Spinal Cord Compression

Spinal cord compression is mechanical compression of the spinal cord causing progressive neurological dysfunction.

It is a syndrome rather than one disease.

Important causes include:

Neoplastic

Vertebral metastasis
Myeloma
Lymphoma
Primary spinal tumour

Infective

Spinal epidural abscess
Tuberculous spondylitis
Discitis with epidural extension

Degenerative

Cervical spondylotic myelopathy
Large acute disc prolapse

Traumatic

Fracture dislocation
Epidural haematoma

Other

Spinal epidural haemorrhage
Severe deformity

Compression above the conus produces spinal cord signs.

Compression below the conus produces cauda equina root dysfunction.

Neurological severity

The neurological examination should document:

Motor power by key myotomes
Sensory level
Reflexes
Sacral sensation
Anal tone
Bladder function

In traumatic spinal cord injury, the ASIA Impairment Scale ranges from complete injury with no sacral preservation to normal neurological function, but management should be based on the actual neurological pattern and imaging rather than the letter grade alone.

High value symptoms are:

Severe progressive spinal pain
Radicular pain
Limb weakness
Gait deterioration
Sensory level
Numbness or paraesthesia
New urinary dysfunction
New bowel dysfunction
Sexual dysfunction
Upper motor neuron signs below the lesion

Metastatic compression

Pain commonly precedes neurological deficit.

Features suggesting malignant vertebral disease include:

Severe unremitting pain
Night pain
Mechanical pain on movement
Pain worsened by coughing or straining
Known cancer

New weakness, sensory change or sphincter dysfunction in a patient with known cancer is an oncological emergency.

Epidural abscess

Consider when there is:

Severe spinal pain
Fever
Raised CRP
Bacteraemia
Diabetes
Immunosuppression
IV drug use
Recent spinal intervention

The classical triad of pain, fever and neurological deficit is frequently absent early.

MRI of the entire relevant spinal axis with contrast: investigation of choice.

For suspected metastatic cord compression with neurological signs, obtain MRI as soon as possible and within 24 hours.

Whole spine sagittal screening is useful in malignancy because noncontiguous spinal metastases are common.

If MRI is contraindicated:

CT with multiplanar reconstruction is the next investigation.

CT myelography is rarely required and should be performed only where appropriate specialist support exists.

Do not rely on plain radiographs to exclude cord compression.

Management is cause specific.

Initial spinal precautions

When mechanical instability is suspected:

Immobilise appropriately
Avoid unsupported transfers
Maintain neutral alignment
Obtain urgent spinal surgical assessment

Prolonged flat immobilisation is not necessary once stability has been assessed.

Metastatic spinal cord compression

With neurological signs:

Give:

Dexamethasone 16 mg orally or IV as soon as possible

then continue approximately:

16 mg daily

while awaiting definitive surgery or radiotherapy.

Taper after surgery or once radiotherapy begins.

Monitor:

Blood glucose
Infection
Gastrointestinal protection

Use a proton pump inhibitor during significant steroid therapy.

If lymphoma or myeloma is suspected but not yet confirmed, obtain specialist haematological advice before corticosteroids where clinically safe because steroids can reduce diagnostic tumour tissue.

Surgical decompression

Urgent decompression plus stabilisation is favoured when there is:

Progressive neurological deficit
Mechanical spinal instability
Significant vertebral collapse
Retropulsed bone or tumour producing focal compression
Radioresistant tumour requiring tissue diagnosis and decompression
Good enough overall prognosis to benefit from surgery

Objectives are:

Decompress spinal cord
Obtain diagnosis when necessary
Restore mechanical stability
Permit mobilisation

Modern metastatic surgery often uses separation surgery, removing epidural tumour sufficiently to create space between cord and tumour, followed by focused radiotherapy rather than attempting radical tumour excision from the entire vertebral body.

Radiotherapy

Use urgent radiotherapy when:

Compression is malignant
Surgery is unsuitable
Spine is stable
Radiosensitive tumour is present

Radiotherapy should begin promptly once the decision is made.

Spinal epidural abscess

Start antibiotics after blood cultures when this does not delay emergency treatment.

A practical empirical regimen is:

Vancomycin IV

plus:

Ceftriaxone 2 g IV every 12 to 24 hours

or cefepime 2 g IV every 8 hours when healthcare associated Gram negative risk or Pseudomonas is significant.

Urgent surgical decompression is required with:

Neurological deficit
Progressive weakness
Significant cord compression
Spinal instability
Abscess not responding to antibiotics
Need for microbiological diagnosis

Traumatic compression

Urgently correct:

Hypotension
Hypoxaemia
Gross mechanical instability

Obtain CT for bony anatomy and MRI for cord, disc and ligament assessment when indicated.

Perform decompression and stabilisation when ongoing mechanical compression or instability threatens neurological recovery.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Head Injury

Also known as: Traumatic brain injury, TBI, Concussion

Injury to the brain or skull from external mechanical force, ranging from mild concussion to severe TBI with structural brain damage.

Primary injury (at the moment of impact; irreversible) is distinguished from secondary injury (subsequent hypoxia, hypotension, raised ICP, seizures; potentially preventable and treatable, and the focus of emergency management).

Classified by GCS at presentation (best post-resuscitation score):

Mild: GCS 13-15
Moderate: GCS 9-12
Severe: GCS ≤8 ; requires airway protection/intubation

Pathology types: extradural hematoma (arterial, typically middle meningeal artery, biconvex on CT), subdural hematoma (venous, bridging veins, crescentic on CT), traumatic subarachnoid hemorrhage, intracerebral hemorrhage/contusion, diffuse axonal injury (shearing forces, often normal initial CT despite a severe clinical picture), skull fracture (linear, depressed, basal).

GCS assessment (Eye 1-4, Verbal 1-5, Motor 1-6) ; serial monitoring is more important than a single value
Extradural hematoma classic pattern: initial loss of consciousness → "lucid interval" → rapid deterioration as the hematoma expands; do not be falsely reassured by a lucid interval
Signs of raised ICP: headache, vomiting, deteriorating GCS, Cushing's triad (hypertension, bradycardia, irregular breathing ; a late, pre-terminal sign), unilateral then bilateral pupil dilation (uncal herniation)
Basal skull fracture signs: Battle's sign (mastoid bruising, delayed), raccoon eyes (periorbital bruising), CSF rhinorrhea/otorrhea, hemotympanum
Focal neurological deficit: localizes the lesion
Seizures: early (within 24h, common, doesn't necessarily predict epilepsy) vs. late (>7 days, higher epilepsy risk)

Red flags requiring urgent CT: GCS <15 at 2 hours post-injury, suspected open/depressed skull fracture, signs of basal skull fracture, post-traumatic seizure, focal neurological deficit, more than one episode of vomiting, age ≥65, dangerous mechanism, retrograde amnesia >30 min, anticoagulant use, GCS <13 at initial assessment.

CT head (non-contrast) : investigation of choice: identifies hemorrhage, mass effect, midline shift, skull fracture; do not delay for mild-moderate injury meeting the criteria above
C-spine imaging: high association with head injury (assess per NEXUS/Canadian C-spine rules), CT C-spine if high-risk mechanism/symptoms
GCS and pupillary response: serial reassessment is the primary monitoring tool, not a single CT
Bloods: FBC, coagulation profile (critical if on anticoagulants/antiplatelets : reverse urgently if intracranial bleed present), glucose (exclude hypoglycemia as cause of reduced GCS), alcohol level if relevant : do not attribute reduced GCS to intoxication without excluding structural injury
MRI: superior for diffuse axonal injury, not first-line acutely

Differentials for altered consciousness post-trauma: hypoglycemia, alcohol/drug intoxication, post-ictal state, hypoxia, hypotension/shock, pre-existing intracranial pathology.

Primary survey first : hypoxia and hypotension are the two most important preventable secondary insults; treat these before focusing on the head injury itself.

Airway protection: intubate if GCS ≤8, maintain C-spine precautions
Maintain cerebral perfusion: target SBP ≥110-120mmHg (a single hypotensive episode significantly worsens outcome), normocapnia, normothermia, normoglycemia

Signs of raised ICP/herniation (unilateral dilated pupil, deteriorating GCS, Cushing's triad):

Head elevation 30 degrees, midline neck position (avoid venous obstruction)
Hyperosmolar therapy: mannitol 0.5-1g/kg IV bolus, or hypertonic saline (3%) 150-250mL bolus : temporizing while arranging definitive management
Brief hyperventilation (target PaCO2 ~30-35mmHg) as a temporizing bridge to surgery only, not sustained therapy
Urgent neurosurgical referral for evacuation (extradural/subdural with mass effect, depressed skull fracture)

Other measures:

Seizure management: benzodiazepine for active seizure; consider prophylactic levetiracetam in severe TBI (reduces early post-traumatic seizures, no proven effect on late epilepsy)
Reverse anticoagulation urgently if intracranial hemorrhage (vitamin K + prothrombin complex concentrate for warfarin, specific reversal agents for DOACs where available)
Mild TBI/concussion: observation period, safety-netting advice (return if worsening headache, vomiting, drowsiness, confusion), avoid return to contact sport until symptom-free with graduated return-to-play
ICU admission for severe TBI (GCS ≤8) : ICP monitoring, ventilation, neuroprotective management (target ICP <20-22mmHg, cerebral perfusion pressure 60-70mmHg)

Disposition: discharge with head injury advice if low-risk, normal CT, and responsible adult supervision available; admit for observation if risk factors present even with a normal CT; neurosurgical transfer for any surgical lesion or GCS ≤8.

Spinal Cord Compression

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management