[18] Spinal Cord Compression Flashcards
What is spinal cord compression?
A medical emergency where the there is compression or displacement of the arterial, venous and CSF spaces, as well as the cord itself
What are the possible causes of spinal cord compression?
- Trauma
- Tumours
- Irradiation
- Prolapsed intervertebral disc
- Epidural or subdural haematoma
- Inflammatory disease
- Spinal infections
- Cervical spondylitic myelopathy
What types of traumatic incident may cause spinal cord compression?
- Car accidents
- Falls
- Sports injuries
How do traumatic injuries lead to spinal cord compression?
Vertebral fracture or facet joint dislocation
What types of tumours can cause spinal cord compression?
Benign or malignant
What malignancies can cause spinal cord compression?
- Primary bone tumours
- Metastatic tumours
- Lymphomas
- Multiple myeloma
- Neurofibromata
What primary cancers most commonly metastasise to bone?
- Breast
- Prostate
- Lung
When is irradiation (leading to spinal cord compression) often encountered?
Radiotherapy
Which intervertebral discs most commonly prolapse to cause spinal cord compression?
L4-L5 or L5-S1
What inflammatory disease can especially cause spinal cord compression?
Rheumatoid arthritis
What are the subtypes of infective spinal cord compression?
Acute and chronic
What is the usual type of causative organism in acute infective spinal cord compression?
Bacteria
What are the usual types of causative organism in chronic infective spinal cord compression?
TB or fungal
What is cervical spondylitic myelopathy?
An aging process leading to narrowing of the spinal canal due to osteophytes, herniated discs and ligamentum flavum hypertrophy
What are the risk factors for spinal cord compression?
- Age 16-30
- Male
- Osteoporosis
- Risk of trauma
Why is osteoporosis a risk factor for spinal cord compression?
It is associated with vertebral column compression fractures
What type of trauma related risk factors increase the risk of spinal cord compression?
- High risk occupation
- High-risk recreational activities
Over what period do the symptoms of spinal cord compression develop?
Quickly or slowly depending on the cause
What are the common symptoms of spinal cord compression?
- Pain and stiffness in neck, back or lower back
- Burning pain that spreads to the arms, buttocks or down into the legs (sciatica)
- Numbness, cramping or weakness in arms, hands or legs
- Loss of foot sensation
- ‘Foot drop’
What can foot drop lead to?
Limp (high stepping gait)
In addition to the common symptoms of spinal cord compression, what else can develop over time?
Motor, sensory, and autonomic dysfunction
What does the clinical features of spinal cord compression depend on?
Extent, rate, and site of the spinal cord compression development
What are the red flags suggesting spinal cord compression?
- Insidious progression
- Neurological symptoms
- Neurological signs
What neurological symptoms are red flags for spinal cord compression?
- Gait disturbance
- Clumsy or weak hands
- Loss of sexual, bladder, or bowel function
What neurological signs are red flags for spinal cord compression?
- Lhermitte’s sign
- UMN signs in lower limbs
- LMN signs in upper limbs
- Sensory changes
What is Lhermitte’s sign?
Flexion of the neck causing an electric shock-type sensation that radiates down the spine and into the limbs
What UMN signs can be seen in the lower limbs in spinal cord compression?
- Babinski’s sign
- Hyper-reflexia
- Clonus
- Spasticity
What is Babinski’s sign?
Up-going plantar reflex
What LMN signs may be seen in the upper limbs in spinal cord compression?
- Atrophy
- Hyporeflexia
What sensory changes may be seen in spinal cord compression?
Loss of vibration and joint position sense
What investigations can be used in assessing spinal cord compression?
- MRI spine
- Gadolinium-enhance MRI spine
- Plain spine x-ray
- CT spine
Which of the previously listed imaging modalities is the study of choice for assessing spinal cord compression?
MRI spine
What may an MRI of the spine show in spinal cord compression?
- Disc displacement
- Epidural enhancement
- Mass effect
- T2 cord signal
When may a gadolinium-enhanced MRI be used in spinal cord compression?
If there is suspicion of infection (osteomyelitis) or epidural abscess
What may also be seen on gadolinium-enhanced MRI in spinal cord compression other than infection?
Metastatic disease
What can be seen on a plain spine x-ray if the underlying cause of the spinal cord compression is disc compression?
Decreased disc space height
What can be seen on a plain spine x-ray if the underlying cause of the spinal cord compression is a tumour?
Loss of bony detail
What can be seen on a plain spine x-ray if the underlying cause of the spinal cord compression is trauma?
Misalignment of vertebral elements
What can be seen on a plain spine x-ray if the underlying cause of the spinal cord compression is infection?
- Loss of bony detail
- Loss of end-plate definition
When might a CT spine be used to assess spinal cord compression?
- MRI unavailable
- Surgical planning
What do further investigations (beyond imaging) depend on in spinal cord compression?
The suspected underlying cause
What further investigations may be required in spinal cord compression?
- FBC
- ESR and CRP
- Blood or CSF cultures
- Tumour biopsy and histopathology
- Urodynamic studies
- PET scan of spine
When may FBC be abnormal in spinal cord compression?
Raised WBC if an infection is the cause
When may ESR and CRP be raised in spinal cord compression?
Underlying infection or inflammation
When may blood or CSF cultures be positive in spinal cord compression?
- Epidural abscess
- Discitis
- Osteomyelitis
When are urodynamic studies useful in spinal cord compression?
- Evaluate degree of sphincter dysfunction
- Monitor recovery of function post-decompression surgery
What are the potential differentials for spinal cord compression?
- Transverse myelitis
- Guillain-Barre syndrome
- HIV-related myelopathy
- Amyotrophic lateral sclerosis (ALS)
- MS
- Diabetic neuropathy
- Polymyositis
- Hereditary muscular dystrophy
- Peripheral neuropathy
In what position should a patient with spinal cord compression be nursed initially and for how long?
Flat, neutral spine alignment until spinal stability and neurological stability are ensured
What should be given in spinal cord compression until a definitive treatment plan is made?
Dexamethasone
What other supportive therapy steps can be used in spinal cord compression?
- Mange postural hypotension
- Insert catheter
- Techniques to clear airways
- VTE prophylaxis
- Prevention of pressure ulcers
- Pain control
What techniques can be used to clear the airways in spinal cord compression?
- Breathing exercises
- Assisted coughing
- Suction
How can pain be managed in spinal cord compression?
- Analgesia
- Palliative radiotherapy
- Spinal orthoses
- Vertebroplasty
- Spinal stabilisation surgery
When should a definitive treatment be started in spinal cord compression if one is possible?
Before the ability to walk is lost and ideally within 24 hours
What definitive treatment options are available for spinal cord compression?
- Surgery
- Radiotherapy
What types of surgery can be used to treat spinal cord compression?
- Laminectomy
- Posterior decompression
What should be provided to a patient post-discharge with spinal cord compression?
Community based rehab and support
What do complications of spinal cord compression depend on?
The site of compression and severity of dysfunction
What are the potential complications of spinal cord compression?
- Pressure sores
- Hypothermia
- Lung complications
- Depression
What lung complications can occur as a result of spinal cord compression?
- Aspiration pneumonia
- Acute respiratory distress syndrome
- Atelectasis
- Ventilation-perfusion mismatch
- Decreased coughing with retention of secretions
Why is depression often a complication of spinal cord compression?
There may be restriction of ADL’s
