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
• 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
  • 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
• 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

• Cauda equina syndrome
• Epidural abscess
• Low back pain
• Transverse myelitis