Questionnaire/history:

Cancer?

Increasing back pain?

- Localised or generalised (can occur anywhere in the spine)?

- Increase when lying down or straining?

Nocturnal pain?

Heaviness or clumsiness of limbs (may be an early sign)?

Progressive weakness (commonly)?

Sensory signs (eg dermatomal paraesthesia or anaesthesia)?

Autonomic involvement with bladder and bowel dysfunction (often late and irreversible sign)?

Referred back pain is multi-segmental or band-like?

Escalating pain which is poorly responsive to treatment (incl medication)?

Different character or site to previous symptoms?

Funny feelings, odd sensations or heavy legs (multi-segmental)?

Lying flat increases back pain?

Agonising pain-causing anguish and despair?

Gait disturbance, unsteadiness, especially on stairs (not just a limp)?

Sleep grossly disturbed due to pain being worse at night?

(Note: A combination of red flag symptoms should increase suspicion of MSCC)

Past medical history?

Current medication?

Known drug allergies?

Examination:

Localised spinal tenderness?

Lower motor neuron (LMN) signs at the level of the lesion?

- Weakness?

- Muscle hypotonia?

- Fasciculations?

- Hypo/areflexia?

- Abdominal reflexes present?

Upper motor neuron (UMN) signs below the level of the lesion?

- Weakness?

- Spasticity, rigidity?

- Clonus?

- Hyperreflexia?

- Abdominal reflexes absent?

Management:

Urgent referral within 24 hours for an MRI (because the ischaemia of the cord is nearly always involved and rapid treatment can reverse ischaemia and improve neurological outcome) if:

- Pain in thoracic or cervical spine

- Progressive lumbar spinal pain

- Severe unremitting spinal pain

- Spinal pain aggravated by straining, coughing or sneezing

- Localised spinal tenderness

- Nocturnal spinal pain preventing sleep

Urgent immediate referral if:

- Neurological symptoms including root pain

- Any limb weakness or difficulty in walking

- Sensory loss or bladder or bowel dysfunction

- Neurological signs of spinal cord or cauda equina compression

16 mg dexamethasone (unless lymphoma)

Definitive management: surgical and/or radiotherapy

(Notes: NICE recommend referral for palliative deep x-ray therapy (DXT) to patients with a poor prognosis

Advised:

Urgent GP review if:

New back pain?

- Increases in severity, may be worse on lying, straining or coughing?

- Back pain, which spreads to the front of the chest?

Progressive weakness, numbness or heaviness of limbs or difficulty in walking?

Bowel or bladder dysfunction?

Pins and needles in the limbs?

Resource(s):

BMJ 2016  

BOA/BSR/RCGP Emergency MSK conditions 2020  

NICE Clinical guideline [CG75]