[2] Spinal Cord Compression Flashcards
What is the importance of acute spinal cord compression (ASCC)?
It is a surgical emergency requiring immediate neurosurgical treatment
What does the prognosis of ASCC vary most depending on?
Time between diagnosis and treatment
What causes ASCC?
Any pathology that leads to compression of the spinal cord compression
What is the most common cause of ASCC?
Metastatic spinal cord compression (MSCC)
What are the categories of causes of ASCC?
Neoplastic
Traumatic
Infective
Disc prolapses
What primary malignancies most commonly caused metastatic spinal cord compression?
Thyroid Lung Breast Renal Prostate
What primary tumours can cause ASCC?
Primary bone tumours
Haemotological malignancies, such as non-Hodgkins lymphoma and myeloma
What are the traumatic causes of ASCC?
Typically a vertebral fracture or facet joint dislocation
What is possible in a vertebral fracture or facet joint dislocation?
Complete severance of the cord
How can infections cause ASCC?
Can lead to abscess formation and cause compression of the spinal cord
What chronic infections can cause ASCC?
Tuberculosis
Fungal infections
Why is disc prolapse a rare cause of spinal cord compression?
Because lumbar disc herniation typically causes compression of the cauda equina inferior to the spinal cord
What can lead to an increased risk of developing ASCC?
Any pathology that can predispose to a narrowed cord canal
What kinds of pathologies can lead to a narrowed cord canal?
Inflammatory conditions
Degenerative conditions
Give two inflammatory conditions that can cause a narrowed spinal cord canal
RA
Ankylosing spondylitis
Give two degenerative conditions that can cause a narrowed spinal cord canal
Ligamentum flavum hypertrophy
Osteophyte formation, contributing to spinal stenosis
What are the history and examination vital for in suspected spinal cord compression?
Differentiating acute spinal cord compression from simple disc herniation
What are the clinical features of ASCC?
Impaired sensation and proprioception Pain Weakness UMN signs Autonomic involvement
What effect will ASCC have on sensation and proprioception?
It will often be impaired at the dermatomal levels below the cord compression
What aggravates the pain caused by ASCC?
Straining, e.g. Coughing and sneezing
Does ASCC cause unilateral or bilateral weakness?
Can be either
What proportion of MSCC are non-ambulatory at diagnosis?
About 2/3
What is the diagnostic importance of UMN signs being present in ASCC?
It can differentiate it from peripheral nerve compression or cauda equina syndrome, which has LMN signs
Give 4 examples of UMN signs that may be seen in ASCC
Hypertonia
Hyperreflexia
Babinski’s sign
Colnus
Where are the UMN signs present in ASCC?
Below the level of the lesion
What tends to happen to reflexes in ASCC?
They tend to be absent at the level of the lesion
Why do reflexes tend to be absent at the level of the lesion in ASCC?
Because the lower motor neurone within the ventral horn is compressed, so produces a lower motor neurone deficit
What is the relevance of any autonomic involvement in ASCC
It is a late stage, and therefore carries a worse prognosis
What clinical features are associated with autonomic involvement in ASCC?
Bowel incontinence, or constipation and urinary retention
What features may be diagnostically useful in ACSS?
May be signs of an underlying cause, e.g. Malignant features such as weight loss and tiredness
What lower motor neurone sign is often the initial manifestation of ASCC?
Flaccidity
I dont really get this, but the card IS supposed to say LMN
What do cord injuries at T12 or above tend to cause over time?
Bladder spasticity
What are the differential diagnoses for spinal cord compression?
Lumbago
Sciatica
Cauda equina syndrome
How can lumbago be differentiated from spinal cord compression?
Lumbago causes pain solely around the lower lumbar area, with no radiation
How will sciatica present?
With lower back pain spreading to the buttocks or lower limbs, depending on dermatome affected
What are lumbago and sciatica often caused by?
A disc herniation pressing on the exiting nerve
What is the result of the disc herniation pressing on the exiting nerve in lumbago and sciatica?
It produces LMN signs
What is cauda equina syndrome typically caused by?
Lumbar disc herniation, compressing the cauda equina
How does cauda equina syndrome present?
LMN signs
Bladder/bowel disturbances
What is the gold standard investigation for ASCC?
MRI of the whole spine
How quickly should an MRI of the whole spine be carried out in suspected ASCC?
Within a week if spinal mets are suggested
Within a day if the cord is believed to be compressed
Are routine bloods helpful in ASCC?
Yes, especially if the underlying cause is not apparent
What investigations should be done as a result of the high chance of surgical intervention if ASCC is present?
G&S and clotting screen
What is involved in the immediate management of ACSS?
High dose corticosteroids should be given immediately, alongside a PPI for gastric protection
What corticosteroid regime is typically given in ASCC?
Typically 16mg dexamethasome PO stat, then 8mg BD thereafter
What is the purpose of high dose corticosteroids in ASCC?
Improve patients prognosis
What should be done following imaging in ASCC?
Immediate referral to neurosurgery and an oncological opinion will be sought as required
What is the definitive treatment option for MSCC?
Surgical compression, if the patient is fit enough for surgery
What might be done alongside surgical decompression for MSCC?
Radiotherapy and chemotherapy
What does the use of radiotherapy and chemotherapy in MCSS depend on?
The sensitivity of the tumour
What does the prognosis of MCSS depend on?
The extent that the disease has progressed before decompression, as well as the underlying cause
What is one of the best indicators of prognosis in MCSS?
Mobility state at the time of treatment - 90% of ambulatory patients remain mobile, whereas only 1/3 of non-ambulatory patients at presentation will regain the ability walk
What is the survival rate for MSCC patient?
About 6 months after onset
Why is the survival rate of MCSS so short?
Due to the nature of metastatic disease, it is likely that the patient will be in an advanced phase of cancer if this is the underlying cause
