Spinal Cord Compression

Ok, this is really random and irrelevant but I just learnt that if you underline a + sign, you get + !!! I can stop with this +/- . Discovered this by complete accident and now I’m just basking in my genius. Yeah, sure, I could have googled it…


Spinal Cord Compression

Definition: compression injury to the spinal cord with neurological symptoms that depend on the site and extent of injury. Acute cord compression is an emergency.

Aetiology/ risk factors:

-compression by bone/disc fragments or haematoma from trauma

-compression from extrinsic lesions e.g.:

-Tumours- secondary (prostate, breast, kidney, thyroid, lung) = commonest cause

     or primary spinal cord tumour

-Prolapsed disc

-Rheumatoid arthritis (atlantoaxial subluxation), cervical spondylosis (cervical spine), Paget’s disease of bone

-Spinal abscesses- TB (Pott’s disease), Staphylococcus

-Multiple myeloma

-Spinal vascular malformations

-Haematoma (warfarin)

Epidemiology:

Common.

Trauma occurs in all age groups, whilst malignancy and disc disease are more common in older ages.

Related imageSymptoms:

 

Depends on site and extent

pain: arm pain (cervical spine), back pain etc.

    spinal or root pain may precede weakness

weakness: typically presents with weak legs +/- arms

weakness is sudden and progressive

arm weakness often less severe (suggests cervical cord lesion)

sensory loss below level of compression

sphincter control– faecal and urinary incontinence- hesitancy, frequency, and later, as painless retention (late)

-impotence

Signs:

-Look for a motor, reflex and sensory level, with:

normal findings above the level of the lesion

lower motor neurone signs at the level (especially in cervical cord compression)

decreased tone, flaccid weakness, hypo/arreflexia, muscle wasting, fasciculations

upper motor neurone signs below the level

increased tone, spastic weakness, hyper-reflexia, extensor plantars

     -but tone and reflexes usually reduced acutely

Acute cord compression = bilateral pain

   LMN signs at level, UMN signs & sensory loss below

-tone and reflexes usually reduced

          reduced anal tone, sphincter disturbance

          priapism (persistent and painful erection of the penis)

          spinal shock- hypotension without tachycardia

Signs of infection = tender spine, pyrexia (e.g. extradural abscess)

Investigations:

Do not delay imaging.

Trauma radiology- AP and lateral radiographs or cervical (also peg view), thoracic or lumbar spine.

High-resolution CT Spine- allows reformatting for 3D visualisation.

Emergency MRI spine = DEFINITIVE modality- to visualise soft tissue and cord. Cord signal change and canal stenosis are key features to identify.

Image result for spinal cord compression mri

Biopsy or surgical exploration– may be needed to identify the nature of any mass.

Bloods- FBC/ ESR/ CRP (infection, abscess?), U&Es, bone profile (Paget’s?), LFTs, Ca (myeloma?), protein electrophoresis (myeloma?), B12, syphilis serology, PSA (prostate cancer?)

CXR- lung malignancy? TB?

Urine- Bence Jones protein (indicate multiple myeloma)

Management:

Cord compression:

-following imaging, if tumour present = high dose steroids- DEXAMETHASONE (IV 4mg/6h) given promptly to reduce cord compression.

-tumours may also respond to emergency radiotherapy or chemotherapy + decompressive laminectomy

Surgery

-necessary in a number of cases to relieve compression and/or remove cause of compression e.g.

discectomy/ microdiscectomy– for disc prolapses

-surgical decompression e.g. laminectomy = removing the lamina — the back part of the vertebra – to relieve compression

Image result for laminectomy

-epidural abscesses need surgical decompression and antibiotics

⇒Multi-disciplinary rehabilitation programme with physiotherapy and occupational therapy

Paralysed patients:

-avoid pressure sores by turning

-avoid DVT by frequent passive movement, pressure stockings +/- low molecular weight heparin

-bladder care e.g. catheterisation

-bowel evacuation- manual or aided by suppositories, increasing fibre may help

-exercise of unaffected or partially paralysed limbs to avoid unnecessary loss of function

Complications:

-with severe injury there is loss of spinal function below the level of the lesion

-above C4 = respiratory paralysis

-C4-T1 = quadriplegia (some degree of paralysis in all limbs)

-mid-thoracic = paraplegia (legs), autonomic dysreflexia (if above T6)

-S1 = loss of sacral parasympathetic control over bladder and rectum

-Complications of immobility: chest and urinary sepsis, pressure sores, DVT, long-term spasticity (with risk of deformity), heterotopic ossification

Prognosis:

-depends on the completeness of cord injury

References: Rapid Surgery, Cheese & Onion

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