Spinal cord compression (non-traumatic): Difference between revisions

(Expanded with concise EM-focused content: time-sensitive diagnosis, red flags, MRI urgency, steroid dosing, abscess distinction, disposition)
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==Background==
==Background==
*Non-traumatic spinal cord compression is an oncologic and neurologic emergency
*Compression of the spinal cord from non-traumatic etiology
*Most commonly from '''metastatic cancer''' (breast, lung, prostate, renal, myeloma, lymphoma)
*A '''neurologic emergency''' — neurologic deficits may become permanent if not promptly treated
*Site: thoracic spine (60-70%) > lumbar > cervical
*Most common cause: metastatic cancer ('''malignant epidural spinal cord compression''') — affects 5-10% of cancer patients<ref name="loblaw">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.</ref>
*Neurologic deficits may be irreversible if treatment is delayed — '''time is spine'''
*Other causes: [[Epidural abscess]], epidural hematoma, disc herniation, degenerative stenosis
*The [[cauda equina]] begins at the L2 level; compression below this level produces a [[cauda equina syndrome|lower motor neuron pattern]]<ref>Cohen MS, Wall EJ, Kerber CW, et al. The Anatomy of the Cauda Equina on CT Scans and MRI. J Bone Joint Surg Br 1991; 73 (3): 381-84.</ref>
*Thoracic spine is the most commonly affected level in malignancy (60%)
{{Epidural compression syndromes types}}
 
==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==
==Clinical Features==
*'''Back pain''' is the earliest and most common symptom (>90%) — often precedes neurologic deficits by weeks
*Back pain (present in >90% of malignant cases) — often worse at night, worse supine
*Progressive weakness (typically bilateral)
*Progressive weakness (upper motor neuron signs below level of compression)
*Sensory loss below the level of compression (sensory level)
**Hyperreflexia, spasticity, positive Babinski sign
*Bowel/bladder dysfunction (late finding — urinary retention, incontinence)
**May present as difficulty walking or frequent falls
*Gait difficulty
*Sensory level — band-like numbness at level of compression
{{Epidural compression syndromes clinical}}
*Bowel/bladder dysfunction — urinary retention, incontinence (late finding; poor prognostic sign)
 
*Fever + back pain + neurologic deficit = epidural abscess until proven otherwise
===Red Flags===
*Vertebral tenderness to palpation
*Known cancer + new back pain (cord compression until proven otherwise)
*Bilateral leg weakness
*Sensory level on exam
*Urinary retention or incontinence
*Saddle anesthesia


==Differential Diagnosis==
==Differential Diagnosis==
{{Spinal cord syndromes DDX}}
*[[Cauda equina syndrome]] (lower motor neuron findings)
{{Lower back pain DDX}}
*[[Transverse myelitis]]
*[[Guillain-Barré syndrome]]
*[[Spinal cord infarction]]
*Vertebral compression fracture without cord compromise
*[[Multiple sclerosis]] relapse


===Causes===
==Evaluation==
*'''Metastatic epidural disease''' (most common)
*'''MRI of entire spine with and without gadolinium''' — imaging of choice<ref name="quraishi">Quraishi NA, et al. Metastatic spinal cord compression. ''BMJ''. 2015;350:h2539. PMID 26037491.</ref>
*'''[[Epidural abscess (spinal)|Epidural abscess]]''' (fever, IVDU, recent procedure)
**Entire spine because multifocal disease is common with malignancy
*'''[[Epidural hematoma (spinal)|Epidural hematoma]]''' (anticoagulation, post-procedure)
**Emergent MRI — do not delay
*Primary spinal tumor
**CT myelography if MRI unavailable or contraindicated
*Disc herniation (massive central herniation)
*Labs
*Vertebral fracture with retropulsion
**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


==Evaluation==
==Management==
*'''MRI of entire spine''' is the study of choice — order emergently
===Malignant Cord Compression===
**Image entire spine (may have multiple levels of compression)
*'''[[Dexamethasone]]''' — give immediately when suspected (before imaging if high suspicion)
**If MRI unavailable: CT myelography
**'''10 mg IV bolus''', then 4 mg IV/PO q6h<ref name="george">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.</ref>
*Bladder scan for post-void residual (>200 mL suggests neurogenic bladder)
*Emergent radiation oncology and/or neurosurgery/spine surgery consultation
{{Epidural compression syndromes diagnosis}}
*Surgical decompression + radiation therapy superior to radiation alone for selected patients
*Pain management: opioids, consider PCA


===Labs===
===Epidural Abscess===
*[[CBC]], [[BMP]], coagulation studies
*Broad-spectrum IV antibiotics: Vancomycin + Ceftriaxone (or Cefepime)
*[[ESR]], [[CRP]] (elevated in abscess, tumor)
*Blood cultures before antibiotics (if does not delay treatment)
*Blood cultures if abscess suspected
*Emergent neurosurgical consultation for drainage
*PSA, serum protein electrophoresis if cancer workup needed
*See [[Epidural abscess]] for detailed management


==Management==
===Epidural Hematoma===
*'''Emergent consultation''': neurosurgery and/or radiation oncology
*Reverse anticoagulation immediately
*'''Dexamethasone''': 10 mg IV bolus then 4 mg IV q6h (for malignant compression)
*Emergent neurosurgical consultation for possible decompression
**Controversial for non-malignant causes — consider risks<ref>Coleman WP, et al. A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury. J Spinal Disord 2000; 13:185.</ref><ref>Hurlbert RJ. Methylprednisolone for acute spinal cord injury: An inappropriate standard of care. J Neurosurgery 2000; 93(1 Suppl):1</ref>
**Do NOT give steroids if [[epidural abscess (spinal)|epidural abscess]] suspected (will worsen infection)
*Definitive treatment: emergent radiation, surgical decompression, and/or chemotherapy based on tumor type
*'''Epidural abscess''': emergent surgical drainage + IV antibiotics
*'''Epidural hematoma''': reverse anticoagulation, emergent surgical evacuation
*Foley catheter for urinary retention
{{Epidural compression syndromes management}}


==Disposition==
==Disposition==
*Admit all patients with confirmed or suspected cord compression
*Admit all cases of spinal cord compression
*ICU if hemodynamically unstable or rapidly progressing deficits
*New neurologic deficits require emergent evaluation and treatment
*Ambulatory status at time of diagnosis is the strongest predictor of outcome — patients who are still ambulatory have the best prognosis
*Ambulatory status at presentation is the strongest predictor of outcome


==See Also==
==See Also==
*[[Epidural compression syndromes]]
*[[Cauda equina syndrome]]
*[[Cauda equina syndrome]]
*[[Spinal Cord Trauma]]
*[[Epidural abscess]]
*[[Epidural abscess (spinal)]]
*[[Low back pain]]
*[[Spinal cord syndromes]]
*[[Transverse myelitis]]


==References==
==References==
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[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Orthopedics]]
[[Category:Hematology and Oncology]]
[[Category:Oncology]]

Latest revision as of 09:26, 22 March 2026

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

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

  1. ↑ 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.
  2. ↑ Quraishi NA, et al. Metastatic spinal cord compression. BMJ. 2015;350:h2539. PMID 26037491.
  3. ↑ 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.
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