# Bilsky ESCC — Epidural spinal cord compression (ESCC / Bilsky) scale

> Per-level six-category MRI morphology for neoplastic epidural disease, assigned on axial T2 at the site of greatest cord compromise. ESCC supplies the neurologic imaging axis of NOMS; it neither measures mechanical instability nor independently chooses surgery or radiation.

**Situação:** vigente · **Órgão:** Coluna · **Órgão emissor:** Spine Oncology Study Group · **Versão:** 2010 scale; current NOMS, NICE 2023 and ASTRO 2024 context · **Ano:** 2010

> ⚠️ Uma versão mais nova pode existir (em revisão).

## Procedência e vigência
- Família: léxico
- Tipo de lógica: flat
- Modalidade: MRI
- Fonte primária: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/
- Última verificação: 2026-07-24
- Última checagem: 2026-08-12

## Lógica de decisão
Assign ESCC per involved cord level on axial T2, preserve uncertainty and emergency red flags, and integrate rather than conflate the neurologic, oncologic, mechanical and systemic NOMS axes.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| 0 | Grade 0, bone-only disease | At the named spinal cord level on axial T2 MRI, neoplastic involvement is confined to bone with no tumor extending into the epidural space or spinal canal. Confirm the apparent absence of epidural disease across multiplanar images and distinguish fracture fragments or non-tumor material. | Report grade 0 per involved level and separately assess pain, fracture, alignment and SINS/mechanical stability. Within NOMS, low-grade epidural morphology may support radiation-first oncologic care when treatment is needed and stability/systemic factors permit, but grade 0 alone neither orders treatment nor excludes surgical referral for instability. | There is no neoplastic epidural cord compromise at that level by the scale, but bone-only disease can still fracture, collapse, deform or cause mechanical pain. ESCC 0 is not a low overall patient-risk label and does not predict neurologic trajectory, survival or treatment response. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, six-point definition of grade 0; Laufer et al. 2013, PMC4063402, Neurologic Assessment and Mechanical Assessment for low-grade ESCC versus SINS/NOMS context. | ✓ |
| 1a | Grade 1a, epidural impingement, no thecal sac deformation | Epidural neoplastic impingement is present on axial T2 MRI, but the thecal sac contour is not deformed. Identify the level, direction and craniocaudal extent of epidural tumor rather than recording only the category. | Treat 1a as low-grade epidural disease within the neurologic NOMS axis and integrate tumor radiosensitivity, prior radiation, SINS stability, neurologic status and systemic fitness. It commonly remains in a radiation-first pathway when otherwise appropriate, but this tendency is conditional and not a grade-only command. | The epidural compartment is involved, although the sac is not yet deformed. Progression risk depends on tumor biology, treatment and time; 1a does not provide a calibrated probability of later compression and must not obscure instability or rapidly evolving neurologic symptoms. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1a definition; Laufer et al. 2013, PMC4063402, ESCC Figure 1 and NOMS low-grade treatment context. | ✓ |
| 1b | Grade 1b, thecal sac deformation, no cord abutment | Epidural tumor deforms the thecal sac on axial T2 MRI without abutting the spinal cord. Demonstrable sac deformation distinguishes 1b from 1a; demonstrable cord contact would move the morphology to 1c. | Report 1b per level with the epidural direction/length and keep cord signal, fracture and stability separate. NOMS generally treats 0-1b as low-grade ESCC for oncologic planning, but management still requires histology/radiosensitivity, prior treatment, examination, SINS and systemic feasibility. | Thecal-sac deformation represents greater epidural compromise than 1a but there is no cord contact or compression by definition. The category remains an ordinal morphology, not an individualized paralysis, recovery or survival estimate. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1b definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment for low-grade ESCC and conditional radiation context. | ✓ |
| 1c | Grade 1c, thecal sac deformation with cord abutment, no compression | Epidural tumor deforms the thecal sac and directly abuts the spinal cord, but the cord itself is not compressed. If contact versus deformation cannot be resolved, preserve 1b-versus-1c uncertainty; if the cord is deformed/compressed, evaluate grade 2 or 3. | Escalate 1c for multidisciplinary NOMS review rather than silently grouping it with either 0-1b or 2-3. The original NOMS publication describes uncertainty about the role and durability of radiosurgery at this boundary; symptoms, radiosensitivity, prior radiation, stability and systemic status determine the actual plan. | Cord contact without compression is an important boundary state, but it is not a validated probability of neurologic deterioration. Rapid clinical decline or myelopathy overrides the stored category and requires emergency assessment even when the morphology remains 1c. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1c definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment noting unresolved grade 1c radiosurgery role. | ✓ |
| 2 | Grade 2, cord compression with CSF visible around the cord | The spinal cord is compressed/deformed by epidural neoplastic disease, while cerebrospinal fluid remains visibly interposed around at least part of the cord on the maximal axial T2 image. If residual CSF cannot be judged, retain grade 2-versus-3 uncertainty. | Grade 2 is high-grade ESCC and warrants urgent multidisciplinary assessment. NOMS commonly considers decompression before radiation for radioresistant tumors, while highly radiosensitive histologies and other patient factors may support a different pathway; current ASTRO guidance conditionally favors surgery plus postoperative radiation over radiation alone in appropriate cord/cauda-equina compression patients. | True cord compression is present. Neurologic risk depends on examination, cord signal, speed of onset, level, tumor and treatment timing; the presence of residual CSF does not make symptomatic compression nonurgent or supply an individual probability of paralysis. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 2 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC NOMS pathway; NICE NG234 recommendations 1.5.2-1.5.5 for urgent MRI; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, cord/cauda-equina compression recommendation context. | ✓ |
| 3 | Grade 3, cord compression with no CSF visible | The spinal cord is compressed by epidural neoplastic disease and no surrounding cerebrospinal-fluid signal remains visible at the site of maximal compression on axial T2 MRI. Verify technical quality and exact level before assigning the category. | Grade 3 is high-grade ESCC and requires urgent MSCC-pathway escalation, with immediate attention to neurologic deficits and ambulation. Surgical, radiation and corticosteroid decisions remain multidisciplinary and patient-specific; tumor radiosensitivity, prior radiation, SINS stability, systemic fitness and goals of care must accompany the grade. | This is the greatest cord-compromise morphology in the scale, but it is not synonymous with irreversible paralysis or futility. Outcome depends on baseline and evolving neurology, duration, cord injury, tumor and timely treatment, so no universal recovery or mortality percentage should be attached. | Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 3 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC/NOMS; NICE NG234 MSCC emergency pathway; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, multimodality treatment context. | ✓ |

### Citações por categoria
- **0**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, six-point definition of grade 0; Laufer et al. 2013, PMC4063402, Neurologic Assessment and Mechanical Assessment for low-grade ESCC versus SINS/NOMS context.
- **1a**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1a definition; Laufer et al. 2013, PMC4063402, ESCC Figure 1 and NOMS low-grade treatment context.
- **1b**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1b definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment for low-grade ESCC and conditional radiation context.
- **1c**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 1c definition; Laufer et al. 2013, PMC4063402, Neurologic Assessment noting unresolved grade 1c radiosurgery role.
- **2**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 2 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC NOMS pathway; NICE NG234 recommendations 1.5.2-1.5.5 for urgent MRI; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, cord/cauda-equina compression recommendation context.
- **3**: Bilsky MH, Laufer I, Fourney DR, et al.. Reliability analysis of the epidural spinal cord compression scale (2010) — https://pubmed.ncbi.nlm.nih.gov/20809724/ · Bilsky et al. 2010, DOI 10.3171/2010.3.SPINE09459, grade 3 definition; Laufer et al. 2013, PMC4063402, high-grade ESCC/NOMS; NICE NG234 MSCC emergency pathway; ASTRO 2024 DOI 10.1016/j.prro.2024.04.018, multimodality treatment context.

## Referências cruzadas
- _fronteira compartilhada_ → [SINS — Spinal Instability Neoplastic Score](https://radcommons.laudos.ai/systems/sins.md) — Components of the NOMS framework for metastatic spine disease: ESCC grades neurologic/cord compromise, SINS grades mechanical instability.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2026-07-25 | revised | Monitored source changed (content_hash). Detected automatically; awaiting reviewer confirmation. | needs_review |
| 2010-09-01 | published | Epidural spinal cord compression scale reliability analysis published in J Neurosurg Spine. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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