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
-Rheumatoid arthritis (atlantoaxial subluxation), cervical spondylosis (cervical spine), Paget’s disease of bone
-Spinal abscesses- TB (Pott’s disease), Staphylococcus
-Spinal vascular malformations
Trauma occurs in all age groups, whilst malignancy and disc disease are more common in older ages.
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)
-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)
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.
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)
-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
-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
-epidural abscesses need surgical decompression and antibiotics
⇒Multi-disciplinary rehabilitation programme with physiotherapy and occupational therapy
-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
-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
-depends on the completeness of cord injury
References: Rapid Surgery, Cheese & Onion