Question
A 65 year old man with known prostate cancer develops thoracic back pain and new difficulty walking. MRI shows a T8 metastasis with epidural compression of the cord.
- What is the immediate management?
- What scoring systems guide decision making?
- What are the surgical options?
Answer
Immediate management
- High dose dexamethasone, often 16 mg daily
- Urgent oncology and spinal surgical referral
- Bed rest with spinal precautions until stability is assessed
- Whole spine MRI, as multiple levels are common
- Staging CT and a biopsy if the primary is unknown
Scoring systems
- NOMS framework for neurological, oncological, mechanical and systemic factors
- Spinal Instability Neoplastic Score (SINS), 0 to 6 stable, 7 to 12 potentially unstable, 13 to 18 unstable
- Epidural spinal cord compression scale (Bilsky)
- Tokuhashi and Tomita scores to estimate prognosis
Surgical options
- Decompression and stabilisation followed by radiotherapy gives better walking outcomes than radiotherapy alone in selected patients (Patchell, Lancet 2005)
- Separation surgery followed by stereotactic radiotherapy
- Percutaneous stabilisation or vertebroplasty for mechanical pain without compression
- Radiotherapy alone for radiosensitive tumours, poor prognosis or established paraplegia over 48 hours
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.