Spinal Metastases and Metastatic Spinal Cord Compression

Definition

Metastatic tumour in the vertebral column. Metastatic spinal cord compression (MSCC) is epidural tumour compressing the cord or cauda equina.

Epidemiology

  • The spine is the most common site of skeletal metastasis
  • Thoracic spine is affected most often, then lumbar and cervical
  • Common primaries are breast, prostate, lung, kidney and thyroid

Clinical Features

  • Progressive axial pain, worse at night and lying flat. Pain usually precedes neurological loss
  • Movement related pain suggests mechanical instability
  • Radicular pain, limb weakness, sensory level and sphincter disturbance in MSCC

Investigations

  • Urgent MRI of the whole spine with contrast
  • CT for bone quality and instability
  • Staging CT and biopsy when the primary is unknown

Classification

The Spine Instability Neoplastic Score (SINS) combines location, pain, bone lesion quality, alignment, vertebral body collapse and posterolateral involvement.

SINS total score

ScoreInterpretation
0 to 6Stable
7 to 12Indeterminate
13 to 18Unstable

Original publication Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fourney DR. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35(22):E1221-9.

Bilsky epidural spinal cord compression scale, grades 0 to 3

GradeCord
0 and 1Cord not compressed
2 and 3Cord compressed

Original publication Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, Vrionis FD, Yamada Y, Gerszten PC, Kuklo TR. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324-8.

Management

  • Dexamethasone. Start when cord compression is suspected
  • External beam radiotherapy. Effective for radiosensitive tumours such as lymphoma, myeloma and seminoma
  • Stereotactic radiosurgery. Used for radioresistant tumours such as renal cell carcinoma, melanoma and sarcoma
  • Surgery. Separation surgery with posterior stabilisation for high grade compression or instability
  • In 101 patients with MSCC, surgery followed by radiotherapy let 84% walk after treatment against 57% with radiotherapy alone
  • NOMS framework weighs neurological status, oncological sensitivity, mechanical stability and systemic disease

References

Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005, 366(9486), 643-8. PubMed

Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fourney DR. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010, 35(22), E1221-9. PubMed

Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, Bilsky MH. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 2013, 18(6), 744-51. PubMed

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 21 October 2026.