• New, progressively severe back pain (particularly thoracic)
• Significant worsening of existing back pain
• New spinal nerve root pain (burning, shooting, numbness); may radiate down anterior or posterior thigh (like sciatica), or like a band around the chest or abdomen
• Coughing, straining or lying flat may aggravate pain
• Pain worse at night.

Late symptoms

• New difficulty walking or climbing stairs; reduced power (motor weakness)
• Sensory impairment or altered sensation in limbs.
• Bowel or bladder disturbance; loss of sphincter control is a late sign with a poor prognosis.

• Spinal tenderness on palpation
• Dermatome level can sometimes be found (but lack of a dermatomal level should not provide reassurance)
• Reduced sensation in a dermatomal distribution (thermal sensation is affected first and can be checked for using an ice cube)
• Power deficits on examination (may be asymmetrical)
• Inability to weight bear (can occur even if power is normal on supine examination)
• Lhermitte’s sign
• Hyper-reflexia
• Saddle anaesthesia and loss of anal sphincter tone
• Palpable bladder.

• Communication with the patient and family to outline the possibility of an MSCC diagnosis
• Urgent admission – keep in supine position (unless felt to be too frail for aggressive management)
• Consider a trial of corticosteroids with gastroprotection (usually proton pump inhibitor),
• †Dexamethasone 16mg orally (or IV) immediately and subsequently †Dexamethasone 8mg twice daily orally (second dose before 2pm if possible). Discontinue promptly if no benefit and reduce gradually in responders.
• Urgent referral for a whole spine MRI (always scan the whole spine, not just area of suspected lesion)
• Immediate discussion with neurosurgery if there is instability of the spine
• Immediate referral to clinical oncology for advice on ongoing management
• If the patient is on disease‑modifying treatment ensure that the treating consultant is aware
• After the initial treatment with radiotherapy or surgery, many specialties may need to be involved in the management of spinal cord compression, including physiotherapy, occupational therapy and orthotics for brace advice
• Goals of treatment should be discussed with patient who may opt for no active treatment.