Spinal cord compression (non-traumatic)
Background
- Compression of the spinal cord from non-traumatic etiology
- A neurologic emergency — neurologic deficits may become permanent if not promptly treated
- Most common cause: metastatic cancer (malignant epidural spinal cord compression) — affects 5-10% of cancer patients[1]
- Other causes: Epidural abscess, epidural hematoma, disc herniation, degenerative stenosis
- Thoracic spine is the most commonly affected level in malignancy (60%)
Etiology
- Malignancy: lung, breast, prostate, renal cell, lymphoma, multiple myeloma
- Epidural abscess: hematogenous spread or direct extension; risk factors include IVDU, immunosuppression, recent spinal procedure
- Epidural hematoma: anticoagulation, post-procedural, coagulopathy
- Disc herniation: central disc causing cord compression (thoracic or cervical)
- Degenerative spinal stenosis with myelopathy
- Vertebral compression fracture (osteoporotic or pathologic)
Clinical Features
- Back pain (present in >90% of malignant cases) — often worse at night, worse supine
- Progressive weakness (upper motor neuron signs below level of compression)
- Hyperreflexia, spasticity, positive Babinski sign
- May present as difficulty walking or frequent falls
- Sensory level — band-like numbness at level of compression
- Bowel/bladder dysfunction — urinary retention, incontinence (late finding; poor prognostic sign)
- Fever + back pain + neurologic deficit = epidural abscess until proven otherwise
- Vertebral tenderness to palpation
Differential Diagnosis
- Cauda equina syndrome (lower motor neuron findings)
- Transverse myelitis
- Guillain-Barré syndrome
- Spinal cord infarction
- Vertebral compression fracture without cord compromise
- Multiple sclerosis relapse
Evaluation
- MRI of entire spine with and without gadolinium — imaging of choice[2]
- Entire spine because multifocal disease is common with malignancy
- Emergent MRI — do not delay
- CT myelography if MRI unavailable or contraindicated
- Labs
- If infection suspected: CBC, ESR, CRP, blood cultures (ESR >20 has high sensitivity for epidural abscess)
- If malignancy: LDH, calcium, alkaline phosphatase
- Coagulation studies if epidural hematoma suspected
- X-rays of spine: may show vertebral body destruction, but cannot rule out cord compression
Management
Malignant Cord Compression
- Dexamethasone — give immediately when suspected (before imaging if high suspicion)
- 10 mg IV bolus, then 4 mg IV/PO q6h[3]
- Emergent radiation oncology and/or neurosurgery/spine surgery consultation
- Surgical decompression + radiation therapy superior to radiation alone for selected patients
- Pain management: opioids, consider PCA
Epidural Abscess
- Broad-spectrum IV antibiotics: Vancomycin + Ceftriaxone (or Cefepime)
- Blood cultures before antibiotics (if does not delay treatment)
- Emergent neurosurgical consultation for drainage
- See Epidural abscess for detailed management
Epidural Hematoma
- Reverse anticoagulation immediately
- Emergent neurosurgical consultation for possible decompression
Disposition
- Admit all cases of spinal cord compression
- New neurologic deficits require emergent evaluation and treatment
- Ambulatory status at presentation is the strongest predictor of outcome
See Also
References
- ↑ Loblaw DA, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression. J Clin Oncol. 2005;23(9):2028-2037. PMID 15774794.
- ↑ Quraishi NA, et al. Metastatic spinal cord compression. BMJ. 2015;350:h2539. PMID 26037491.
- ↑ George R, et al. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015;(9):CD006716. PMID 26337716.