagnosis with MR imaging versus myelography . Radiology . 1989 ; 173 ( 1 ): 225 – 229 . doi: 10.1148/radiology.173.1.2675185 . 2675185

33 Husband DJ , Grant KA , Romaniuk CS. MRI in the diagnosis and treatment of suspected malignant spinal cord compression . Br J Radiol . 2001 ; 74 ( 877 ): 15 – 23 . doi: 10.1259/bjr.74.877.740015 . 11227772

34 Rades D , Blach M , Bremer M , et al. Prognostic significance of the time of developing motor deficits before radiation therapy in metastatic spinal cord compression: one-year results of a prospective trial . Int J Radiat Oncol Biol Phys . 2000 ; 48 ( 5 ): 1403 – 1408 . doi: 10.1016/s0360-3016(00)01408-5 . 11121640

35 Borenstein SH , Gerstle T , Malkin D , et al. The effects of prebiopsy corticosteroid treatment on the diagnosis of mediastinal lymphoma . J Pediatr Surg . 2000 ; 35 ( 6 ): 973 – 976 . doi: 10.1053/jpsu.2000.6945 . 10873047

36 Sodji Q , Kaminski J , Willey C , et al. Management of Metastatic Spinal Cord Compression . South Med J . 2017 ; 110 ( 9 ): 586 – 593 . doi: 10.14423/SMJ.0000000000000700 . 28863223

37 Simoff MJ , Lally B , Slade MG , et al. Symptom management in patients with lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines . Chest . 2013 ; 143 ( 5 Suppl ): e455S – e4e97 . S. doi: 10.1378/chest.12-2366 . 23649452

38 Boussios S , Cooke D , Hayward C , et al. Metastatic spinal cord compression: unraveling the diagnostic and therapeutic challenges . Anticancer Res . 2018 ; 38 ( 9 ): 4987 – 4997 . doi: 10.21873/anticanres.12817 . 30194142

39 Alcorn S , Cortés ÁA , Bradfield L , et al. External beam radiation therapy for palliation of symptomatic bone metastases: an ASTRO Clinical Practice Guideline . Pract Radiat Oncol . 2024 ; 14 ( 5 ): 377 – 397 . doi: 10.1016/j.prro.2024.04.018 . 38788923

40 Sørensen S , Helweg-Larsen S , Mouridsen H , et al. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial . Eur J Cancer . 1994 ; 30a ( 1 ): 22 – 27 . doi: 10.1016/s0959-8049(05)80011-5 . 8142159

41 Vecht CJ , Haaxma-Reiche H , van Putten WL , et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression . Neurology . 1989 ; 39 ( 9 ): 1255 – 1257 . doi: 10.1212/wnl.39.9.1255 . 2771077

42 Heimdal K , Hirschberg H , Slettebø H , et al. High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression . J Neurooncol . 1992 ; 12 ( 2 ): 141 – 144 . doi: 10.1007/BF00172664 . 1560260

43 Scarpignato C , Gatta L , Zullo A , et al. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression . BMC Med . 2016 ; 14 ( 1 ): 179 . doi: 10.1186/s12916-016-0718-z . 27825371 PMC5101793

44 Spratt DE , Beeler WH , de Moraes FY , et al. An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report . Lancet Oncol . 2017 ; 18 ( 12 ): e720 – e30 . doi: 10.1016/S1470-2045(17)30612-5 . 29208438

45 von Spreckelsen N , Ossmann J , Lenz M , et al. Role of decompressive surgery in neurologically intact patients with low to intermediate intraspinal metastatic tumor burden . Cancers (Basel) . 2023 ; 15 ( 2 ):385. doi: 10.3390/cancers15020385 . PMC9857075 36672334

46 Weber-Levine C , Jiang K , Al-Mistarehi AH , et al. The role of combination surgery and radiotherapy in patients with metastatic spinal cord compression: what are the remaining grey areas? A systematic review . Clin Neurol Neurosurg . 2025 ; 248 : 108632 . doi: 10.1016/j.clineuro.2024.108632 . 39637710

47 Bach F , Agerlin N , Sørensen JB , et al. Metastatic spinal cord compression secondary to lung cancer . J Clin Oncol . 1992 ; 10 ( 11 ): 1781 – 1787 . doi: 10.1200/JCO.1992.10.11.1781 . 1328552

48 Ma Y , He S , Liu T , et al. Quality of life of patients with spinal metastasis from cancer of unknown primary origin: a longitudinal study of surgical management combined with postoperative radiation therapy . JBJS . 2017; 99 ( 19 ): 1629 – 1639 . 10.2106/JBJS.16.00286 28976427

49 Patchell RA , Tibbs PA , Regine WF , et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial . Lancet . 2005 ; 366 ( 9486 ): 643 – 648 . doi: 10.1016/S0140-6736(05)66954-1 . 16112300

50 Fisher CG , DiPaola CP , Ryken TC , et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the spine oncology study group. spine . Spine (Phila Pa 1976) . 2010 ; 35 ( 22 ): E1221 – E1229 . doi: 10.1097/BRS.0b013e3181e16ae2 . 20562730

51 Young RF , Post EM , King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy . J Neurosurg . 1980 ; 53 ( 6 ): 741 – 748 . doi: 10.3171/jns.1980.53.6.0741 . 7441333

52 Stark RJ , Henson RA , Evans SJ. Spinal metastases. A retrospective survey from a general hospital . Brain . 1982 ; 105 ( Pt 1 ): 189 – 213 . (Pt 1): 7066672 10.1093/brain/105.1.189

53 Gilbert RW , Kim JH , Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment . Ann Neurol . 1978 ; 3 ( 1 ): 40 – 51 . doi: 10.1002/ana.410030107 . 655653

54 Klimo P , Jr. , Thompson CJ , Kestle JR , et al. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease . Neuro Oncol . 2005 ; 7 ( 1 ): 64 – 76 . doi: 10.1215/S1152851704000262 . 15701283 PMC1871618

55 Bresolin N , Sartori L , Drago G , et al. Systematic review and meta-analysis on optimal timing of surgery for acute symptomatic metastatic spinal cord compression . Medicina (Kaunas) . 2024 ; 60 ( 4 ):631. doi: 10.3390/medicina60040631 . PMC11052148 38674277

56 Fattal C , Fabbro M , Gelis A , et al. Metastatic paraplegia and vital prognosis: perspectives and limitations for rehabilitation care. Part 1 . Arch Phys Med Rehabil . 2011 ; 92 ( 1 ): 125 – 133 . doi: 10.1016/j.apmr.2010.09.017 . 21187215

57 Kakutani K , Sakai Y , Zhang Z , et al. Survival rate after palliative surgery alone for symptomatic spinal metastases: a prospective cohort study . J Clin Med . 2022 ; 11 ( 21 ): 6227 . doi: 10.3390/jcm11216227 . 36362455 PMC9658518

58 Suzuki A , Terai H , Takahashi S , et al. Risk factors for poor outcome after palliative surgery for metastatic spinal tumors . J Clin Med . 2023 ; 12 ( 10 ): 3442 . doi: 10.3390/jcm12103442 . 37240548 PMC10219010

59 Maseda M , Uei H , Nakahashi M , et al. Neurological outcome of treatment for patients with impending paralysis due to epidural spinal cord compression by metastatic spinal tumor . J Orthop Surg Res . 2019 ; 14 ( 1 ): 291 . doi: 10.1186/s13018-019-1348-x . 31481077 PMC6724255