Spinal Cord Compression (Malignant)

VERSION: 1.0 CREATED: January 27, 2026 STATUS: Approved

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DIAGNOSIS: Malignant Spinal Cord Compression (MSCC) / Metastatic Epidural Spinal Cord Compression (MESCC)

ICD-10: G95.20 (Unspecified cord compression), C79.49 (Secondary malignant neoplasm of other parts of nervous system), C79.51 (Secondary malignant neoplasm of bone), M49.50 (Collapsed vertebra in diseases classified elsewhere), G82.20 (Paraplegia, unspecified)

CPT CODES: 85025 (CBC with differential), 80053 (CMP (BMP + LFTs)), 87040 (Blood cultures (x2 sets)), 82947 (Blood glucose), 86900 (Type and screen), 82310 (Calcium (ionized or corrected)), 81003 (Urinalysis), 86334 (SPEP / UPEP with immunofixation), 84100 (Phosphate), 84145 (Procalcitonin), 82306 (Vitamin D (25-OH)), 72132 (CT myelogram), 78816 (PET/CT (FDG)), 78300 (Bone scan (Tc-99m)), 70552 (MRI brain with contrast), 96374 (Dexamethasone (high-dose for MSCC))

SYNONYMS: Malignant spinal cord compression, MSCC, metastatic epidural spinal cord compression, MESCC, cord compression, spinal metastases, spinal tumor compression, epidural metastases, cancer spine compression, vertebral metastases with cord compression

SCOPE: Emergency evaluation and management of malignant (metastatic) spinal cord compression in adults. Covers dexamethasone protocols, emergent imaging, surgical decompression criteria (Patchell criteria), radiation therapy, vertebral body assessment, functional prognostication, and disposition. Excludes non-malignant compressive myelopathy (disc herniation, epidural abscess — separate templates), primary spinal cord tumors (intramedullary), and cauda equina syndrome from malignancy (partially overlaps — see separate template for CES).

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP

1A. Essential/Core Labs

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	STAT	Baseline; surgical candidacy; chemotherapy effects; infection (epidural abscess differential)	Normal; leukocytosis may suggest infection; thrombocytopenia affects surgical/procedural candidacy
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	STAT	Renal function (contrast, medications); electrolytes (hypercalcemia of malignancy); hepatic function (chemotherapy dosing, metastatic disease)	Normal; calcium >10.5 mg/dL → assess for hypercalcemia of malignancy
PT/INR, aPTT (CPT 85610, 85730)	STAT	STAT	ROUTINE	STAT	Coagulopathy assessment; surgical candidacy; anticoagulation reversal if emergent surgery needed	Normal; INR <1.5 for surgery
ESR / CRP (CPT 85652, 86140)	STAT	STAT	ROUTINE	STAT	Epidural abscess differential (highly elevated ESR >30-50 typically); inflammatory markers for malignancy	Normal-mildly elevated in malignancy; markedly elevated ESR/CRP → strongly consider abscess
Blood cultures (x2 sets) (CPT 87040)	STAT	STAT	-	STAT	Epidural abscess differential; bacteremia if febrile	Negative; positive → epidural abscess more likely than tumor
Blood glucose (CPT 82947)	STAT	STAT	ROUTINE	STAT	Baseline before high-dose dexamethasone; steroid hyperglycemia	<180 mg/dL; anticipate significant hyperglycemia with high-dose steroids
Type and screen (CPT 86900)	STAT	STAT	-	STAT	Surgical candidacy; blood product availability	On file
Calcium (ionized or corrected) (CPT 82310)	STAT	STAT	ROUTINE	STAT	Hypercalcemia of malignancy (present in 10-30% of cancer patients); can cause confusion, weakness mimicking cord compression progression	Corrected Ca <10.5 mg/dL; if elevated → IV fluids, calcitonin, bisphosphonate
LDH	STAT	ROUTINE	ROUTINE	STAT	Tumor burden marker; lymphoma (very high LDH); prognostic	Normal; very high → lymphoma, aggressive malignancy
Urinalysis (CPT 81003)	STAT	STAT	-	STAT	Urinary retention (neurogenic bladder from cord compression); UTI (fever differential); baseline renal function	Normal; retention with high post-void residual expected in cord compression

1B. Extended Workup (Second-line)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Tumor markers (PSA, CEA, CA 19-9, CA 125, CA 15-3, AFP, β-hCG)	-	ROUTINE	ROUTINE	-	Unknown primary cancer; PSA (prostate — most common spinal metastasis), CEA (GI, lung), CA 15-3 (breast), etc.	Elevations guide primary site identification
SPEP / UPEP with immunofixation (CPT 86334)	-	ROUTINE	ROUTINE	-	Multiple myeloma (common cause of vertebral compression/cord compression); M-protein, light chains	No monoclonal protein; if present → myeloma workup
Free light chains (kappa/lambda ratio)	-	ROUTINE	ROUTINE	-	Myeloma; light chain disease	Normal ratio (0.26-1.65); abnormal suggests myeloma
Serum protein electrophoresis (CPT 86334)	-	ROUTINE	ROUTINE	-	Myeloma; lymphoma	No M-spike
Alkaline phosphatase (bone-specific)	-	ROUTINE	ROUTINE	-	Osteoblastic metastases (prostate, breast); Paget's disease differential	Normal; elevated suggests bone turnover
Phosphate (CPT 84100)	-	ROUTINE	ROUTINE	-	Hypercalcemia workup; oncologic emergency assessment	Normal
Uric acid	-	ROUTINE	-	ROUTINE	Tumor lysis syndrome risk (lymphoma, rapidly proliferating tumors); pre-treatment assessment	Normal
Procalcitonin (CPT 84145)	STAT	STAT	-	STAT	If infection/abscess differential is high; more specific than CRP for bacterial infection	<0.25 ng/mL (low probability bacterial); >0.5 → consider abscess/infection
TSH, free T4 (CPT 84443, 84439)	-	ROUTINE	ROUTINE	-	Thyroid cancer metastases (follicular thyroid cancer has bony tropism)	Normal
Vitamin D (25-OH) (CPT 82306)	-	ROUTINE	ROUTINE	-	Bone health; pathologic fracture risk; supplement if deficient	>30 ng/mL

1C. Rare/Specialized (Refractory or Atypical)

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Flow cytometry (peripheral blood)	-	EXT	EXT	-	Lymphoma/leukemia presenting as epidural mass	Abnormal lymphocyte population = lymphoproliferative disorder
Bone marrow biopsy	-	EXT	EXT	-	Myeloma; lymphoma; unknown primary with bone marrow involvement	Normal; abnormal → specific diagnosis
Paraneoplastic antibody panel	-	EXT	EXT	-	If myelopathy features atypical for compression (e.g., subacute progressive without clear structural compression)	Negative; positive changes diagnosis from compression to paraneoplastic myelopathy
AQP4-IgG (NMO antibody)	-	EXT	EXT	-	If imaging shows longitudinal intramedullary lesion rather than epidural compression → NMOSD differential	Negative; positive → NMOSD not metastatic compression
CT-guided biopsy of vertebral lesion	-	URGENT	ROUTINE	-	Unknown primary; tissue diagnosis needed before treatment; lymphoma requires tissue for definitive diagnosis (sensitive to steroids — obtain tissue BEFORE steroids if possible in suspected lymphoma)	Histopathologic diagnosis

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI entire spine with and without contrast (gadolinium) (CPT 72156+72157+72158)	STAT	STAT	URGENT	STAT	Within 4 hours of presentation (24h max); GOLD STANDARD; must image ENTIRE spine (multifocal metastases in 30-40%)	Epidural mass with cord compression; level(s) of compression; Bilsky grade (0-3); vertebral body involvement; number of levels; intramedullary vs. extramedullary-intradural vs. epidural; cord signal change (T2 hyperintensity = edema/myelopathy — poor prognostic sign); paraspinal soft tissue extension	MRI-incompatible implants; severe claustrophobia (sedate); GFR <30 (gadolinium risk — benefit outweighs risk in emergency)
Plain radiographs (spine, targeted)	STAT	STAT	-	STAT	Immediate while awaiting MRI; identifies vertebral collapse, pathologic fracture, alignment; 70% sensitivity for vertebral metastases (30% miss rate)	Vertebral body collapse; pedicle erosion ("winking owl sign" on AP); pathologic fracture; kyphosis; alignment	Pregnancy (shield)
CT chest/abdomen/pelvis with contrast (CPT 71260, 74178)	URGENT	URGENT	ROUTINE	-	Within 24-48h; staging; primary identification; lung is most common primary	Primary tumor; staging of metastatic disease; lymphadenopathy; visceral metastases	Contrast allergy; renal impairment
CT spine (targeted level) without contrast	STAT	STAT	-	STAT	If MRI contraindicated or unavailable; pre-operative planning for bone assessment; vertebral body stability (SINS score); CT myelogram if MRI not possible	Bone destruction pattern (lytic vs. blastic vs. mixed); posterior element involvement; fracture; canal compromise; vertebral body collapse >50%	Pregnancy (risk vs. benefit)

2B. Extended

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
CT myelogram (CPT 72132)	STAT	STAT	-	STAT	If MRI contraindicated (pacemaker, implant); intrathecal contrast via LP → CT; demonstrates level of block	Complete or partial subarachnoid block; level of compression; multiple levels of disease	LP contraindicated if complete block above puncture site (risk of neurologic deterioration); coagulopathy
PET/CT (FDG) (CPT 78816)	-	ROUTINE	ROUTINE	-	Staging; primary identification; assessing treatment response; distinguishing active tumor from treated/necrotic bone	Active metastatic disease; primary tumor identification	Uncontrolled diabetes; pregnancy
Bone scan (Tc-99m) (CPT 78300)	-	ROUTINE	ROUTINE	-	Skeletal staging; identifies additional osseous metastases; blastic > lytic sensitivity; useful for prostate, breast	Additional bone metastases; may miss purely lytic lesions (renal, thyroid, myeloma)	Pregnancy
MRI brain with contrast (CPT 70552)	-	URGENT	ROUTINE	-	If lung primary or melanoma (high brain metastasis risk); symptoms suggesting intracranial disease	Brain metastases (concurrent in 10-30% of patients with MSCC)	Same as MRI
CT-guided biopsy (vertebral/paraspinal)	-	URGENT	ROUTINE	-	Tissue diagnosis if unknown primary; CRITICAL for suspected lymphoma (radiosensitive — may not need surgery); obtain BEFORE steroids if lymphoma suspected (steroids can render biopsy non-diagnostic)	Histopathologic diagnosis; molecular profiling	Coagulopathy; inaccessible lesion
DEXA scan	-	-	ROUTINE	-	Baseline bone density if prolonged steroids anticipated; osteoporosis risk	T-score; fracture risk assessment	None significant

2C. Rare/Advanced

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Spinal angiography	-	EXT	EXT	-	If highly vascular tumor suspected (RCC, thyroid) — pre-operative embolization to reduce surgical bleeding	Tumor vascularity; feeding vessels; embolization candidacy	Contrast allergy; renal impairment; coagulopathy
Pre-operative embolization	-	URGENT	-	-	Highly vascular metastases (RCC, thyroid); 24-48h before surgery to reduce intraoperative blood loss	Reduction of tumor blood supply	Contrast allergy; tumor supplying anterior spinal artery (risk of cord infarction)
Dynamic flexion-extension radiographs	-	-	ROUTINE	-	Post-treatment stability assessment; if clinical instability suspected	Mechanical instability (translation, angulation)	Acute cord compression (do NOT flex/extend if acute neurologic deficit)
Nuclear medicine thyroid scan	-	-	EXT	-	If thyroid primary suspected (follicular thyroid cancer has high bone tropism)	Thyroid nodule; functional assessment	Recent iodinated contrast (wait 4-6 weeks)

Lumbar Puncture

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
LP — Generally NOT indicated	-	-	-	-	LP is NOT routinely indicated in MSCC; CSF cytology only if leptomeningeal disease suspected AND no complete block; CT myelogram if MRI not available (different indication)	N/A — LP is diagnostic adjunct only in specific situations	CONTRAINDICATED with complete spinal block above LP level (risk of neurologic deterioration/coning); coagulopathy; local infection

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3. TREATMENT PROTOCOLS

3A. Acute/Emergent Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Dexamethasone (high-dose for MSCC) (CPT 96374)	IV	-	10 mg :: IV :: q6h :: Standard loading dose: 10 mg IV bolus STAT; Then: 4 mg IV/PO q6h (16 mg/day); High-dose (severe deficits or rapidly progressive): 96 mg IV bolus (controversial — see evidence) → 24 mg q6h x 3 days → rapid taper; Moderate deficits / ambulatory: 10 mg IV → 4 mg q6h; Begin taper after definitive treatment initiated; GI prophylaxis: PPI while on steroids; Monitor glucose q6h	-	Sorensen et al. (1994): Dexamethasone + radiation vs. radiation alone → 81% vs. 63% ambulatory at treatment end; High-dose (96 mg) vs. standard (10 mg): Vecht et al. (1989) — higher response rate at 1 week but more side effects; MOST centers now use moderate dose (10 mg load → 16 mg/day); Begin within 6h of diagnosis	STAT	STAT	URGENT	STAT
Spinal precautions / immobilization	-	-	N/A :: - :: per protocol :: Strict log-roll precautions; flat bed transport; cervical collar if cervical spine involved; thoracolumbar brace (TLSO) if thoracolumbar; avoid flexion/extension; transfer on spine board if unstable fracture suspected	-	Unstable pathologic fracture may worsen cord compression with movement; SINS score guides instability assessment	STAT	STAT	-	STAT
Bladder management	-	-	200 mL :: - :: - :: Assess for urinary retention (cord compression causes neurogenic bladder); straight catheterize if retention → place Foley if residual >200 mL or ongoing retention; monitor I&O strictly	-	Urinary retention is a common presenting feature and may be the first sign of cord compression; bladder function correlates with motor recovery prognosis	STAT	STAT	-	STAT
DVT prophylaxis	SC	-	40 mg :: SC :: daily :: SCDs immediately; pharmacologic prophylaxis (enoxaparin 40 mg SQ daily) within 24-48h unless surgery imminent; spinal cord compression patients have VERY HIGH VTE risk (up to 25-50% without prophylaxis)	-	Cancer + immobility + spinal cord injury = extremely high VTE risk; mechanical prophylaxis alone insufficient	STAT	STAT	-	STAT
Pain management	IV	-	650-1000 mg :: IV :: q6h :: Back pain often severe; acetaminophen 650-1000 mg q6h scheduled + opioids PRN (morphine 2-4 mg IV q3h PRN or oxycodone 5-10 mg PO q4h PRN); NSAIDs cautiously (renal function, bleeding risk); dexamethasone itself reduces pain from edema/inflammation; neuropathic pain: gabapentin 300 mg TID (titrate) or pregabalin 75 mg BID	-	Pain is the presenting symptom in 83-95% of patients; median 7 weeks before diagnosis; adequate analgesia essential for function and quality of life	STAT	STAT	ROUTINE	STAT
Bowel regimen	-	-	100 mg :: - :: BID :: Neurogenic bowel from cord compression + opioid constipation; docusate 100 mg BID + senna 2 tabs HS; bisacodyl suppository PRN; monitor for ileus	-	Bowel dysfunction common; proactive management prevents complications	STAT	STAT	ROUTINE	STAT
Glucose monitoring	-	-	N/A :: - :: q6h :: Fingerstick q6h on high-dose dexamethasone; insulin sliding scale → basal-bolus if persistent >180; anticipate glucose will rise significantly within hours of steroid initiation	-	High-dose dexamethasone causes severe hyperglycemia in majority of patients	STAT	STAT	ROUTINE	STAT

3B. Definitive/Targeted Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Surgical decompression + stabilization	-	-	N/A :: - :: once :: Indications (Patchell criteria + expanded): (1) Single site of compression, (2) Paraplegia ≤48h, (3) Not radiosensitive tumor (not lymphoma, myeloma, SCLC, germ cell), (4) Life expectancy >3 months, (5) ECOG ≤2 / able to tolerate surgery, (6) Mechanical instability (SINS ≥7), (7) Neurologic deterioration during radiation; Approach: Posterior decompressive laminectomy ± instrumented stabilization; anterior corpectomy with cage/cement for anterior compression with instability; Timing: Within 24h of presentation (ideally <12h); Followed by radiation within 2-4 weeks post-op	-	Patchell et al. (2005) — LANDMARK: Surgery + radiation vs. radiation alone: ambulatory rate 84% vs. 57% (p=0.001); maintained ambulation longer (122 vs. 13 days); more patients regained ambulation (62% vs. 19%); surgery retained continence longer; survival trend (126 vs. 100 days)	-	STAT	-	-
External beam radiation therapy (EBRT)	-	-	N/A :: - :: per protocol :: Primary modality if: Radiosensitive tumor (lymphoma, myeloma, SCLC, seminoma), surgical contraindication, multiple noncontiguous levels, life expectancy <3 months, poor surgical candidate; Standard: 30 Gy in 10 fractions (2 weeks) or 20 Gy in 5 fractions (1 week); Short course (poor prognosis): 8 Gy single fraction; Begin within 24h of diagnosis; Can start same day as dexamethasone; Radiation field covers 1-2 vertebral bodies above and below involved segment	-	Rades et al. (2008): No significant difference between 30 Gy/10 vs. 20 Gy/5 for motor function recovery or local control; 8 Gy single fraction appropriate for poor prognosis (life expectancy <6 months)	-	STAT	ROUTINE	-
Stereotactic body radiation therapy (SBRT) / Spine SRS	-	-	N/A :: - :: per protocol :: Indications: Previously irradiated segment (re-irradiation); radioresistant histology (RCC, melanoma, sarcoma); oligometastatic disease; post-operative; Dose: 16-24 Gy single fraction or 24-30 Gy in 3 fractions; Requires: Spinal cord dose constraints (max cord dose 10-14 Gy single fraction); MRI-based planning; Timing: As soon as technically feasible	-	RTOG 0631 and multiple institutional series: High local control (85-95%) for radioresistant histologies; superior to conventional EBRT for RCC, melanoma; separation surgery + SBRT emerging as preferred approach for radioresistant tumors	-	URGENT	ROUTINE	-
Separation surgery + SBRT	-	-	N/A :: - :: once :: Indication: Epidural tumor compressing cord from radioresistant primary (RCC, melanoma, sarcoma); goal is NOT gross total resection — goal is to decompress cord and create ≥2mm separation between tumor and cord to enable safe SBRT delivery; Followed by SBRT within 2-4 weeks	-	Laufer et al. (2013): Separation surgery + SBRT: 90% local control at 1 year for radioresistant tumors; allows definitive radiation dose to tumor while respecting cord tolerance	-	URGENT	-	-
Vertebroplasty / Kyphoplasty	-	-	N/A :: - :: per protocol :: Indications: Painful pathologic compression fracture; vertebral body instability; post-radiation pain; NO epidural extension compressing cord (cement leak risk into canal); SINS 7-12 (indeterminate stability): Consider as adjunct; Procedure: Percutaneous PMMA cement injection into vertebral body	-	Pain relief in 70-90% within 24-48h; structural support; does NOT address epidural disease; risk of cement leak into epidural space (1-5%)	-	URGENT	ROUTINE	-
Systemic chemotherapy	-	-	N/A :: - :: per protocol :: Radiosensitive tumors as primary/adjunct therapy: Lymphoma (R-CHOP or equivalent); myeloma (bortezomib-based); SCLC (cisplatin/etoposide); germ cell (BEP); Other primaries: Per disease-specific guidelines after stabilization; coordinate with medical oncology	-	Chemosensitive tumors (lymphoma, myeloma, germ cell, SCLC) may respond rapidly to systemic therapy; may be used as primary treatment with radiation or as consolidation post-radiation	-	ROUTINE	ROUTINE	-
Hormonal therapy (if applicable)	-	-	N/A :: - :: per protocol :: Prostate cancer: ADT (LHRH agonist/antagonist) + enzalutamide/abiraterone/darolutamide; Breast cancer: anti-estrogen/AI per receptor status; Thyroid: levothyroxine suppression + RAI (spine metastases do NOT concentrate RAI well — external radiation preferred)	-	Prostate and breast cancer spinal metastases may respond to hormonal manipulation; adjunct to radiation	-	ROUTINE	ROUTINE	-

3C. Adjunctive Treatment

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Steroid taper	-	-	2-4 mg :: - :: once :: Begin taper once definitive treatment (surgery/radiation) initiated and neurologic status stable/improving; Taper schedule: Reduce by 2-4 mg every 3-5 days; typical: 16→12→8→6→4→2→off over 2-3 weeks; slower taper if symptoms recur; monitor for adrenal insufficiency if >2-3 weeks of steroids	-	Prolonged high-dose steroids cause significant morbidity; steroid myopathy (proximal weakness — may mimic neurologic progression); PJP risk; hyperglycemia; GI bleed	-	ROUTINE	ROUTINE	-
PPI (stress ulcer/GI prophylaxis)	PO	-	20 mg :: PO :: daily :: Omeprazole 20 mg daily or pantoprazole 40 mg daily while on dexamethasone	-	Steroid + critical illness increases GI bleed risk	STAT	STAT	ROUTINE	STAT
Calcium + Vitamin D	PO	-	1000-1200 mg :: PO :: daily :: Calcium 1000-1200 mg + Vitamin D 800-1000 IU daily during steroid course and beyond (bone health in cancer patients)	-	Steroid-induced osteoporosis prevention; already compromised bone integrity	-	ROUTINE	ROUTINE	-
Bone-modifying agents	IV	-	4 mg :: IV :: - :: Zoledronic acid 4 mg IV q4 weeks OR denosumab 120 mg SQ q4 weeks; reduces skeletal-related events (SRE); dental clearance before starting (ONJ risk); renal adjustment for zoledronic acid (hold if GFR <35)	-	Zoledronic acid: Rosen et al. (2003) — reduced SRE by 48% in bone metastases; denosumab: Fizazi et al. (2011) — superior to zoledronic acid for SRE reduction in bone metastases (prostate trial)	-	ROUTINE	ROUTINE	-
Neuropathic pain management	-	-	300 mg :: - :: TID :: Gabapentin 300 mg TID → titrate to 600-900 mg TID; OR pregabalin 75 mg BID → titrate to 150-300 mg BID; duloxetine 30-60 mg daily as alternative; amitriptyline 10-25 mg HS (anticholinergic caution with urinary retention)	-	Radicular and central neuropathic pain common in cord compression; adjuvant analgesics reduce opioid requirements	-	STAT	ROUTINE	STAT
Rehabilitation (inpatient)	-	-	N/A :: - :: daily :: PT/OT evaluation within 24h of admission; early mobilization when cleared by spine surgery; adaptive equipment; wheelchair assessment if paraparetic/paraplegic; ROM exercises; strengthening; transfer training	-	Early rehabilitation improves functional outcomes; cancer rehabilitation is evidence-based; patients with MSCC benefit from structured rehab programs	-	URGENT	ROUTINE	-
Skin care / pressure ulcer prevention	-	-	N/A :: - :: q2h :: Turn q2h; pressure-reducing mattress; heel protectors; skin assessment with Braden scale; nutrition optimization	-	Immobile patients with cord compression at very high risk for pressure injuries; prevention is critical	-	STAT	-	STAT

3D. Medications to AVOID or Use with Caution

Treatment	Route	Indication	Dosing	Pre-Treatment Requirements	Contraindications	Monitoring	ED	HOSP	OPD	ICU
NSAIDs (prolonged use)	-	-	-	-	-	-	-	-	-	-
Methotrexate (high-dose, with spinal radiation)	-	-	-	-	-	-	-	-	-	-
Intrathecal chemotherapy (with spinal block)	IT	-	-	-	-	-	-	-	-	-
Anticoagulation (full-dose, peri-operative)	-	-	-	-	-	-	-	-	-	-
Steroids in suspected lymphoma (BEFORE biopsy)	-	-	-	-	-	-	-	-	-	-
Bevacizumab (peri-operative)	-	-	-	-	-	-	-	-	-	-
Bisphosphonates (if GFR <35 for zoledronic acid)	-	-	-	-	-	-	-	-	-	-

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4. OTHER RECOMMENDATIONS

4A. Essential

Recommendation	ED	HOSP	OPD	ICU	Details
Neurosurgery / Spine surgery consultation — EMERGENT	STAT	STAT	-	STAT	Surgical candidacy assessment; Patchell criteria evaluation; SINS score; stabilization; ALL patients with MSCC need spine surgery consultation even if radiation is primary treatment (assess stability)
Radiation oncology consultation — EMERGENT	STAT	STAT	ROUTINE	STAT	Within hours of diagnosis; concurrent with neurosurgery evaluation; EBRT planning; SBRT candidacy; begin radiation within 24h if non-surgical
Medical oncology consultation	-	URGENT	ROUTINE	-	Systemic therapy options; primary identification; staging; prognosis; clinical trial eligibility; coordinate bone-modifying agents
Multidisciplinary spine tumor board	-	URGENT	ROUTINE	-	Neurosurgery, radiation oncology, medical oncology, interventional radiology, pathology; optimal treatment sequencing; NOMS framework application
Goals of care discussion	-	URGENT	ROUTINE	URGENT	Prognosis (Tokuhashi score, Tomita score); functional goals; code status; palliative vs. aggressive treatment; quality of life; patient values and preferences
Physical medicine & rehabilitation	-	URGENT	ROUTINE	-	PT/OT; functional assessment; rehabilitation candidacy; inpatient rehab planning if motor deficits present; assistive devices
Foley catheter management	STAT	STAT	-	STAT	If urinary retention: Foley placement with monitoring; intermittent catheterization if partial function; urology consult if prolonged retention anticipated
Social work / case management	-	ROUTINE	ROUTINE	-	Equipment needs (wheelchair, hospital bed); caregiver training; home safety assessment; insurance authorization; hospice if appropriate
Pain management / palliative care	-	STAT	ROUTINE	STAT	If pain refractory to standard analgesics; assist with goals of care; symptom management; advance care planning

4B. Extended

Recommendation	ED	HOSP	OPD	ICU	Details
Interventional radiology consultation	-	URGENT	ROUTINE	-	Pre-operative embolization (RCC, thyroid metastases); vertebroplasty/kyphoplasty; CT-guided biopsy for tissue diagnosis
Orthotics / bracing	-	ROUTINE	ROUTINE	-	Custom TLSO (thoracolumbar) or cervical collar based on level; post-operative stabilization; external support for non-surgical patients
Wound care (post-operative)	-	ROUTINE	ROUTINE	-	Irradiated tissue heals poorly; monitor surgical wound closely; avoid radiation to fresh surgical wound for 2-3 weeks (coordinate timing)
Nutrition / dietitian	-	ROUTINE	ROUTINE	-	Cancer cachexia assessment; steroid-induced appetite changes; adequate protein for wound healing (if surgical); calcium/vitamin D optimization
Psychology / psychiatry	-	ROUTINE	ROUTINE	-	Depression, anxiety, adjustment disorder common with acute paralysis/paresis and cancer diagnosis; screening with PHQ-9; support for functional loss
Urology consultation	-	ROUTINE	ROUTINE	-	If persistent neurogenic bladder; intermittent catheterization training; long-term bladder management plan
Home health referral	-	ROUTINE	ROUTINE	-	Nursing visits; PT/OT in home; wound care; medication management; caregiver education

4C. Atypical/Refractory

Recommendation	ED	HOSP	OPD	ICU	Details
Re-irradiation (spine)	-	ROUTINE	ROUTINE	-	Recurrent MSCC at previously irradiated site; SBRT preferred for re-irradiation (better dose targeting, cord sparing); cumulative cord dose must be calculated; re-irradiation feasible if >6 months since prior radiation
Repeat surgery	-	URGENT	ROUTINE	-	Hardware failure; recurrent compression at operated level; progressive neurologic decline despite radiation; infection at surgical site
Intrathecal drug delivery	-	-	EXT	-	Refractory pain; intrathecal morphine or ziconotide pump; palliative care indication
Cement augmentation (post-radiation)	-	ROUTINE	ROUTINE	-	Persistent pain or progressive collapse after radiation; vertebroplasty/kyphoplasty as pain control adjunct
Hospice referral	-	ROUTINE	ROUTINE	-	Exhausted treatment options; life expectancy <6 months; patient preference for comfort-focused care; poor functional status (ECOG 3-4)
Clinical trial enrollment	-	ROUTINE	ROUTINE	-	Novel radiosensitizers; immunotherapy combinations; spine-specific SBRT protocols

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═══════════════════════════════════════════════════════════════ SECTION B: SUPPORTING INFORMATION ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS

Primary Differential Diagnoses

Diagnosis	Key Differentiating Features	Distinguishing Studies
Spinal epidural abscess	Fever (present in 50-66%); IV drug use, recent procedure, immunosuppression; rapidly progressive; ESR >20 (sensitivity 94%); CRP markedly elevated; ring-enhancing epidural collection on MRI; restricted diffusion in abscess; spine pain with percussion tenderness; leukocytosis	MRI: T2-hyperintense epidural collection with rim enhancement; restricted diffusion (DWI bright, ADC dark) within abscess; blood cultures (positive in 60%); ESR/CRP markedly elevated; procalcitonin >0.5
Degenerative spinal stenosis (cervical/lumbar)	Chronic progressive symptoms; myelopathic signs insidious onset; no cancer history; disc/osteophyte complex on imaging; NO destructive bone lesion; congenital canal narrowing	MRI: disc-osteophyte complex; ligamentum flavum hypertrophy; NO bone destruction; NO contrast enhancement of epidural mass; chronic degenerative changes
Primary spinal cord tumor (intramedullary)	Intramedullary (within cord parenchyma); ependymoma, astrocytoma; cord expansion with central lesion; no vertebral body destruction; slow progression; syrinx may be present	MRI: cord expansion with intramedullary enhancing lesion; no epidural mass; no vertebral body involvement; ependymoma: central location, hemosiderin cap; astrocytoma: eccentric, irregular
Vertebral compression fracture (osteoporotic)	No cancer history; older patient with osteoporosis; acute back pain after minor trauma/lifting; no neurologic deficits (usually); vertebral body collapsed but NO epidural mass; NO posterior element involvement	MRI: vertebral body edema (T1 low, STIR high) WITHOUT epidural mass or posterior element involvement; CT: no bone destruction beyond fracture; DEXA: osteoporosis; if ambiguous → biopsy
Multiple myeloma	Older adult; bone pain; anemia, renal insufficiency, hypercalcemia ("CRAB"); diffuse lytic lesions; monoclonal protein on SPEP; punched-out skull lesions; responsive to chemotherapy AND radiation	SPEP: M-protein; UPEP: Bence Jones protein; free light chains: abnormal ratio; bone marrow biopsy: >10% plasma cells; CT/MRI: multiple lytic lesions; biopsy: plasmacytoma; KEY: myeloma is RADIOSENSITIVE — radiation first-line
Lymphoma (epidural)	May present as isolated epidural mass; radiosensitive; responds dramatically to steroids (may "melt" before biopsy); younger patients; constitutional symptoms (B symptoms); elevated LDH	MRI: epidural mass; homogeneous enhancement; may be paraspinal; CT: lymphadenopathy; LDH elevated; flow cytometry; KEY: obtain biopsy BEFORE steroids if possible; radiation is primary treatment
Transverse myelitis / NMOSD	Intramedullary T2 lesion on MRI (NOT epidural mass); autoimmune history; AQP4/MOG antibodies; longitudinally extensive (≥3 segments in NMOSD); responds to IV steroids/PLEX; no bone lesion	MRI: intramedullary T2 hyperintensity, NOT epidural mass; AQP4-IgG or MOG-IgG positive; CSF: pleocytosis; no vertebral body destruction
Spinal epidural hematoma	Acute onset, often on anticoagulation; post-procedural (LP, epidural injection); acute neurogenic deficit; hyperacute T1 signal on MRI (blood)	MRI: epidural collection with blood signal characteristics (T1 hyperintense in subacute phase); history of anticoagulation or procedure; coagulation studies abnormal; neurosurgical emergency

Red Flags Requiring Urgent Reassessment

Red Flag	Concern	Action
Progressive motor weakness despite treatment	Increasing cord compression; treatment failure; hematoma; instability	STAT MRI; neurosurgery re-evaluation; consider surgical salvage; dose-escalate steroids
New/complete loss of bowel or bladder function	Progressing to complete cord injury; cauda equina involvement	STAT MRI; emergent surgical evaluation if within 48h window; Foley placement
Ascending sensory level	Rostral progression of compression; edema expansion; additional metastatic levels	STAT MRI entire spine; escalate dexamethasone; emergent neurosurgery
Saddle anesthesia (new)	Conus medullaris or cauda equina involvement	STAT MRI; emergent surgical evaluation
Fever after steroid initiation	Masked infection (steroids suppress fever); abscess; post-operative infection; UTI	Blood cultures; UA; CRP; imaging; broaden antibiotics; consider pausing immunosuppressive therapy
Acute hypotension + bradycardia	Neurogenic shock (spinal cord injury with loss of sympathetic tone)	IV fluids; vasopressors (norepinephrine or phenylephrine preferred); atropine for symptomatic bradycardia; ICU transfer
Bilateral leg DVT / PE symptoms	High VTE risk in MSCC; pulmonary embolism can be fatal	STAT CT angiography (PE); bilateral lower extremity duplex US (DVT); therapeutic anticoagulation (weigh against surgical planning)
Respiratory compromise	High cervical cord compression affecting diaphragm (C3-5); pulmonary embolism; pneumonia in immobilized patient	Bedside spirometry; ABG; CT angiography; intubation if needed; phrenic nerve pacing consideration

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6. MONITORING PARAMETERS

Acute Phase Monitoring (First 72h)

Parameter	Frequency	Target	Action if Abnormal
Neurologic examination (motor strength, sensory level, rectal tone, reflexes)	q4h x 48h → q6h	Stable or improving motor function; stable sensory level; preserved rectal tone	If declining: STAT MRI; escalate dexamethasone to 24 mg/day; emergent neurosurgery
Blood glucose	q6h (q4h if on insulin drip)	140-180 mg/dL	Sliding scale → basal-bolus insulin; endocrine consult if refractory
Pain score (NRS)	q4h	NRS <4/10	Escalate analgesics; add neuropathic agents; palliative care consultation
Blood pressure	q4h (continuous if neurogenic shock)	SBP >90 (avoid hypotension — cord perfusion); MAP >65-70	IV fluids; vasopressors if neurogenic shock; avoid excessive hypertension (post-operative bleeding risk)
Bladder function (I&O, post-void residual)	q shift; post-void residual daily	Volitional voiding; PVR <200 mL	Foley if retention; intermittent catheterization if PVR 200-500
Bowel function	Daily	Bowel movement within 48-72h	Aggressive bowel regimen; rectal exam; abdominal X-ray if distended
Skin integrity (Braden scale)	q shift	No pressure injuries; Braden ≥18	Turn q2h; specialty mattress; heel protectors; wound care if injury develops
Temperature	q4h	Afebrile	If febrile: blood cultures, UA, chest imaging; consider abscess vs. tumor fever
Respiratory function (if cervical/high thoracic)	q4h; bedside spirometry daily	FVC >15 mL/kg; stable respiratory rate	If FVC declining: ICU transfer; prepare for intubation; consider phrenic nerve involvement

Subacute/Outpatient Monitoring

Parameter	Frequency	Target	Action if Abnormal
MRI spine (affected region) with contrast	6-8 weeks post-treatment, then q3 months x 1 year, then q6 months	Tumor regression or stability; improved cord compression; resolution of edema	Progression: multidisciplinary re-evaluation; re-irradiation, surgery, systemic therapy change
Neurologic examination	Each clinic visit (q2-4 weeks initially, then q1-3 months)	Stable or improving motor function; improving or stable pain	New deficits: urgent MRI; consider disease progression, hardware failure, radiation myelopathy
Steroid taper progress	Each visit	Off steroids or minimum effective dose	Steroid-dependent: attempt taper after each treatment milestone
Bone-modifying agent monitoring	Monthly during treatment; dental exam q6 months	No skeletal-related events; stable calcium; no ONJ symptoms	Hold zoledronic acid if GFR <35; dental referral if jaw pain/exposed bone
Functional status (ECOG / KPS)	Each visit	Stable or improving	Declining function: reassess treatment goals; rehabilitation intensification; palliative care
Calcium, renal function	Monthly during bisphosphonate therapy	Ca >8.5; GFR >35 (for zoledronic acid)	Supplement calcium; switch to denosumab if renal decline
Spinal stability assessment	Each visit; dynamic imaging if clinical concern	Stable alignment; no hardware migration	Orthotics adjustment; re-fixation surgery if hardware failure
Depression/adjustment screening	Each visit	PHQ-9 <5	Psychology referral; SSRI; support groups

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7. DISPOSITION CRITERIA

Admission Criteria

Level of Care	Criteria
ICU admission	Neurogenic shock (hypotension + bradycardia from spinal cord injury); respiratory compromise from high cervical lesion; post-operative monitoring (first 24h after major spine surgery); acute paraplegia/quadriplegia requiring close monitoring; hemodynamic instability
General neurology/neurosurgery/oncology floor	New MSCC diagnosis requiring workup and treatment planning; surgical candidate awaiting decompression; radiation therapy initiation; motor deficits requiring monitoring and rehabilitation; pain management; high-dose steroid initiation
Observation	Known metastatic disease with new pain but preserved neurologic function; MRI showing compression without cord signal change; stable neurologic exam

Discharge Criteria

Criterion	Details
Neurologic stability	Stable or improving neurologic exam for ≥24-48h; clear trend of improvement or plateau
Definitive treatment initiated	Surgery completed and recovering; radiation started or completed; systemic therapy plan in place
Pain controlled	Adequate pain control on oral medications; able to participate in PT/OT
Steroid regimen established	Oral dexamethasone with documented taper schedule; glucose management plan; PPI prescribed
Bladder function assessed	Voiding spontaneously OR clean intermittent catheterization teaching completed OR Foley with urology follow-up
Bowel regimen	Having regular bowel movements on established regimen
Mobility assessment	PT/OT clearance; safe with appropriate assistive device; OR inpatient rehab transfer planned
VTE plan	Pharmacologic DVT prophylaxis transition plan (enoxaparin at home or DOACs if indicated)
Spine stability	Bracing/orthotic fitted if indicated; activity restrictions clearly documented
Follow-up arranged	Neurosurgery (1-2 weeks), radiation oncology (as per treatment schedule), medical oncology (1-2 weeks), PM&R (outpatient rehab), PCP (steroid monitoring); MRI spine at 6-8 weeks
Patient/family education	Spinal precautions; steroid side effects; when to return to ED (new weakness, loss of bladder/bowel, severe pain, fever); caregiver training for mobility
Equipment ordered	Wheelchair, walker, hospital bed, shower chair, commode — as appropriate per functional assessment

Discharge Prescriptions Checklist

Medication	Details
Dexamethasone	Taper schedule clearly documented (e.g., 4 mg q6h → taper per schedule over 2-3 weeks)
PPI	While on steroids
Analgesics	Opioids with taper plan; gabapentin/pregabalin for neuropathic pain
Bowel regimen	Docusate + senna; PRN bisacodyl
DVT prophylaxis	Enoxaparin 40 mg SQ daily (if continued DVT prophylaxis indicated); duration per oncology recommendation
Bone-modifying agent	Zoledronic acid or denosumab (outpatient schedule)
Calcium + Vitamin D	If on steroids or bisphosphonates
Insulin (if needed)	For steroid-induced hyperglycemia with glucometer/supplies
Antiemetics PRN	If on chemotherapy or persistent nausea

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8. EVIDENCE & REFERENCES

Key Guidelines

Guideline	Source	Year	Key Recommendation
MSCC Management	NICE Clinical Guideline CG75 (updated)	2008/2023	MRI within 24h (urgent within 4h if progressive deficit); dexamethasone 16 mg/day; surgical decompression within 24h if indicated; definitive treatment within 24h; multidisciplinary team approach
Spinal Metastases	NCCN Clinical Practice Guidelines	2025	NOMS framework (Neurologic, Oncologic, Mechanical instability, Systemic disease) for treatment decision-making; multidisciplinary approach; SINS scoring
Bone-Modifying Agents	ASCO Clinical Practice Guideline	2017	Zoledronic acid or denosumab recommended for all patients with bone metastases from solid tumors; start within 3 months of bone metastasis diagnosis
MSCC Radiation	Cochrane Systematic Review (George et al.)	2015	No significant difference between short-course (1-2 fractions) and longer-course (5-10 fractions) for motor outcomes in poor prognosis patients

Landmark Studies

Study	Finding	Impact
Patchell et al. (2005) — Lancet	Direct decompressive surgery + radiation vs. radiation alone for MSCC: ambulatory 84% vs. 57% (p=0.001); regained ambulation 62% vs. 19%; maintained ambulation 122 vs. 13 days; maintained continence longer	LANDMARK study establishing surgery + radiation as superior to radiation alone for single-level MSCC in non-radiosensitive tumors with life expectancy >3 months
Sorensen et al. (1994)	Dexamethasone + radiation vs. radiation alone: ambulation 81% vs. 63% at end of treatment; 59% vs. 33% at 3 months	Established dexamethasone as standard adjunct to radiation in MSCC
Vecht et al. (1989)	High-dose (96 mg) vs. standard (10 mg) dexamethasone: faster initial response with high-dose but similar outcomes at 1 week; more side effects with high-dose	Most centers now use moderate dose (10 mg load → 16 mg/day) due to side effect profile
Rades et al. (2008)	Short-course (20 Gy/5 fractions) vs. standard (30 Gy/10 fractions): no significant difference in motor function improvement for patients with poor prognosis	Short-course radiation appropriate for patients with limited life expectancy
Laufer et al. (2013)	Separation surgery + SBRT for radioresistant MSCC: 90% local control at 1 year; enabled delivery of effective radiation doses to previously radioresistant tumors	Established separation surgery + SBRT paradigm for RCC, melanoma, sarcoma spinal metastases
Rosen et al. (2003)	Zoledronic acid reduced skeletal-related events by 48% compared to placebo in bone metastases from breast cancer and myeloma	Standard bone-modifying therapy for cancer-related bone disease
Fizazi et al. (2011)	Denosumab superior to zoledronic acid in reducing SRE in prostate cancer bone metastases (HR 0.82, p=0.008)	Denosumab as alternative/preferred bone-modifying agent; no renal adjustment needed

Grading Scales

Spinal Instability Neoplastic Score (SINS)

Component	Score
Location
Junctional (occiput-C2, C7-T2, T11-L1, L5-S1)	3
Mobile (C3-C6, L2-L4)	2
Semi-rigid (T3-T10)	1
Rigid (S2-S5)	0
Pain
Mechanical (movement-related)	3
Non-mechanical / occasional	1
Pain-free	0
Bone lesion quality
Lytic	2
Mixed (lytic/blastic)	1
Blastic	0
Spinal alignment
Subluxation/translation	4
De novo deformity (kyphosis/scoliosis)	2
Normal alignment	0
Vertebral body collapse
>50% collapse	3
<50% collapse	2
No collapse with >50% body involved	1
None of the above	0
Posterolateral involvement
Bilateral	3
Unilateral	1
None	0

SINS Total Score	Interpretation	Action
0-6	Stable	Non-surgical management appropriate
7-12	Indeterminate (potentially unstable)	Surgical consultation recommended
13-18	Unstable	Surgical stabilization recommended

Bilsky Epidural Spinal Cord Compression Scale

Grade	Description
0	Bone-only disease
1a	Epidural impingement without deformation of thecal sac
1b	Thecal sac deformation without cord abutment
1c	Thecal sac deformation with cord abutment, no compression
2	Cord compression with visible CSF around cord
3	Cord compression without visible CSF around cord

Tokuhashi Revised Scoring System (Prognosis)

Parameter	Score 0	Score 1	Score 2
General condition (KPS)	Poor (10-40%)	Moderate (50-70%)	Good (80-100%)
Number of extraspinal bone metastases	≥3	1-2	0
Number of vertebral body metastases	≥3	2	1
Metastases to major organs	Unremovable	Removable	None
Primary tumor site	Lung, osteosarcoma, stomach, bladder, esophagus, pancreas	Liver, gallbladder, unidentified	Thyroid, breast, prostate, renal (carcinoid treated as thyroid)
Neurologic deficit (Frankel)	Complete (A/B)	Incomplete (C/D)	None (E)

Tokuhashi Score	Predicted Survival	Recommended Treatment
0-8	<6 months	Palliative/conservative (short-course radiation)
9-11	6-12 months	Palliative or excisional surgery depending on factors
12-15	>12 months	Excisional surgery; aggressive treatment justified

NOMS Decision Framework (Memorial Sloan Kettering)

Factor	Assessment	Treatment Implications
Neurologic	Degree of cord compression (Bilsky grade); functional status; myelopathy	High-grade compression (Bilsky 2-3) → surgical decompression; low-grade → radiation alone may suffice
Oncologic	Radiosensitivity; expected tumor response to radiation	Radiosensitive (lymphoma, myeloma, SCLC) → radiation primary; Radioresistant (RCC, melanoma, sarcoma) → surgery + SBRT
Mechanical instability	SINS score	SINS ≥7 → surgical consultation for stabilization
Systemic disease	Extent of metastatic burden; medical comorbidities; life expectancy	Widespread disease, poor prognosis → palliative approach; oligometastatic → aggressive local treatment

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APPENDICES

Appendix A: Most Common Primary Cancers Causing Spinal Metastases

Primary Cancer	Frequency	Typical Pattern	Treatment Sensitivity
Breast	20-25%	Lytic, blastic, or mixed; thoracic predilection; hormonal status guides therapy	Moderately radiosensitive; hormone-responsive
Lung (NSCLC)	15-20%	Lytic; any level; molecular markers (EGFR, ALK) guide systemic therapy	Moderately radiosensitive; targeted therapy if driver mutation
Prostate	15-20%	Blastic (sclerotic); lumbar/sacral predilection; PSA monitoring	Moderately radiosensitive; very hormone-responsive
Renal cell carcinoma	10-15%	Highly lytic; vascular (hemorrhage risk at surgery); may be solitary	Radioresistant → SBRT preferred; pre-op embolization; immunotherapy (ipi/nivo)
Multiple myeloma	5-10%	Lytic (punched-out); diffuse involvement; vertebral compression fractures	Highly radiosensitive; chemotherapy-responsive
Lymphoma	3-5%	Epidural mass; may be paraspinal; dramatic steroid response	Highly radiosensitive; chemotherapy-responsive
Thyroid (follicular)	3-5%	Lytic; vascular; may present years after thyroidectomy	Radioresistant → SBRT or surgery; RAI does NOT work well in bone
Melanoma	2-5%	Lytic; may be hemorrhagic; rapidly progressive	Radioresistant → surgery + SBRT; immunotherapy (ipi/nivo, anti-PD1)
Colorectal	2-3%	Lytic; late-stage finding; sacral predilection	Moderately radiosensitive
Unknown primary	5-10%	Variable; biopsy essential	Depends on histology; empiric radiation if urgent

Appendix B: Emergency MSCC Algorithm

SUSPECTED MALIGNANT SPINAL CORD COMPRESSION
              │
              ├── Neurologic deficit? (weakness, sensory level, bladder/bowel dysfunction)
              │         YES → EMERGENT pathway
              │         NO → URGENT pathway
              │
    EMERGENT PATHWAY                      URGENT PATHWAY
         │                                      │
    Dexamethasone 10mg IV STAT             Dexamethasone 4-10mg IV
         │                                      │
    MRI whole spine STAT                   MRI whole spine <24h
    (within 4h)                                 │
         │                                 Plan treatment based
         │                                 on MRI findings
    CONFIRMED MSCC on MRI
         │
         ├── Radiosensitive tumor?
         │     (lymphoma, myeloma, SCLC, germ cell)
         │         YES → Radiation within 24h
         │                (± chemotherapy)
         │         NO ↓
         │
         ├── Surgical candidate?
         │     (Patchell criteria met)
         │         • Single level compression
         │         • Paraplegia <48h
         │         • Life expectancy >3 months
         │         • ECOG ≤2
         │         • Not radiosensitive
         │
         │    YES → Surgery within 24h → Post-op radiation (2-4 weeks)
         │    NO  → Radiation within 24h
         │
         ├── Mechanically unstable? (SINS ≥7)
         │         YES → Spine surgery for stabilization
         │               (even if radiation is primary treatment)
         │
         └── Radioresistant + not ideal surgical candidate?
                   → Consider separation surgery + SBRT
                   → Or SBRT alone if no high-grade compression

Appendix C: Ambulatory Status and Prognosis

Pre-treatment Status	Likelihood of Post-treatment Ambulation	Key Prognostic Factor
Ambulatory at presentation	80-90% maintain ambulation	MOST IMPORTANT predictor — early detection is critical
Paraparetic (some motor function)	40-60% regain ambulation	Timing critical: better outcomes if treated within 24-48h of deficit onset
Paraplegic <24h	30-40% may regain ambulation	Emergency surgery offers best chance; radiation alone less effective
Paraplegic 24-48h	10-20% may regain some function	Surgery if feasible; diminishing returns after 48h
Paraplegic >48h	<5% regain functional ambulation	Goals of care discussion; pain control; prevent secondary complications
Complete loss >72h	Very unlikely to recover	Palliative focus; comfort measures; rehabilitation for adaptation

Key message: Ambulatory status at time of treatment is the single most important prognostic factor. Early diagnosis and treatment within 24h of symptom onset is critical.

Appendix D: Dexamethasone Dosing Summary for MSCC

Clinical Scenario	Loading Dose	Maintenance	Taper
Mild deficit, ambulatory	10 mg IV	4 mg PO q6h (16 mg/day)	Start taper after radiation begins; reduce 2 mg q3-5 days
Moderate deficit, paraparetic	10 mg IV	4 mg PO q6h (16 mg/day)	Taper once improving; 2 mg reduction q3-5 days
Severe/complete deficit, rapidly progressive	96 mg IV (controversial) OR 10 mg IV	24 mg PO q6h → taper to 16 mg/day within 48h	Aggressive but systematic taper; 4 mg reduction q3-5 days
Post-operative / post-radiation (improving)	N/A	Continue at current dose until stable	Taper over 2-3 weeks once treatment response confirmed
Side effect management	GI: PPI; Glucose: insulin; Sleep: dose dexamethasone before 4 PM; Myopathy: minimize duration

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This template represents the initial build phase (Skill 1) and requires validation through the checker pipeline (Skills 2-6) before clinical deployment.