Treating painful spinal metastases and

preventing metastatic spinal cord compression

NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/metastatic-spinal-cord-compression
NICE Pathway last updated: 28 April 2020

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Adult with spinal metastases

No additional information

2 Treatment options

All decisions on the most appropriate combinations of treatment for pain or preventing paralysis
caused by MSCC should be made by relevant spinal specialists in consultation with primary
tumour site clinicians and with the full involvement of the patient.

3 Analgesia and referral for specialist pain care

Offer conventional analgesia (including NSAIDs, non-opiate and opiate medication) as required
to patients with painful spinal metastases in escalating doses as described by the WHO three-
step pain relief ladder.

Consider referral for specialist pain care including invasive procedures (such as epidural or
intrathecal analgesia) and neurosurgical interventions for patients with intractable pain from
spinal metastases.

See what NICE says on opioids for pain relief in palliative care.

4 Drug treatments for specific cancers

Bisphosphonates

Offer patients with vertebral involvement from myeloma or breast cancer bisphosphonates to
reduce pain and the risk of vertebral fracture/collapse.

Offer patients with vertebral metastases from prostate cancer bisphosphonates to reduce pain
only if conventional analgesia fails to control pain.

Bisphosphonates should not be used to treat spinal pain in patients 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

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controlled trial.

Degarelix

The following recommendations are from NICE technology appraisal guidance on degarelix for
treating advanced hormone-dependent prostate cancer.

Degarelix is recommended as an option for treating advanced hormone-dependent prostate

cancer in people with spinal metastases, only if the commissioner can achieve at least the same
discounted drug cost as that available to the NHS in June 2016.

This guidance is not intended to affect the position of patients whose treatment with degarelix
was started within the NHS before this guidance was published. Treatment of those patients
may continue without change to whatever funding arrangements were in place for them before
this guidance was published until they and their NHS clinician consider it appropriate to stop.

NICE has written information for the public explaining its guidance on degarelix.

Denosumab

The following recommendations are from NICE technology appraisal guidance on denosumab
for the prevention of skeletal-related events in adults with bone metastases from solid tumours.

Denosumab is recommended as an option for preventing skeletal-related events (pathological

fracture, radiation to bone, spinal cord compression or surgery to bone) in adults with bone
metastases from breast cancer and from solid tumours other than prostate if:

bisphosphonates would otherwise be prescribed and

the manufacturer provides denosumab with the discount agreed in the patient access
scheme.

Denosumab is not recommended for preventing skeletal-related events in adults with bone
metastases from prostate cancer.

Adults with bone metastases from solid tumours currently receiving denosumab for the
prevention of skeletal-related events that is not recommended according to the criteria above
should be able to continue treatment until they and their clinician consider it appropriate to stop.

NICE has written information for the public explaining its guidance on denosumab.

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5 Radiotherapy

Offer patients with spinal metastases causing non-mechanical spinal pain 8 Gy single fraction
palliative radiotherapy even if they are completely paralysed.

Patients with asymptomatic spinal metastases should not be offered radiotherapy with the
intention of preventing MSCC except as part of a randomised controlled trial.

6 Spinal stabilisation surgery or external spinal support

Urgently consider patients with spinal metastases and imaging evidence of structural spinal
failure with spinal instability for surgery to stabilise the spine and prevent MSCC.

Consider patients with spinal metastases and mechanical pain resistant to conventional
analgesia for spinal stabilisation surgery even if completely paralysed.

Consider patients with MSCC who have severe mechanical pain and/or imaging evidence of
spinal instability, but who are unsuitable for surgery, for external spinal support (for example, a
halo vest or cervico-thoraco-lumbar orthosis).

Patients with spinal metastases without pain or instability should not be offered surgery with the
intention of preventing MSCC except as part of a randomised controlled trial.

7 Vertebroplasty or kyphoplasty

Consider vertebroplasty1 or kyphoplasty for patients who have vertebral metastases and no
evidence of MSCC or spinal instability if they have:

mechanical pain resistant to conventional analgesia, or

vertebral body collapse.

Vertebroplasty or kyphoplasty for spinal metastases should only be performed after agreement
between appropriate specialists (including an oncologist, interventional radiologist, and spinal
surgeon), with full involvement of the patient and in facilities where there is good access to
spinal surgery.

1
The Medicines and Healthcare Products Regulatory Agency has issued safety notices relating to this procedure.

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Interventional procedures

NICE has published guidance on the following with normal arrangements for consent, audit
and clinical governance:

percutaneous cementoplasty for palliative treatment of bony malignancies

balloon kyphoplasty for vertebral compression fractures
percutaneous vertebroplasty.

8 Treating metastatic spinal cord compression

See Metastatic spinal cord compression / Treating metastatic spinal cord compression

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Glossary

ASA

American Society of Anaesthetists

MSCC

metastatic spinal cord compression

Non-specific lumbar spinal pain

spinal pain that is not progressive, severe or aggravated by straining and has no accompanying
neurological symptoms

STIR

short T1 inversion recovery

Sources

Metastatic spinal cord compression in adults: risk assessment, diagnosis and management
(2008) NICE guideline CG75

Degarelix for treating advanced hormone-dependent prostate cancer (2016) NICE technology
appraisal guidance 404

Denosumab for the prevention of skeletal-related events in adults with bone metastases from
solid tumours (2012) NICE technology appraisal guidance 265

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual

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needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,
and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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Treating painful spinal metastases and pre
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Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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