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National Collaborating Centre for Cancer (UK). Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression. Cardiff (UK): National Collaborating Centre for Cancer (UK); 2008 Nov. (NICE Clinical Guidelines, No. 75.)

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Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression.

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Appendix 7Guideline scope

Guideline title

Metastatic spinal cord compression: diagnosis and management of adults at risk of and with metastatic spinal cord compression

Short title

Metastatic spinal cord compression


The National Institute for Health Clinical Excellence (‘NICE’ or ‘the Institute’) has commissioned the National Collaborating Centre for Cancer to develop a clinical guideline on the diagnosis and management of patients with metastatic spinal cord compression for use in the NHS in England and Wales. This follows referral of the topic by the Department of Health (see appendix). The guideline will provide recommendations on clinical practice and service provision that are based on the best available evidence of clinical and cost effectiveness.

The Institute’s service guidance will support the implementation of the National Service Frameworks (NSFs) in those aspects of care where a Framework has been published. The statements in each NSF reflect the evidence that was used at the time the Framework was prepared. The clinical guidelines and technology appraisals published by the Institute after an NSF has been issued will have the effect of updating the Framework.

This guideline will support current national initiatives outlined in the ‘NHS cancer plan’, the ‘Calman Hine report’, the ‘Cameron report’, the ‘Manual of cancer service standards for England’ and the ‘Wales cancer standards’. The guideline will also refer to other NICE guidance including ‘Referral guidelines for suspected cancer’, ‘Improving supportive and palliative care for adults with cancer’, and ‘Improving outcomes for people with brain and other CNS tumours’. Cross reference will be made to these and other documents as appropriate.

NICE clinical guidelines support the role of healthcare professionals in providing care in partnership with patients, taking account of their individual needs and preferences, and ensuring that patients (and their carers and families, where appropriate) can make informed decisions about their care and treatment.

Clinical need for the guideline

It is difficult to know what the true incidence of metastatic spinal cord compression (MSCC) is in England and Wales because the cases are not systematically recorded. However, evidence from an audit carried out in Scotland between 1997 and 19991 and from a published study from Ontario, Canada2, suggests that the incidence may be up to 80 cases per million population per year. This would mean around 4000 cases per year in England and Wales or more than 100 cases per cancer network per year.

The Clinical Resource and Audit Group (CRAG) audit clearly showed that there were significant delays from the time when patients first developed symptoms until hospital doctors and general practitioners recognised the possibility of spinal cord compression and made the appropriate referral. The median times from the onset of back pain and nerve root pain to referral were 3 months and 9 weeks respectively. As a result, 48% of patients were unable to walk at the time of diagnosis and of these the majority (67%) had recovered no function at 1 month. Of those walking unaided at the time of diagnosis (34%), 81% were able to walk (either alone or with aid) at 1 month. The ability to walk at diagnosis was also significantly related to overall survival.

At present, relatively few patients with malignant spinal cord compression in the UK receive surgery for the condition. But research evidence suggests that early surgery may be more effective than radiotherapy in a selected subset of patients.

The guideline

The guideline development process is described in detail in two publications which are available from the NICE website (see ‘Further information’). ‘The guideline development process: an overview for stakeholders, the public and the NHS’ describes how organisations can become involved in the development of a guideline. ‘The guidelines manual’ provides advice on the technical aspects of guideline development.

This document is the scope. It defines exactly what this guideline will (and will not) examine, and what the guideline developers will consider. The scope is based on the referral from the Department of Health (see appendix).

The scope forms the basis on which the work of a guideline development group is planned and should be very clear about which patient groups are included and which areas of clinical care will be considered (sections 4.14.3).

The areas that will be addressed by the guideline are described in the following sections.


Groups that will be covered

  • Adults with metastatic spinal disease at risk of developing metastatic spinal cord compression.
  • Adults with suspected and diagnosed spinal cord and nerve root compression due to metastatic malignant disease.
  • Adults with primary malignant tumours (for example, lung cancer, mesothelioma or plasmacytoma) and direct infiltration that threatens spinal cord function.

Groups that will not be covered

  • Adults with spinal cord compression due to primary tumours of the spinal cord and meninges.
  • Adults with spinal cord compression due to non-malignant causes.
  • Adults with nerve root tumours compressing the spinal cord.
  • Children.

Healthcare setting

  • Primary care, including referral, rehabilitation, continuing care and follow up.
  • Secondary care, including diagnosis, treatment and rehabilitation.
  • Tertiary care in cancer centres, neurosurgical units and spinal surgery units.
  • Specialist rehabilitation centres.
  • Palliative care services.

Clinical management (including service delivery where appropriate)

  • Identification of patients at risk.
  • Diagnosis – clinical and radiological.
  • Treatment:



    interventional radiology

    medical therapy.

  • Rehabilitation and supportive care.
  • Specific elements of palliative care that meet the particular needs of patients with metastatic spinal cord compression and of their families and carers.
  • Communication and information resources for patients, carers, family members and healthcare professionals.
  • Follow up.



This is the final version of the scope.

The development of the guideline recommendations will begin in September 2006.

Further information

Related NICE guidance

Information on the guideline development process is provided in:

  • ‘The guideline development process: an overview for stakeholders, the public and the NHS’
  • ‘The guidelines manual’.

These booklets are available as PDF files from the NICE website ( guidelinesmanual). Information on the progress of the guideline will also be available from the website.

Appendix – Referral from the Department of Health

The Department of Health asked the Institute to develop a guideline on:

‘Diagnosis and management of patients with metastatic spinal cord compression, including service delivery where appropriate.’



Levack, P, Collie D, Gibson A et al. (2001) A prospective audit of the diagnosis, management and outcome of malignant cord compression (CRAG 97/08). Edinburgh: CRAG.


Loblaw DA, Laperriere NJ, Mackillop WJ (2003) A population-based study of malignant spinal cord compression in Ontario. Clinical Oncology 15 (4) 211–7.

Copyright © 2008, National Collaborating Centre for Cancer.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licenses issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK55005


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