Prefer to watch? 4-minute lesson13 slides · same content, shorter

1 · SNAPSHOT

Spinal Metastases (and Metastatic Spinal Cord Compression) body chart — Illustrative, not diagnostic. Canva body chart for Spinal Metastases (and Metastatic Spinal Cord Compression).

Who: Anyone with a history of cancer, and sometimes someone who doesn't yet know they have one. Not excluded by age — it has been described in children.
What: Metastatic deposit in the spine. The emergency is what it does to the cord.
How it behaves: Constant, deep, unremitting back pain. Worse at night or lying down. History of cancer. Unexplained weight loss or fatigue. Non-mechanical — position and rest don't change it.

The one thing to take from this page:

"Night pain + history of cancer = image immediately."

Why that pearl is right and the rest of the checklist isn't

The habit	What the evidence says
Run through a long red-flag list and tick boxes	Most individual red flags perform poorly (Downie et al. 2013, BMJ), and the flags in current guidelines are inconsistent with each other (Verhagen et al. 2016)
Night pain means cancer	Weak on its own. Night pain in a healthy 30-year-old is not night pain in someone with breast cancer
It's rare, so relax	Prevalence is genuinely low — studied in Australian primary care — and that is exactly why single flags screen badly. Low base rate, poor test, false alarms
A history of cancer	The one that carries weight. Ask it every time.

Screening isn't a checklist you tick. It's a probability you update — and a cancer history moves it more than anything else on the list.

2 · SE — THE SUBJECTIVE PATTERN (the 70%)

On this page the subjective is essentially the whole assessment. Five stages, in your course's order.

MAIN PROBLEM

"It's there all the time and nothing shifts it."
"It's worse when I lie down, which makes no sense to me."
"I had breast cancer eight years ago — but that's finished."

That last sentence is the one. "Finished" is not a clearance.

BODY CHART

Where, and does it stay there? Non-mechanical pain doesn't move with position.
Any band of pain around the trunk? A cord level.
Both legs? Mark them.
Saddle area — any change in sensation?

BEHAVIOUR — this is where it declares itself

	Mechanical	This
Position	Changes it	Doesn't
Rest	Helps	Doesn't, or makes it worse
Night	Position-related	Worse lying down. Gets them up and pacing
Course	Fluctuates, better days	Constant. Progressive
Movement	Reproduces it	Often doesn't

HISTORY — and one question outranks everything

"Have you ever been treated for cancer?" Ask it directly, ask it of everyone, and don't accept "years ago" as a no.
If yes: which cancer, when, what treatment, are they still under review, and when was the last scan?
Unexplained weight loss? How much, over how long, and were they trying?
Fatigue that's new and not explained by sleep or load?
Age, and general health.
Any recent fall, or pain after minimal trauma? Pathological fracture.

SPECIAL / SCREENING QUESTIONS — every time, on every non-mechanical back pain

Any change in walking, balance, or how the legs feel? This is the question that matters most.
Any numbness or heaviness in both legs?
Any bladder or bowel change? Any numbness in the saddle area?
Any fever, night sweats?
Is it getting worse week on week?

Assessing this region? Download the Lumbar Spine & SIJ assessment template →

3 · HYPOTHESIS RANKING

Inverted, as on every red-flag page: you are not ranking towards a diagnosis, you are ranking what you cannot miss.

What you must not miss	The feature that raises it
Metastatic spinal cord compression	Any change in walking, bilateral leg symptoms, a sensory level, UMN signs. This is the emergency.
Cauda equina syndrome	Bladder or bowel change, saddle anaesthesia, bilateral leg symptoms.
Pathological fracture	Sudden severe pain after minimal or no trauma, especially with a cancer history.
Spinal infection / discitis	Fever, systemic illness, immunosuppression, IV drug use, recent procedure.
Undiagnosed primary malignancy	Weight loss, fatigue, night pain, and no cancer history yet.
Abdominal aortic aneurysm	Pulsatile mass, non-mechanical pain, older male with vascular risk.
Then, and only then: non-specific low back pain, discogenic, radicular, stenosis	Mechanical behaviour. Reproducible. Fluctuating.

The reframe that matters

The title says "spinal metastases." The emergency is metastatic spinal cord compression — and what decides the outcome is whether they are still walking when someone acts. Functional status in this population has been studied [1], gait has been correlated with life expectancy [2], and the timing of surgery has been examined against function [3]. The direction is the whole point.

4 · RED FLAGS — DON'T MISS THIS

This section is free, on every pattern, forever. On this page the whole thing is.

Ambulatory status is the clock

The question is not how bad the pain is. It is whether they are still walking — and whether that has changed this week.

Finding	What it suggests	What you do
New difficulty walking, unsteadiness, or falls	MSCC	EMERGENCY — now. This is the one
Bilateral leg weakness, heaviness or numbness	Cord or cauda equina	EMERGENCY
Bladder or bowel change, saddle anaesthesia	Cauda equina	EMERGENCY
A band of altered sensation around the trunk	A cord level	EMERGENCY
Hyperreflexia, clonus, upgoing plantars	UMN — cord	EMERGENCY
Known cancer history with new spinal pain	Metastasis until proven otherwise	Urgent medical review and imaging
Constant, unremitting, non-mechanical pain	Serious pathology	Medical review
Night pain that gets them out of bed	With a cancer history: image. Without: still investigate	Medical review
Unexplained weight loss, fever, night sweats	Malignancy, infection	Urgent medical review
Severe pain after minimal or no trauma	Pathological fracture	Urgent medical review and imaging
Progressive worsening week on week	Whatever the cause	Medical review

What to do, in order

Stop. Do not treat.
Neurological examination — power, reflexes, sensation, plantars, gait and tandem gait. Record all of it.
Decide the tier: emergency department today · urgent same-day GP · urgent medical review this week.
Write it down: the features present, the features absent, the neurological findings with values, the cancer history in full, and whether their walking has changed.
Ring. Don't hand a letter to someone and hope.
Say the words "I'm worried about their spinal cord." Vague referrals get triaged as back pain.

Cross-links: Cauda equina syndrome · Infection / malignancy · Non-specific low back pain · Abdominal aortic aneurysm

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Guideline anchor

No Australian guideline covers spinal metastases beyond the lumbar screen in the ACSQHC Low Back Pain Clinical Care Standard (2022), which screens for serious pathology and reserves imaging for suspected serious pathology; it does not cover managing the cancer.

The two anchors that matter here are both about the screening itself — the BMJ systematic review of red flags to screen for malignancy and fracture in low back pain (Downie et al. 2013, PMID 24335669) and the Australian primary-care prevalence and screening study (Henschke et al. 2009, PMID 19790051). Red flags as they appear in current guidelines have been reviewed (Verhagen et al. 2016, PMID 27376890). Imaging is anchored to the ACR Appropriateness Criteria for low back pain, 2021 update (Hutchins et al. 2021, PMID 34794594).

PubMed Source

These are not management guidelines — they are studies of how well the screening you are doing actually performs. That is the right anchor for a physiotherapist, because your role here is recognition and referral, not treatment.

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The evidence summary is for members

Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.

Sources · 20

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Every source on this page resolves and title-verifies against PubMed. Newest first.

2018Santos et al. (2018). Functional status of patients with metastatic spinal cord compression. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 26(9), 3225-3231. https://doi.org/10.1007/s00520-018-4182-5
2022Sugita et al. (2022). Correlation Between Gait and Life Expectancy in Patients with Spinal Metastases. World neurosurgery, 163, e156-e161. https://doi.org/10.1016/j.wneu.2022.03.079
2022Meyer et al. (2022). Surgery in Acute Metastatic Spinal Cord Compression: Timing and Functional Outcome. Cancers, 14(9). https://doi.org/10.3390/cancers14092249
2021Hutchins et al. (2021). ACR Appropriateness Criteria® Low Back Pain: 2021 Update. Journal of the American College of Radiology : JACR, 18(11S), S361-S379. https://doi.org/10.1016/j.jacr.2021.08.002
2022Kuah et al. (2022). State-of-the-Art Imaging Techniques in Metastatic Spinal Cord Compression. Cancers, 14(13). https://doi.org/10.3390/cancers14133289
1997Helweg-Larsen et al. (1997). Radiologic features compared to clinical findings in a prospective study of 153 patients with metastatic spinal cord compression treated by radiotherapy. Acta neurochirurgica, 139(2), 105-11. https://doi.org/10.1007/BF02747189
2024Kovarik et al. (2024). Metastatic spinal cord compression: the Spinal Instability Neoplastic Score and early surgical intervention. BMJ supportive & palliative care. https://doi.org/10.1136/spcare-2023-004537
2023Pérez-Romasanta et al. (2023). The Management of Metastatic Spinal Cord Compression in Routine Clinical Practice. Cancers, 15(10). https://doi.org/10.3390/cancers15102821
2023Esperança-Martins et al. (2023). Multidisciplinary Approach to Spinal Metastases and Metastatic Spinal Cord Compression-A New Integrative Flowchart for Patient Management. Cancers, 15(6). https://doi.org/10.3390/cancers15061796
2022Rispoli et al. (2022). Multidisciplinary Approach to Patients With Metastatic Spinal Cord Compression: A Diagnostic Therapeutic Algorithm to Improve the Neurological Outcome. Frontiers in oncology, 12, 902928. https://doi.org/10.3389/fonc.2022.902928
2022Hershkovich et al. (2022). Acute Metastatic Spinal Cord Compression: Urgent Surgery versus Radiotherapy and Treatment Result Prediction versus Actual Results. Current oncology (Toronto, Ont.), 29(10), 7420-7429. https://doi.org/10.3390/curroncol29100583
2023Quraishi et al. (2023). Malignant spinal cord compression in the paediatric population-a systematic review, meta-analysis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 32(12), 4306-4313. https://doi.org/10.1007/s00586-023-07820-3
2022Giglio et al. (2022). Incidence and risk factors associated with the development of metastatic spinal cord compression due to bone metastasis in women with cervical cancer. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 31(11), 3139-3145. https://doi.org/10.1007/s00586-022-07314-8
2024Shakil et al. (2024). Contemporary trends in the incidence and timing of spinal metastases: A population-based study. Neuro-oncology advances, 6(1), vdae051. https://doi.org/10.1093/noajnl/vdae051
2009Henschke et al. (2009). Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis and rheumatism, 60(10), 3072-80. https://doi.org/10.1002/art.24853
2013Downie et al. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.), 347, f7095. https://doi.org/10.1136/bmj.f7095
2016Verhagen et al. (2016). Red flags presented in current low back pain guidelines: a review. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 25(9), 2788-802. https://doi.org/10.1007/s00586-016-4684-0
2020Galliker et al. (2020). Low Back Pain in the Emergency Department: Prevalence of Serious Spinal Pathologies and Diagnostic Accuracy of Red Flags. The American journal of medicine, 133(1), 60-72.e14. https://doi.org/10.1016/j.amjmed.2019.06.005
2020DePalma (2020). Red flags of low back pain. JAAPA : official journal of the American Academy of Physician Assistants, 33(8), 8-11. https://doi.org/10.1097/01.JAA.0000684112.91641.4c
2022Chu & Trager (2022). Prevalence of Serious Pathology Among Adults with Low Back Pain Presenting for Chiropractic Care: A Retrospective Chart Review of Integrated Clinics in Hong Kong. Medical science monitor : international medical journal of experimental and clinical research, 28, e938042. https://doi.org/10.12659/MSM.938042

Mapped to this pattern

BPI
Brief Pain Inventory
pain severity and interference · 6 min

Generic measures that also apply

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