Indicators of significantly poor prognosis:
a. Intramedullary T1 hypointensity
Represents irreversible cord injury due to myelomalacia, necrosis, or chronic ischemia.

b. Long-segment T2 hyperintensity
Indicates extensive cord edema or ischemic injury across multiple segments from sustained compression.

c. Complete CSF effacement with cord flattening
Signifies critical mechanical compression with loss of the protective CSF buffer around the cord.

d. High-grade (Bilsky 2–3) compression
Reflects severe epidural tumor encroachment causing obliteration of CSF space and deformation of the cord.

Additional features suggestive of poor prognosis:
Multilevel compression
Circumferential epidural disease – severe canal compromise and high tumor burden.
Vertebral collapse with retropulsion
Intramedullary enhancement – Represents active cord injury with vascular compromise and inflammatory response.

As per NICE guideline NG234 (2023), those presenting with signs of suspected spinal cord compression, such as limb weakness, sensory changes, bowel or bladder dysfunction, gait disturbance or any neurological deficit should undergo MRI evaluation as soon as possible and always within 24 hrs.

Those presenting with lower backache in the setting of vertebral metastases (suspected spinal metastases without neurological deficit) are advised to undergo MRI evaluation within a week.

The term spinal metastases encompasses all structures within and around the spinal cord, including bony vertebrae, neural tissue and surrounding soft tissue elements.

References

Cole, J. S., & Patchell, R. A. (2008). Metastatic epidural spinal cord compression. The Lancet Neurology, 7(5), 459–466. https://doi.org/10.1016/S1474-4422(08)70089-9

Loblaw, D. A., Perry, J., Chambers, A., & Laperriere, N. J. (2005). Systematic review of the diagnosis and management of malignant extradural spinal cord compression. Journal of Clinical Oncology, 23(9), 2028–2037. https://doi.org/10.1200/JCO.2005.00.067

Bilsky, M. H., Laufer, I., & Burch, S. (2010). Shifting paradigms in the treatment of metastatic spine disease. Spine, 34(22 Suppl), S101–S107. https://doi.org/10.1097/BRS.0b013e3181b8b6a0

National Institute for Health and Care Excellence. (2023). Spinal metastases and metastatic spinal cord compression (NG234). NICE. https://www.nice.org.uk/guidance/ng234