Cancer alliances and commissioners

1.1.1.

Service commissioners, working with their cancer alliance, should:

• ensure clear care pathways for referral, diagnosis, treatment, rehabilitation and ongoing care of people with suspected or confirmed spinal metastases or MSCC
• ensure appropriate services are commissioned and in place for efficient and effective implementation of the care pathways
• monitor services regularly through prospective audit of the care pathways (for example, collecting outcome data for treatments). [2023]

1.1.2.

The cancer alliance should appoint a lead for MSCC whose responsibilities include:

• advising the cancer alliance, commissioners and providers about the provision and organisation of clinical services
• ensuring that the local care pathways are documented, agreed and implemented consistently across the alliance
• maintaining an alliance-wide audit of incidence, timeliness of management and outcomes using nationally agreed measures
• arranging and chairing regular meetings of the MSCC steering group (at least twice a year), at which treatment outcomes will be reported and the local care pathways reviewed and amended if necessary (see also recommendation 1.1.4 for details of the steering group). [2023]

1.1.3.

Services within the cancer alliance (including those in primary, community, secondary and tertiary care) should have an identified lead healthcare professional for MSCC whose responsibilities include:

• representing their service at alliance level in the development of care pathways
• implementing and disseminating information about the care pathways
• ensuring timely and effective communication between all relevant healthcare professionals involved in the care pathways, including those in palliative care
• raising and maintaining awareness and understanding of treatments among all clinical staff across the locality
• contributing to regular alliance MSCC audits of care
• attending and contributing to regular alliance MSCC steering group meetings. [2023]

1.1.4.

Every cancer alliance should have a steering group for MSCC that:

• includes people with lived experience and representatives from primary, community, secondary and tertiary care
• includes an MSCC service representative, for example, the MSCC coordinator
• has strong links to cancer alliance groups for primary tumours. [2023]

Providing a coordinated MSCC and spinal metastases service

1.1.5.

Ensure that there is a designated local MSCC service with clear processes and referral pathways so that all people with suspected or confirmed spinal metastases or MSCC are referred to an MSCC service with an appropriate level of urgency (see recommendations 1.3.2 and 1.3.3 about when to contact the MSCC coordinator, and recommendations 1.5.2 and 1.5.3 about when to offer an MRI scan). [2023]

1.1.6.

MSCC services should ensure that the first point of contact for people referred to the service is the MSCC coordinator. When the MSCC coordinator is not working, the role should be carried out by a designated clinician with appropriate expertise (for example, an on-call oncology registrar). [2023]

1.1.7.

MSCC services should ensure that the role of MSCC coordinator is covered at all times (24 hours a day, 7 days a week) and is based in an oncology service. [2023]

1.1.8.

MSCC services should have arrangements in place to coordinate care between different specialties and services, for example, by having:

• clear referral criteria and processes
• processes for information sharing
• effective channels for communication between specialties. [2023]

1.1.9.

MSCC services should operate through a multidisciplinary approach, with key members from relevant specialties, including:

• acute oncology
• haematology
• histopathology
• oncology
• palliative care
• physiotherapy
• radiology
• spinal surgery. [2023]

1.1.10.

Specialties providing treatment within the MSCC service (for example, spinal surgery and radiotherapy) should designate a single point of contact to liaise with other services, provide advice and contribute to the coordination of care. [2023]

1.1.11.

MSCC services should establish links and communication pathways with primary and community care and other relevant services (for example, palliative care and social services) so that information about the person’s care and support needs is shared effectively to ensure safe discharge from hospital, continuity of care and appropriate follow up (see also the section on providing support and rehabilitation services). [2023]

1.1.12.

MSCC services should have systems and processes in place for recording data, audit evaluation, and investigating and reporting incidents. [2023]

1.1.13.

Be aware of the impact of health inequalities (for example, deprivation) on outcomes for people with spinal metastases or MSCC. Ensure that:

• information is collected and analysed by local services to identify any health inequalities
• education is provided within services on reducing local health inequalities
• reasonable adjustments are made by local services to address any health inequalities, in line with the Equality Act 2010. [2023]

1.1.14.

Hospital and community services should establish coordinated care pathways with each other, and with social services, to ensure that people with spinal metastases or MSCC:

• are discharged in a safe and timely manner and
• receive the support they need for themselves and their families and carers once home. [2023]

Roles in a coordinated MSCC and spinal metastases service

1.1.15.

The person in the role of MSCC coordinator should ensure that:

• key information about each person is recorded; this includes information on:

  –

  clinical presentation

  –

  neurological assessment

  –

  performance status

  –

  frailty assessment

  –

  investigations, including imaging reports

  –

  oncology assessment and disease staging

  –

  individual needs, preferences and circumstances (for example, language and communication needs)

• initial triage of information about the person’s care is performed
• appropriate information is shared with primary care and with the multidisciplinary team
• discharge planning is coordinated. [2023]

1.1.16.

The person in the role of MSCC coordinator should provide initial advice to referring healthcare professionals on:

• pain management (see the section on pain management)
• spinal stability (see the sections on imaging investigations and tools for assessing spinal stability and prognosis)
• immobilisation (see the section on immobilisation)
• use of dexamethasone (see the section on corticosteroid therapy)
• referral and transfer for specialist treatment. [2023]

1.1.17.

A senior clinician from the multidisciplinary team with expertise in diagnosing and managing spinal metastases and MSCC should develop a personalised care plan with the person. This should take into account the person’s needs and preferences, and advice from the multidisciplinary team (see recommendation 1.1.9) and other clinicians, if relevant, such as:

• allied health professionals
• pharmacists
• the referring health professional. [2023]

1.1.18.

Centres treating spinal metastases or MSCC should ensure that a senior clinician is available at all times to give advice and support to the MSCC service. [2023]

Providing urgent imaging and radiotherapy services

1.1.19.

MSCC services should ensure that there is local access to urgent MRI scans (within 24 hours) for all people with suspected MSCC who have neurological signs and symptoms. MRI scans should be available outside normal working hours if needed to start immediate treatment (see recommendation 1.5.4). [2023]

1.1.20.

Imaging departments should make provision for short-notice spinal scans, taking into account the relative urgency of scans investigating suspected spinal metastases or MSCC (see recommendations 1.5.2 and 1.5.4). [2023]

1.1.21.

MSCC services should ensure that radiotherapy and simulator facilities are available for urgent (within 24 hours) daytime sessions, 7 days a week for people with MSCC so that radiotherapy can be given within 24 hours of a decision to treat (see recommendation 1.10.4). [2023]

Providing support and rehabilitation services

1.1.22.

Ensure access to community-based nursing and rehabilitation services, and equipment and support to meet the needs of people with suspected or confirmed spinal metastases or MSCC, and their families and carers. [2023]

1.1.23.

Ensure access for people with MSCC to appropriate specialist rehabilitation services (including to specialist rehabilitation units) if they are likely to benefit from it, based on an assessment of their circumstances, their level of function and the type of treatment they received. [2023]

1.1.24.

Discharge planning should be led by a named individual from within the responsible clinical team and involve:

• the person and their family and carers, if appropriate
• the primary oncology site team
• the rehabilitation team
• a pharmacist
• community support, including primary care and specialist palliative care, if needed. [2023]

1.1.25.

MSCC services should establish clear pathways of care, linking hospital and community-based healthcare and social services to ensure that equipment and support for people with MSCC returning home, and their families and carers, are available and coordinated. [2023]

1.1.26.

MSCC and rehabilitation services should provide support and training to the families and carers of people with MSCC before discharge from hospital (see the section on support and training for carers in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs). [2023]

1.1.27.

MSCC and rehabilitation services should take account of the section on discharge from hospital in the NICE guideline on transition between inpatient hospital settings and community or care home settings for adults with social care needs for hospital discharge planning. [2023]

1.1.28.

MSCC and rehabilitation services should take account of the principles of rehabilitation in the NICE guideline on rehabilitation after critical illness in adults. [2023]

Supporting decision making

1.2.1.

Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers are given information and support that is tailored to their needs and preferences so that they are fully informed and supported to be involved in all decisions about their care. Follow the principles in NICE’s guidelines on shared decision making and patient experience in adult NHS services. [2023]

1.2.2.

Discuss with the person and their family or carers the reasons why investigations and treatments are being offered by the multidisciplinary team, and the risks and benefits of these, so that they fully understand their options and are involved in decisions about their care. [2023]

1.2.3.

Give opportunities to the person and their family or carers to discuss their concerns and ask questions about issues such as:

• their diagnosis and what it might mean for them
• initial treatment options
• risks and benefits of treatment options
• how the condition could affect them in the future, including the possibility of worsening symptoms and functional decline
• ways to manage pain
• when further treatment options could be considered. [2023]

1.2.4.

Ensure that people with suspected or confirmed spinal metastases or MSCC and their families and carers know who to contact if they develop new symptoms or signs (see box 1) or if their existing symptoms worsen. [2023]

Providing support

1.2.5.

Carry out a holistic needs assessment with the person, and their family or carers if appropriate, as soon as possible after initial diagnosis, once the person is physically and emotionally able to be involved in the assessment, and revisit this when needs or preferences change. [2023]

1.2.6.

Give advice on how to access support based on the holistic needs assessment, including help with psychological, emotional, spiritual and financial needs. [2023]

1.2.7.

Discuss with the person their needs and preferences and the support they receive, and aim to help them:

• maintain their independence and quality of life
• deal with uncertainty
• adapt to potential changes in their level of function. [2023]

1.2.8.

Discuss with the person and their family or carers their experience of the service and explore whether changes can be made to better meet their needs. Ask about any concerns they may have, such as:

• accessing the service and attending appointments
• undergoing investigations
• adhering to treatment
• their social and practical circumstances
• disabilities that may be relevant to their care. [2023]

1.2.9.

Offer the person opportunities to discuss advance care planning (with support from family and carers if appropriate). For principles of advance care planning, see the section on advance care planning in the NICE guideline on decision making and mental capacity and the NICE quick guide on advance care planning. [2023]

1.2.10.

Offer the person end-of-life care, when appropriate, following NICE’s guidelines on end of life care for adults and care of dying adults in the last days of life. [2023]

1.2.11.

When the person is approaching the end of their life, discuss the bereavement support available with their family or carers and provide written information. Give advice on how to access bereavement support according to their wishes and preferences. [2023]

Support from healthcare services including discharge from hospital

1.2.12.

Ensure that all people with spinal metastases or MSCC, and their families or carers, if appropriate:

• have access to support and advice from the full range of healthcare services needed
• are supported by healthcare services to adapt to changes and to maintain their independence and quality of life. [2023]

1.2.13.

Ensure that people with spinal metastases or MSCC and their families or carers have ongoing access to support and training on appropriate care techniques and use of equipment both in hospital and after they are discharged home. This may include:

• manual handling
• use of spinal braces
• use of equipment (such as wheelchairs)
• managing bladder and bowel problems. [2023]

Radiologist involvement

1.5.1.

Radiological imaging of the spine in people with suspected spinal metastases or MSCC should be overseen by a radiologist to ensure:

• appropriate and complete imaging is performed and
• they report the results urgently. [2023]

MRI assessment

1.5.2.

Offer an MRI scan to people with suspected MSCC (see recommendation 1.3.2), to be performed:

• as soon as possible (and always within 24 hours)
• at the local hospital or appropriate centre with direct access to imaging facilities.

  Transfer to a tertiary centre for MRI should only be undertaken if local MRI is not possible. [2023]

1.5.3.

Offer an MRI scan to guide treatment options for people with clinical suspicion of spinal metastases but without suspicion of MSCC (see recommendation 1.3.3), to be performed:

• within 1 week
• at the local hospital. [2023]

1.5.4.

Offer overnight MRI only in clinical circumstances in which urgent diagnosis is needed to enable treatment to start immediately. [2023]

1.5.5.

MRI of the spine should include:

• sagittal T1 and/or short TI inversion recovery (STIR) sequences of the whole spine, to identify spinal metastases
• sagittal T2-weighted sequences, to show the level and degree of compression of the cord or cauda equina by a soft tissue mass and to assess possible MSCC and detect lesions within the cord itself
• supplementary axial imaging through any significant abnormality noted on the sagittal scan. [2023]

1.5.6.

In people with an existing diagnosis of spinal metastases without symptoms or signs of cord compression, do not perform MRI of the spine solely for the early radiological detection of cord compression. [2023]

Other imaging techniques for diagnosis and management

1.5.7.

If MRI is contraindicated, carry out a CT scan for people with suspected spinal metastases or MSCC. Rarely, if more information is needed for diagnosis and to guide management, carry out myelography after CT scanning. [2023]

1.5.8.

If myelography is indicated, only perform it at a neuroscience or spinal surgical centre. [2023]

1.5.9.

Do not perform plain X-ray of the spine to diagnose or rule out spinal metastases or MSCC. [2023]

1.5.10.

Consider multiplanar viewing or 3-plane reconstruction of recent or new CT images for people with spinal metastases or MSCC to:

• assess spinal stability and
• plan vertebroplasty, kyphoplasty or spinal surgery. [2023]

Using orthoses in mobilisation

1.6.6.

Seek advice from a specialist (for example, a physiotherapist) on the use of orthoses to promote mobility and to prevent loss of range of limb movement. [2023]

Individualised pain assessment and management plan

1.7.1.

Ensure adequate pain relief is provided promptly for people with suspected or confirmed spinal metastases or MSCC, including while the person is waiting for investigations or treatment. [2023]

1.7.2.

Carry out an individualised pain assessment for people presenting with pain related to suspected or confirmed spinal metastases or MSCC. This should include assessing:

• the severity, location and characteristics of the pain
• the underlying cause of the pain and whether this has deteriorated
• the impact of pain on lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

1.7.3.

Discuss and agree a pain management plan with the person based on their individualised pain assessment and taking into account any previous strategies tried, as well as their concerns and expectations. Discussions may include:

• why a particular management plan is being suggested
• the psychological impact of pain, including the effect on emotional wellbeing
• pharmacological analgesic treatment options, with individualised information and advice, including possible risks and benefits, and dosage titration
• individualised coping strategies for pain
• other treatment options, if suitable, for example:

  –

  physical therapy

  –

  immobilisation (for example, bracing)

  –

  psychological therapies

  –

  systemic anticancer treatments

  –

  bisphosphonates (see the section on bisphosphonates)

  –

  denosumab (see the section on denosumab)

  –

  corticosteroids (see the section on corticosteroid therapy)

  –

  radiotherapy (see the section on radiotherapy)

  –

  surgery (see the section on invasive interventions)

• when and how to seek further advice if pain persists, progresses or changes in character.

  For more information about involving people in decisions and supporting adherence, see the NICE guidelines on shared decision making and medicines adherence. [2023]

1.7.4.

After starting or changing a pain management plan, carry out a clinical review to assess the effectiveness of the chosen treatment. [2023]

1.7.5.

Consider referring the person to a specialist pain service (or, if appropriate, a palliative care service) if pain is difficult to manage at any stage, including at initial presentation, and if:

• they have severe pain or
• their pain significantly limits their lifestyle, daily activities (including sleep) and participation in work, education, training or recreation. [2023]

Analgesic medication

1.7.6.

When deciding on analgesic medication, discuss with the person and take into account:

• the possible side effects
• the possible effects on existing comorbidities and new comorbidities that could arise from treatment
• concurrent medications (including over-the-counter medicines) and possible drug interactions. [2023]

1.7.7.

Offer non-opioid or opioid analgesic medication, individually or in combination, to people with pain associated with suspected or confirmed spinal metastases or MSCC. The choice of medicine should be based on the ongoing individualised pain assessment and agreed in the pain management plan. [2023]

1.7.8.

At each review, discuss analgesic drug dosage, titration, tolerability and adverse effects, and agree to continue or update the pain management plan where necessary. [2023]

1.7.9.

For people with pain that has neuropathic features or is unresponsive to opioid analgesia, consider managing pain according to the NICE guideline on neuropathic pain in adults. [2023]

1.7.10.

For people having strong opioids in palliative care, follow the recommendations on starting and titrating opioid analgesia and managing side effects in the NICE guideline on palliative care for adults. [2023]

1.7.11.

When using strong opioids, follow the processes for their safe use and management in the NICE guideline on controlled drugs. [2023]

Bisphosphonates

1.7.12.

For people with spinal involvement from myeloma or breast cancer, offer bisphosphonates to reduce pain and the risk of vertebral fracture or collapse. [2008]

1.7.13.

For people with spinal metastases from prostate cancer, offer bisphosphonates to reduce pain only if conventional analgesia fails to control pain. [2008]

1.7.14.

Do not use bisphosphonates to treat spinal pain in people:

• with vertebral involvement from tumour types other than myeloma, breast cancer or prostate cancer (if conventional analgesia fails) or
• with the intention of preventing MSCC, except as part of a randomised controlled trial. [2008]

Denosumab

1.7.15.

For people with bone metastases from breast cancer and from solid tumours other than prostate, follow the NICE technology appraisal guidance on denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. [2023]

Radiotherapy and fertility

1.10.1.

When considering radiotherapy as a treatment option, explain the impact of the cancer and its treatment on future fertility. Explore the person’s priorities for fertility and offer referral to a fertility specialist if suitable, but do not delay urgent treatment for spinal metastases or MSCC. See also the section on people with cancer who wish to preserve fertility in the NICE guideline on fertility problems. [2023]

Radiotherapy to treat painful spinal metastases and prevent MSCC

1.10.2.

For people with spinal metastases without MSCC who have non-mechanical spinal pain:

• offer 8 Gy single fraction radiotherapy, even if they are paralysed or
• consider stereotactic ablative body radiotherapy for people with a good overall prognosis (see the section on tools for assessing spinal stability and prognosis) or oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement. [2023]

1.10.3.

Be aware that radiotherapy for haematological malignancy with spinal metastases may reduce the success of stem cell harvest. If stem cell harvest is being considered, discuss the use of radiotherapy with the relevant haematology multidisciplinary team. [2023]

Radiotherapy to treat MSCC

1.10.4.

Offer urgent radiotherapy (to be given as soon as possible and within 24 hours) to people with MSCC that is not suitable for spinal surgery, unless:

• they have had complete tetraplegia or paraplegia for 2 weeks or longer and their pain is well controlled or
• their overall prognosis is considered to be poor (see also the section on tools for assessing spinal stability and prognosis). [2023]

1.10.5.

Use 8 Gy single fraction radiotherapy for people with MSCC having radiotherapy unless they are at high risk of side effects. [2023]

1.10.6.

Consider multiple fraction radiotherapy for people at high risk of side effects from radiation, for example, if they have:

• disease requiring a large treatment field or fields
• had previous radiotherapy treatments. [2023]

Radiotherapy for asymptomatic spinal metastases

1.10.7.

For people with asymptomatic spinal metastases, consider radiotherapy only:

• as part of a randomised controlled trial with the intention of preventing MSCC or
• as part of a treatment strategy for oligometastases (up to 3 discrete metastases anywhere in the body) with spinal involvement or
• if there are radiological signs of impending cord compression by an epidural or intradural tumour. [2023]

Postoperative radiotherapy

1.10.8.

Offer postoperative radiotherapy after the person has recovered from surgery for spinal metastases or MSCC. For information on surgery, see the section on invasive interventions. [2023]

Further radiotherapy treatment

1.10.9.

Consider further radiotherapy for people with spinal metastases or MSCC who have:

• had a good response to previous radiotherapy and
• developed recurrent symptoms at least 3 months after initial radiotherapy. [2023]

1.10.10.

If further radiotherapy is being considered, discuss the possible benefits and risks with the person and take into account the following factors before agreeing a treatment plan:

• total biological equivalent dose
• the time since the previous treatment
• volume of tissue to be irradiated. [2023]

Timing of invasive interventions

1.11.1.

Before an invasive intervention is offered, make a treatment plan in discussion with the appropriate specialists (such as an oncologist and spinal surgeon) within the MSCC service multidisciplinary team. [2023]

1.11.2.

If the primary cancer has not been identified, carry out a radiologically guided biopsy if:

• identifying the primary cancer may affect treatment decisions and
• there is no need for immediate treatment. [2023]

1.11.3.

Offer surgical intervention intended to halt or reverse neurological decline as soon as possible after the onset of neurological symptoms or signs indicating MSCC. [2023]

1.11.4.

Take into account the speed of onset and rate of progression of neurological symptoms and signs when determining the urgency of surgical intervention. [2023]

1.11.5.

Do not use a time limit after complete tetraplegia or paraplegia as the only factor to decide whether to offer surgical intervention to restore neurological function. [2023]

Options for invasive interventions

Cancer alliances and commissioners

Recommendations 1.1.1 to 1.1.4

Providing a coordinated MSCC and spinal metastases service

Recommendations 1.1.5 to 1.1.14

Roles in a coordinated MSCC and spinal metastases service

Recommendations 1.1.15 to 1.1.18

Providing urgent imaging and radiotherapy services

Recommendations 1.1.19 to 1.1.21

Providing support and rehabilitation services

Recommendations 1.1.22 to 1.1.28

Supporting decision making

Recommendations 1.2.1 to 1.2.4

Providing support

Recommendations 1.2.5 to 1.2.11

Support from healthcare services including discharge from hospital

Recommendations 1.2.12 and 1.2.13

Why the committee made the recommendations

Back pain is a common early symptom of spinal metastases and MSCC. The committee were aware of tools that are used for risk assessment in people presenting with low back pain in current practice, so they cross referred to recommendations in the NICE guideline on low back pain and sciatica in over 16s.

Early identification is important to enable early treatment and prevent disease progressing. Evidence was reviewed on symptoms and signs that may support early recognition. This included evidence that compared symptoms in people with metastatic spinal disease with symptoms in people with low back pain due to other causes, and evidence of symptoms of spinal metastases in people presenting with undiagnosed cancer.

The evidence showed that a past or current diagnosis of cancer was a strong indicator that back pain could be a symptom of metastatic spinal disease. Other symptoms that the evidence highlighted related to characteristics of pain and neurological signs and symptoms. The committee used this evidence and their experience to list factors suggesting possible spinal metastases or MSCC that should alert a healthcare professional to think of these conditions and enable early recognition.

The committee agreed that a past or current diagnosis of cancer and any of the neurological symptoms or signs listed should be considered a medical emergency requiring immediate action to prevent the spine becoming unstable. They agreed that this should involve an immediate discussion with the MSCC coordinator to organise emergency care.

The committee noted that currently MSCC services and MSCC coordinators focus on people with suspected or confirmed MSCC rather than people with spinal metastases and that this has led to people presenting late to services. They agreed that advice is needed promptly (within 24 hours) for people with a past or current diagnosis of cancer who present with pain that has characteristics suggesting spinal metastases to ensure that the correct investigations are done with the appropriate level of urgency. They agreed that this should involve a discussion with the MSCC coordinator to organise their ongoing care.

The committee noted that once the condition is suspected, prompt action is needed to prevent progression. They therefore highlighted the areas of advice that may need to be discussed initially with the MSCC coordinator.

The committee discussed that sometimes people who do not have a prior diagnosis of cancer report symptoms and pain characteristics consistent with those listed in box 1 that raise suspicions of cancer, and took into account the NICE guideline on suspected cancer. They decided that in these cases, it is important to urgently refer to oncology services so that cancer is not missed.

Based on their experience and expertise, the committee agreed that information (which is tailored to the person’s needs) should be provided to people with a past or current diagnosis of cancer who have back pain without evidence of spinal metastases or MSCC to ensure that they are alert to the risks and know what symptoms to look out for and when to contact their healthcare professional without delay.

How the recommendations might affect practice

In practice, it is hard to distinguish back pain due to other causes from potential spinal metastases. This has resulted in variation in practice. Involving MSCC services and MSCC coordinators in treatment and advice for people with suspected or confirmed spinal metastases is a change for some centres, but the committee decided that this is needed to treat spinal metastases and prevent progression of disease. The committee provided the list of pain characteristics to raise awareness and improve recognition so that actions are taken without delay to prevent serious consequences.

Return to recommendations

Why the committee made the recommendations

No evidence was identified on immobilisation, so the committee reviewed the recommendations from the previous guideline and used their expertise and experience to update them.

The committee agreed that people who present with neurological signs and symptoms of spinal instability should have interventions to reduce the spinal load (immobilisation) such as reclined support, either flat or elevated and guided by comfort and assistance because of the risk of damage to an unstable spine. They also agreed that people with pain associated with movement may be at risk of spinal instability (see the section on tools for assessing spinal stability and prognosis) and should also be considered for immobilisation based on clinical assessment of their symptoms.

The committee were concerned that currently some people are immobilised for longer than necessary, lying in a flat position, which has a detrimental impact on their physical and mental wellbeing. The committee discussed that care of the spine needs to be balanced with the needs of the patient and the risk of complications from prolonged bedrest. They agreed that immobilisation could involve lying in a supine position either flat or with partial elevation depending on the person’s comfort and preferences. The committee also discussed that for some people, lying supine can be painful or affect their breathing. It was highlighted that the person’s position might have to be adjusted to relieve symptoms and improve comfort without risking weight bearing onto the spine.

To avoid people being immobilised for too long, the committee recommended that expert advice on spinal stability should be sought within 24 hours and assessment should be started (see the section on MRI assessment) to determine how long immobilisation may be necessary. The committee gave some examples of who to seek advice from, but noted that they cannot be prescriptive about this because it would depend on the person’s individual condition and treatment plan.

Given the lack of evidence and the impact that immobilisation has on a person’s quality of life, the committee made a recommendation for research to investigate different forms of immobilisation.

How the recommendations might affect practice

Immediate immobilisation to prevent the spine from collapsing is current practice for people with MSCC. However, this usually involves lying flat. The change to partial elevation could have a positive impact on the person’s quality of life. The committee expressed concerns that some people are immobilised for too long, so the recommendation on minimising the duration of immobilisation will standardise good current practice.

Return to recommendations

Why the committee made the recommendations

There was a large evidence base that the committee considered for radiological imaging techniques for the diagnosis of spinal metastases or MSCC. The committee based recommendations on this evidence as well as on their expertise and knowledge.

How the recommendations might affect practice

The recommendations on MRI assessment will reinforce current good practice and standardise imaging. There is variation in where the MRI is performed and the recommendation that this is done at the local hospital, if possible, will prevent unnecessary transfers and save time. Cost, availability and timing of MRI were discussed, but because of the nature of the condition and the need for urgent treatment to prevent major loss of function, the committee agreed that cost and urgency are justified.

Return to recommendations

Why the committee made the recommendations

There was a large evidence base that the committee considered for radiological imaging techniques for the diagnosis of spinal metastases or MSCC. The committee based recommendations on this evidence as well as on their expertise and knowledge.

The committee acknowledged that there are people who cannot have an MRI scan, for example, those with an aneurysm clip in their brain or any other metal part in their body. They discussed that usually a CT scan would be sufficient to assess the spine and plan treatment for these people. They agreed that myelography could also be an option, but it would result in a delay and carry additional risks. It is an invasive procedure, which should be carried out at a neuroscience or spinal surgical centre because it needs technical expertise and because of the risk of deterioration needing urgent decompression. Therefore, the committee highlighted that myelography should only be carried out if necessary (for example, if clearer information is needed about soft tissue) following a CT scan.

There was evidence that plain X-rays plus neurological assessment had a very low sensitivity for diagnosing spinal cord compression. It was shown that more than half of radiotherapy plans based on plain X-rays with neurological assessment were changed when information from MRI became available. The committee therefore agreed that plain X-rays should not be used for diagnosis.

Evidence from a randomised trial indicated that carrying out screening spinal MRIs for people at high risk of MSCC had no clinically important impact on overall survival, neurological and functional status, pain or quality of life. Based on this, the committee agreed that MRI should not be performed for the early detection of cord compression in people with diagnosed spinal metastases who are asymptomatic for cord compression.

There was no evidence related to radiological imaging techniques to help plan the management. The committee drew on the research identified for radiological imaging techniques in diagnosis as well as on their experience and expertise. They agreed that multiplanar viewing or 3-plane reconstruction of recent or, if not available, new CT images should be considered to assess spinal stability but also to plan vertebroplasty, kyphoplasty or spinal surgery because, based on their expertise, they noted that it can provide a more precise tumour location, which is needed when planning surgery to avoid making large or multiple incisions to find and remove a tumour.

How the recommendations might affect practice

The committee noted that the recommendations are consistent with current practice and will standardise imaging. The committee discussed whether CT scans could be used alone instead of CT and MRI scanning but the committee agreed that both may be needed for diagnosis and management to ensure the accurate inspection of soft and bony tissue, and to clearly locate the tumour site.

Return to recommendations

Why the committee made the recommendations

No evidence was identified on mobilisation, so the committee reviewed the recommendations from the previous guideline and used their expertise and experience to update them.

If investigations, imaging or clinical assessment indicate that there is likely spinal stability, mobility should be gradually increased so that the person can better engage with their environment and the people around them. To ensure people are thinking about mobilising straight away, and not only following radiotherapy or systemic treatment, they added that mobilisation could start regardless of whether the person has received treatment or not. The committee noted that healthcare professionals need to check the person’s blood pressure for orthostatic hypotension and monitor symptoms, such as pain or neurological symptoms, continuously. If there is a significant deterioration in the person’s symptoms, they may have to return to a more tolerable position. The committee discussed that a significant increase in symptoms may indicate spinal instability and agreed that reassessment should be carried out.

There are some people for whom treatment may not be appropriate or possible, and it is sometimes assumed that they do not need mobilisation or that it is unsafe. The committee agreed that mobilisation should still be carried out, if possible, to improve the person’s quality of life, independence, and interactions with others and their environment.

Based on experience, the committee discussed that some people may benefit from the use of orthoses to promote mobilisation. There was no evidence identified for this, so the committee suggested that specialist advice should be sought if orthoses are considered as an option. The committee did not want to be prescriptive about which specialist would give this advice because this would depend on the person and their condition.

Given that no evidence was identified in this area, and that appropriate and timely mobilisation can have a big impact on the person’s quality of life, the committee made a recommendation for research to investigate different forms of remobilisation.

How the recommendations might affect practice

The committee agreed that these recommendations reinforce and standardise current practice.

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Why the committee made the recommendations

Based on their experience, the committee discussed that pain is often the reason why people seek help, both before and after diagnosis. Immediate action is often needed to coordinate and start investigations and treatment, but the person’s pain should not be overlooked and needs to be managed promptly too. To prevent delays to pain management, the committee agreed that adequate and timely pain relief should be provided.

The committee noted that an assessment of all aspects related to a person’s pain is needed for effective pain management. They agreed that this would involve a detailed discussion with the person about issues such as the characteristics of the pain and how it affects them in their daily life. The committee highlighted that in current practice, such assessments are not always individualised, for example, focusing on pain scales, and do not take into account the personal experience of pain and different ways of describing their pain, which can mean that people do not feel listened to.

To further strengthen the person-centred approach to pain management, the committee decided that people should have opportunities to discuss their pain management options, what they have tried previously, what they expect from the treatment and raise concerns. Such discussions would allow a shared decision to be made to agree the most acceptable and effective options with the person. The committee listed issues that would be most relevant for this population.

The committee agreed that it is important to assess regularly whether the treatment adequately relieves pain, so they recommended that it should be reviewed after starting and changing treatment. Based on experience, the committee discussed that some people would benefit from specialist pain management services, depending on their pain assessment and the impact the pain has on their life, and agreed that a referral could be made.

How the recommendations might affect practice

The committee noted that there is variation in how pain assessment is carried out and what is discussed with the person. They also discussed that the recommendation related to referral to a specialist pain service may increase demand and increase costs. It was agreed that this was justified because it will improve outcomes for those who have severe pain or pain that significantly affects their activities. The recommendations will standardise assessment and ensure that people are listened to and understood so that they can get the most appropriate pain treatment.

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Why the committee made the recommendations

The evidence on pain management was limited, consisting of 3 randomised controlled trials, the largest of which included 60 people with stable spinal metastases. The committee acknowledged that there was not enough evidence for them to make recommendations based on these studies alone, so they drew on their knowledge of the World Health Organization (WHO) guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents (2018), as well as related NICE guidelines. They also discussed their own experience and reviewed the recommendation from the previous guideline.

The committee agreed that the adverse effects of analgesic medication can affect quality of life and adherence to treatment, and that the risks are not always fully discussed. They highlighted the importance of these discussions to ensure that people understand the possible risks and benefits of different treatment options and are supported to make decisions about their treatment.

Since the previous NICE guideline, the advice from WHO has changed and they are no longer using the ‘3-step pain ladder’ previously recommended. The committee agreed that the new recommendations should be in line with the current WHO guidance, which recommends analgesic treatment with non-opiate medicines (for example, paracetamol or non-steroidal anti-inflammatory drugs) and opiate medication as options for initial treatment. The choice of medicine, used individually or in combination, is dependent on the ongoing individualised pain assessment and severity of pain, and agreed with the person in their pain management plan. The committee noted that this is consistent with their experience, reflects current practice and ensures that the medication is tailored to the person’s needs.

The committee also discussed that people’s responses to pain treatment vary and that it is important not to leave people on a treatment that may not be working or may require a different dosage to achieve effective pain relief. To avoid inadequate pain relief, they recommended that dosage, titration and tolerability are discussed at each review and the management plan updated if necessary.

The committee discussed the use of medicines for neuropathic pain and, based on their knowledge and experience, decided that they could be given if the pain has neuropathic features or opioid analgesia has been ineffective. There was no direct evidence for this identified for people with MSCC so they decided that this should be prescribed in line with recommendations in the NICE guideline on neuropathic pain in adults.

Palliative pain relief for people having strong opioids in palliative care and the safe use of controlled drugs were also discussed as critical issues in cancer pain relief but the committee were aware of other guidelines that are dedicated to these topics and signposted to the NICE guideline on palliative care for adults and the NICE guideline on controlled drugs.

How the recommendations might affect practice

The recommendations reinforce good current practice and support implementation of national and international guidance on pain management.

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Why the committee made the recommendations

How the recommendations might affect practice

The recommendations are consistent with current practice.

Return to recommendations

Why the committee made the recommendations

The evidence for corticosteroid therapy was limited, originating from 3 small studies, so the committee also took into account the recommendations from the previous version of the guideline and used their expertise and experience to make the recommendations.

The committee noted that the previous recommendations no longer reflected current practice, particularly in relation to giving corticosteroids to all people with MSCC regardless of their symptoms. The committee also discussed that the use of corticosteroids in people with suspected MSCC could reduce the chance of a positive biopsy.

There was some evidence that functional status was improved with dexamethasone, but the studies were too small to draw clear conclusions. The committee noted that this finding was supported by their expertise and experience. They agreed that for people with cord compression with neurological symptoms or signs, corticosteroids can reduce inflammation and promote stabilisation of blood vessel membranes at the compression site, consequently reducing back pain and neurological deficits. The evidence also showed an increase in treatment-related toxicity but numbers in the trial were small so there was some uncertainty in these findings. The committee also agreed that, because of potential toxicity and other side effects, corticosteroids should be stopped once other treatment options, such as surgery or radiotherapy, are available. In such instances, corticosteroids should be reduced gradually because a sudden withdrawal may cause adverse events, such as a sharp fall in blood pressure, and affect blood glucose levels. If spinal metastases or MSCC is ruled out, dexamethasone given before imaging should be discontinued because of the potential for adverse events. The duration of corticosteroid use would be short so they can be stopped without reducing the dose.

The committee decided that it was important to make separate recommendations for haematological malignancy. Based on their expertise, the committee agreed that dexamethasone is beneficial for people with confirmed haematological malignancy with infiltration of the spinal column or canal, regardless of whether they have neurological symptoms. Corticosteroid treatment is commonly used for treating myeloma once a haematological malignancy is confirmed (which the committee acknowledged is in line with the NICE guideline on myeloma). The committee agreed that a 16 mg dose of oral dexamethasone (or equivalent parenteral dose) to start with is current practice, but were aware that in some cases, a different corticosteroid or a different dose may be used, so they recommended that ongoing treatment should be discussed with the specialist haematology team.

The committee discussed that corticosteroids should be avoided if a haematological malignancy is suspected but has not been confirmed, because of the potential for a direct anti-tumour effect on B-cell lymphoma causing a reduction in MRI abnormalities, and making biopsy and histologic confirmation more difficult. Therefore, based on experience and expertise, the committee agreed that in these cases, specialist haematological advice would be needed before corticosteroid treatment is started.

The committee agreed, based on their knowledge and expertise, that toxicity is a problem, particularly if dexamethasone is given longer term. They therefore recommended that it should not be used for people without neurological symptoms except where it is part of a radiotherapy regimen. However, they agreed that it could be considered if the person has severe pain or the person has a haematological malignancy (see above).

In situations where there are no other treatment options (because they have been tried and were not effective, the person is too unwell to tolerate other treatment, or giving another treatment is too risky) and symptoms return or worsen as dexamethasone is reduced, the committee agreed that it could be considered for longer.

Increased blood glucose is a side effect of corticosteroid treatment, so the committee recommended blood glucose monitoring. They agreed that a proton pump inhibitor should also be prescribed to reduce the potential risk of peptic ulcer associated with corticosteroid therapy. They acknowledged that glucose monitoring and giving adjunct proton pump inhibitor treatment is common practice but agreed that they are important issues to highlight.

How the recommendations might affect practice

The committee agreed that the recommendations reflect good current practice.

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Why the committee made the recommendations

The committee considered the evidence as well as using their knowledge and experience to make the recommendations.

There were only 2 studies of scoring systems to assess spinal stability, both using the Spinal Instability Neoplastic Score (SINS). The evidence showed that it was effective at ruling out instability, but the number of false-positive results was relatively high at the usual threshold. There was also some uncertainty about the quality of the evidence.

The committee discussed that scoring systems can be helpful additions to clinical assessment, especially for less experienced clinicians, ensuring that the main features for determining spinal instability are assessed. They also allow assessments to be standardised, documented and audited.

Although the evidence was limited to SINS, the committee were aware of other systems used in current practice. They included SINS as an example, but did not want to discourage the use of other validated scoring systems already in use or in development.

There was a large amount of evidence for many different prognostic scoring systems, including original and revised versions for some. Analysis showed that these varied in their ability to predict survival, and none of the systems reviewed were better overall at predicting prognosis. The committee noted that, although the Tokuhashi (and the revised Tokuhashi) scoring system was less accurate at predicting short-term (under 6 months) to medium-term (6 to 12 months) survival, it was better than other tools at predicting longer-term prognosis (over 12 months). The committee did not want to be too prescriptive about using a particular scoring system so they gave the revised Tokuhashi scoring system as an example, but they agreed that other validated scoring systems with evidence of accuracy could be used.

The committee wanted to encourage the use of scoring systems that demonstrated good accuracy (both calibration and discrimination) to encourage a more standardised approach to assessing survival. However, because of the lack of certainty, they agreed that treatment decisions should not be based solely on a prognostic score. The evidence showed that many people lived both longer and shorter than predicted, particularly for short- to medium-term survival. To ensure fair access to treatments, the committee agreed that a broader, individualised assessment should be used that includes other prognostic factors alongside a scoring system.

The committee noted that scoring systems have an important role in determining prognosis and informing decisions about treatment (both oncological and surgical). However, such decision making is complex and many other factors need to be taken into account. The committee agreed that scoring systems should not be used in isolation but could help support decision making alongside other clinical factors and patient preferences.

How the recommendations might affect practice

The recommendations reinforce current practice, which takes into account multiple sources of information, such as clinical assessment and results from investigations, as well as scores from validated scoring systems to inform decisions about treatment.

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Why the committee made the recommendation

The committee took into account the recommendations from the previous version of the guideline and their expertise and experience to make the recommendation.

The committee agreed that the impact on future fertility of both the cancer and the radiotherapy treatment should be discussed with the person and, if appropriate (for example, depending on age and preferences), a referral should be made to a fertility specialist. The committee discussed that treatment of MSCC is usually urgent and fertility treatment can take time to organise and undertake in practice. Therefore, it is important to note that MSCC treatment should not be delayed awaiting further discussions with a fertility specialist. It was also acknowledged that radiotherapy fields for MSCC would usually not affect the gonads, so urgent radiotherapy treatment might not have as much of an impact on fertility as for other cancers.

How the recommendation might affect practice

The committee agreed that the recommendation reflects current practice.

Return to recommendation

Why the committee made the recommendations

The committee discussed the evidence and also took into account the recommendations from the previous version of the guideline and their expertise and experience to make the recommendations.

The evidence showed that for treating painful spinal metastases (with no evidence of MSCC), 8 Gy single fraction radiotherapy was as effective as multiple fractions in terms of pain reduction, spinal stability and overall survival, and it had fewer treatment-related adverse events. The committee agreed that it should be offered in preference to multiple fraction radiotherapy.

There was also evidence from a randomised controlled trial showing that stereotactic ablative body radiotherapy was more effective than conventional radiotherapy in reducing pain for people with spinal metastases without MSCC. This would deliver a precise dose while sparing damage to healthy tissue. Even though the evidence was limited, the committee agreed that this could be an option for people with a good overall prognosis because the evidence showed that it was safe and effective. They also discussed that those with limited metastatic disease (currently up to 3 discrete metastases would be considered standard for oligometastases in accordance with NHS commissioning of stereotactic ablative body radiotherapy) could benefit from this. They agreed that this number would balance the potential that all cancer sites could be controlled with an acceptable level of toxicity.

The committee discussed that there is a lack of awareness about the risks of radiotherapy for haematological spinal metastatic disease and the potential for reducing the success of stem cell harvesting. Depending on the dose, radiotherapy in the lower lumbar or pelvic area can be toxic and compromise haemopoietic stem cell collection. The committee agreed that a discussion with a relevant specialist (pain specialist or haematologist) should take place if radiotherapy is considered for people with haematological disease.

How the recommendations might affect practice

The committee discussed that stereotactic ablative body radiotherapy is not currently made available for painful spinal metastases and would be a challenge to implement initially because new pathways for this would need to be established. However, all centres have access to this technology because it is used in the treatment of other cancers (such as lung cancer) and, once pathways are organised, this would not have a significant resource impact.

Return to recommendations

Why the committee made the recommendations

The committee discussed the evidence and also took into account the recommendations from the previous version of the guideline and their expertise and experience to make the recommendations.

Although there was no evidence on the timing of radiotherapy, the committee agreed that MSCC is an oncological emergency and rapid access to radiotherapy is needed to prevent neurological impairment. They also agreed that the previous guideline set a benchmark of 24-hour access to radiotherapy 7 days a week, and changing this would lower the standard of care for people needing emergency treatment for MSCC. The committee discussed that radiotherapy is likely to prevent further neurological damage in people who have MSCC that is unlikely to be suitable for spinal surgery. They therefore recommended it as an urgent option in such situations. However, they decided that it is not likely to be beneficial for people with MSCC and complete tetraplegia or paraplegia (for 2 weeks or longer) whose pain is controlled or for people whose overall prognosis is considered to be poor, because the benefits would be outweighed by the side effects of the radiotherapy.

The evidence showed that single fractionation was as effective as multiple fractions, and the committee agreed that it provides a better patient experience, is more convenient and lower in cost. Avoiding multiple unnecessary hospital visits can be particularly important for people with reduced life expectancy. The studies all used an 8 Gy fraction and therefore the committee recommended this because it was shown to be safe and effective.

The committee were concerned about the increased risk of long-term side effects associated with treating a large volume of spinal cord with a single dose of radiotherapy, for example, when treating a large treatment field or fields. This may also be a concern when retreatment with radiotherapy is being considered. There is no clear definition of a large volume or treatment field and the committee agreed that this should be decided using clinical judgement. In these circumstances, multiple fraction radiotherapy would be appropriate.

In the absence of evidence related to stereotactic ablative body radiotherapy for the treatment of MSCC, the committee could not comment on its effectiveness but made a recommendation for research to compare postoperative stereotactic ablative radiotherapy with postoperative standard radiotherapy.

How the recommendations might affect practice

The committee acknowledged that recommending single rather than multiple fraction radiotherapy was a change to current practice. They agreed that this would improve the efficiency of services and would be cost saving because it would avoid multiple hospital visits and therefore also reduce costs while being equally safe and effective.

Return to recommendations

Why the committee made the recommendation

There was no evidence on the use of radiotherapy for people with asymptomatic spinal metastases, so the committee made recommendations based on their experience. They agreed that the adverse effects of radiotherapy would outweigh the potential benefits of the treatment and that it should only be considered in the exceptional circumstances listed: for those in a randomised trial with the intention of preventing MSCC, those with limited metastatic disease (currently up to 3 discrete metastases would be considered standard for oligometastases in accordance with NHS commissioning of stereotactic ablative body radiotherapy) and where radiotherapy could be used to control disease, and for those with radiological signs of spinal cord compression by an epidural or intradural tumour (where radiotherapy may prevent progression to symptomatic MSCC).

How the recommendation might affect practice

The committee discussed that the recommendation is consistent with current practice.

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Why the committee made the recommendations

How the recommendations might affect practice

The recommendations are consistent with current good practice. Postoperative radiotherapy is commonly given in current practice and the recommendation will reinforce this.

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Why the committee made the recommendations

Based on experience, the committee noted that there are many different factors to consider that may impact the success of surgical interventions. These include overall fitness for surgery, but also prognosis and issues related to primary cancer type and stage. To ensure that all relevant information is taken into account and to make decisions more efficient, the committee recommended that discussions should take place before surgery is offered, between people from the appropriate specialties within the multidisciplinary team in the MSCC service. This would usually include the oncologist and spinal surgeon but could also draw on other people’s expertise where necessary.

The committee discussed, based on experience, that people are sometimes referred to MSCC services without a known primary cancer type. Establishing this could make a difference to management plans, so the committee agreed that a radiologically guided biopsy should be performed in this situation as long as an intervention is not needed immediately.

There was no evidence about different timing of treatments, but the committee recognised that timing is important to prevent neurological decline. They agreed that surgery should be carried out as soon as possible. They decided not to be too prescriptive about exact timeframes because there is variation in how much information is needed and available to come up with a clear surgical treatment approach. However, they agreed that speed of onset and rate of progression of neurological symptoms and signs would be an indicator of urgency.

The committee discussed that in current clinical practice some clinicians use a time limit from onset of paralysis as the only factor to make decisions about whether to offer surgery to people with complete tetraplegia or paraplegia. They noted that this was not evidence-based and that it is not impossible for some paralysis to be reversed even if some time has already passed.

How the recommendations might affect practice

There is variation in who is making decisions about surgery and whether or not this would involve other specialties than spinal surgery. The committee agreed that having joint discussions about surgical treatment plans would make the treatment more tailored to the individual and therefore more efficient and likely to improve outcomes. The recommendations related to timing of surgical interventions reflect current practice and will standardise it.

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Why the committee made the recommendations

Options for invasive interventions depend on whether there is cord compression or not, and there was some evidence relating to interventions for both of these groups. The committee considered clinical evidence, published economic evidence and a new economic model when drafting the recommendations. The evidence was related to very specific populations and mainly compared different types of surgery, making it hard to apply to the whole population. The committee therefore also drew on their expertise and experience.

The economic evidence and economic model only found vertebroplasty and kyphoplasty to be cost effective in some circumstances. However, given that these interventions are used to prevent serious adverse events, including collapse of the spine, the committee agreed that they could be considered if appropriate.

How the recommendations might affect practice

The committee discussed that there is variation in practice, but this is due to differences in the characteristics of the condition that are being treated. However, the committee agreed that the recommendations would be consistent with current practice and give clinicians the tools to tailor their surgical approach to each person.

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Why the committee made the recommendations

The committee discussed the recommendations on service configuration for support and rehabilitation and how they would be implemented in practice. They also reviewed the recommendations in the previous guideline.

Based on their experience, the committee noted that for rehabilitation to be effective, it needs to be supported by a full range of support services and be considered at the earliest opportunity so that people have a plan in place to regain function after treatment, based on their own preferences, priorities and goals.

The committee agreed that specialist rehabilitation should be offered if needed and could include admission to a specialist rehabilitation unit depending on the person’s circumstances, level of function, treatment and likelihood to benefit from this. They decided that they could not be prescriptive about who would most likely benefit from this because it would need to be based on clinical judgement taking into account many different clinical and social factors.

The previous guideline included recommendations on preventing and managing complications; however, these are covered in more detail in other NICE guidance, so cross references have been included.

How the recommendations might affect practice

The recommendations are consistent with current good practice.

Return to recommendations