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

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==Background==
==Background==
*Most often from cancer
*Compression of the spinal cord from non-traumatic etiology
**[[Multiple myeloma]], [[lymphoma]], prostate, lung, breast
*A '''neurologic emergency''' — neurologic deficits may become permanent if not promptly treated
*Site of Compression: Thoracic > Cervical > Lumbar
*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>
*The [[cauda equina]] (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves.  It is distal to the tapered end of the spinal cord, or conus medularis.<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>
*Other causes: [[Epidural abscess]], epidural hematoma, disc herniation, degenerative stenosis
*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==
{{Epidural compression syndromes clinical}}
*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==
==Differential Diagnosis==
{{Spinal cord syndromes DDX}}
*[[Cauda equina syndrome]] (lower motor neuron findings)
 
*[[Transverse myelitis]]
{{Lower back pain DDX}}
*[[Guillain-Barré syndrome]]
*[[Spinal cord infarction]]
*Vertebral compression fracture without cord compromise
*[[Multiple sclerosis]] relapse


==Evaluation==
==Evaluation==
*[[mri|MRI]] is study of choice
*'''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>
**If unavailable consider CT myelography
**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


{{Epidural compression syndromes diagnosis}}
==Management==
===Malignant Cord Compression===
*'''[[Dexamethasone]]''' — give immediately when suspected (before imaging if high suspicion)
**'''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>
*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


==Management==
===Epidural Abscess===
#Consult neurosurgery and/or rad onc
*Broad-spectrum IV antibiotics: Vancomycin + Ceftriaxone (or Cefepime)
#[[Corticosteroid]] therapy
*Blood cultures before antibiotics (if does not delay treatment)
#*Extremely controversial and perhaps no longer indicated in nontraumatic compression<ref>Coleman WP, et al: A critical appraisal of the reporting of the National
*Emergent neurosurgical consultation for drainage
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
*See [[Epidural abscess]] for detailed management
inappropriate standard of care. J Neurosurgery 2000; 93(1 Suppl):1</ref>
#*Consider emergent radiation, surgical intervention, and/or chemo therapy


{{Epidural compression syndromes management}}
===Epidural Hematoma===
*Reverse anticoagulation immediately
*Emergent neurosurgical consultation for possible decompression


==Disposition==
==Disposition==
*Admit
*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==
==See Also==
*[[Spinal Cord Trauma]]
*[[Cauda equina syndrome]]
*[[Spinal Column Injuries (Cervical)]]
*[[Epidural abscess]]
*[[Neurogenic Shock]]
*[[Low back pain]]
*[[Spinal cord syndromes]]
*[[Transverse myelitis]]
*[[Epidural compression syndromes]]


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