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.