Epidural compression syndromes

Background

• 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.

• Presentation and initial management are similar; difference is level of neuro deficit

Epidural compression syndromes

Sensory dermatome by spinal level.

• Syndromes
  • Spinal cord injury
  • Spinal cord compression (non-traumatic)
  • Cauda equina syndrome
  • Conus medullaris syndrome
• Causes
  • Spinal cord injury
  • Epidural abscess (spinal)
  • Epidural hematoma (spinal)
  • Syringomyelia

Etiology

• Epidural abscess
• Malignancy
• Massive mid-line disk herniation
• Spinal canal hemorrhage

Clinical Features

Syndrome	Spinal cord compression	Conus medullaris syndrome	Cauda equina syndrome
Lesion	Back pain with neuro deficits	Lesions at vertebral level L2	Low Back Pain
	Weakness in lower extremities, paresthesias/sensory deficits, gait difficultly	Early and prominent sphincter dysfunction with flaccid paralysis of the bladder and rectum, impotence, and saddle (S3-S5) anesthesia	Urinary retention with or without overflow incontinence (Sn 90%, Sp 95%)
	Deficits usually affect both legs but are often asymmetric		Rectal incontinence
	Bladder and rectal sphincter paralysis usually reflect involvement of S3-S5 nerve roots		Bilateral sciatica
			Saddle anesthesia (75% pts)
			Decreased anal sphincter tone (60-80% pts)
			Difficulty ambulating and/or wew foot-drop
			Symptoms worsened by coughing (increases intraspinal pressure)

Differential Diagnosis

Lower Back Pain

• Spine related
  • Acute ligamentous injury
  • Acute muscle strain
  • Disk herniation (Sciatica)
  • Degenerative joint disease
  • Spondylolithesis
  • Epidural compression syndromes
    • Spinal cord compression (non-traumatic)
    • Cauda equina syndrome
    • Conus medullaris syndrome
    • Epidural abscess (spinal)
    • Epidural hematoma (spinal)
  • Thoracic and lumbar fractures and dislocations
  • Cancer metastasis
  • Spinal stenosis
  • Transverse myelitis
  • Vertebral osteomyelitis
  • Ankylosing spondylitis
  • Spondylolisthesis
  • Discitis
  • Spinal Infarct
• Renal disease
  • Kidney stone
  • Pyelonephritis
  • Nephrolithiasis
• Intra-abdominal
  • Abdominal aortic aneurysm
  • Ulcer perforation
  • Retrocecal appendicitis
  • Large bowel obstruction
  • Pancreatitis
• Pelvic disease
  • PID
• Other
  • Retroperitoneal hemorrhage/mass
  • Meningitis

Spinal Cord Syndromes

• Complete spinal cord transection syndrome
• Anterior cord syndrome
• Central cord syndrome
• Brown-Séquard syndrome
• Epidural compression syndromes
  • Spinal cord compression (non-traumatic)
  • Cauda equina syndrome
  • Conus medullaris syndrome
  • Epidural abscess (spinal)
  • Epidural hematoma (spinal)

• Emergent MRI
  • If considering compression due to neoplasm obtain scan of entire spine
• Consider Bladder scan/ultrasound for bladder volume (post-void residual)

General Epidural Compression Syndrome Management

• Dexamethasone: at least 16 mg IV as soon as possible after assessment
  • Note: dexamethasone can be used to reduce compressive edema from epidural metastases, but is more likely to worsen an infection from spinal epidural abscess.
• Consult spine service
• Consider foley for bladder decompression

See Also

• Epidural Abscess (Spinal)