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Miscellaneous: Oncological emergency: MSCC

Free question published 31 August 2026

MiscellaneousOncological emergency: MSCC

A 67-year-old man with known metastatic prostate cancer presents with 48 hours of worsening mid-thoracic back pain, bilateral leg weakness and urinary hesitancy. Whole-spine MRI confirms metastatic spinal cord compression at T6 with no spinal instability, and he remains ambulant with assistance. He has not yet received corticosteroids. According to NICE NG234, what is the most appropriate immediate pharmacological step while definitive treatment is arranged?

  1. AOral dexamethasone 2 mg once daily
  2. BIntravenous methylprednisolone 1 g for three days
  3. COral dexamethasone 16 mg as soon as possible, continued daily while awaiting definitive treatment
  4. DNo corticosteroid until radiotherapy planning is complete
  5. EOral prednisolone 5 mg once daily

Why C is correct

NICE NG234 recommends offering 16 mg of oral dexamethasone (or equivalent parenteral dose) as soon as possible for people with neurological symptoms or signs of MSCC, continued daily while awaiting definitive treatment and then reduced after surgery or at the start of radiotherapy. The high dose reduces vasogenic cord oedema and helps preserve neurological function until urgent radiotherapy (within 24 hours) or surgery is delivered.

And why the others are not

  • A2 mg is far below the NICE-recommended 16 mg dose for symptomatic MSCC and would under-treat cord oedema.
  • BHigh-dose methylprednisolone is the acute spinal trauma protocol, not the NICE recommendation for malignant MSCC.
  • DWithholding steroids until planning is complete forgoes the immediate neuroprotective step NICE mandates as soon as possible.
  • ELow-dose prednisolone is an inadequate corticosteroid choice and dose for acute MSCC.

Source NICE NG234 - Spinal metastases and metastatic spinal cord compression — National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression. NICE guideline NG234. Published September 2023 (updates and replaces CG75).

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