Acute spinal cord compression Flashcards
What is spinal cord compression?
processes that compress or displace arterial, venous and cerebropsinal fluid spaces, as well as the cord itself
What is the most common aetiology of acute spinal cord compression?
metastatic spinal cord compression
What are 6 key clinical features of acute spinal cord compression?
- Acute upper motor neuron signs below level of lesion
- Sensory disturbance below the level of the lesion
- Proprioception impairment below level
- Deep and localised back pain is ofen also present
- Stabbing radicular sensory disturbance at level of the lesion
- Bladder and bowel involvement commonly seen
What are 5 upper motor neuron signs?
- Hyperreflexia
- Hypertonia/ spastic
- No fasciculations
- No atrophy
- Positive Babinski sign (aka upgoing plantar)
What are 5 lower motor neuron signs?
- Hyporeflexia
- Decreased/ flaccid tone
- Fasciculations
- Severe atrophy
- Absent Babinski’s sign
What are 7 causes of acute spinal cord compression?
- Trauma
- Neoplasia
- Infection (especially TB in at-risk patients)
- Disc prolapse
- Epidural haematoma
- Inflammatory: RA or ankylosing spondylitis
- Degenerative: ligamentum flavum hypertrophy or osteophyte formation
What proportion of cancer patients suffer from acute spinal cord compression?
5-10%
What investigation is urgently needed for patients with clinical features suggestive of spinal cord compression or cauda equina syndrome?
urgent WHOLE spine MRI
What is the aim for the time frame of management of acute spinal cord compression / cauda equina sndrome?
aim to surgically decompress within 48h
What intervention should be carried out when malignancy is demonstrated as the cause of acute spinal cord compression on MRI?
administration of dexamethasone 16mg daily in divided doses + PPI cover
In neoplastic spinal cord compression, what is the commonest source of the compressive mass?
extradural compression: usually vertebral body metastases
What are 3 types of cancer in which metastatic spinal cord compression is most common?
- Breast
- Prostate
- Lung
What are 2 things that can cause back pain to worsen if the cause is metastatic compression?
- Worse on lying down
- Coughing
What is the earliest and most common symptom of neoplastic spinal cord compression?
back pain
What sensory changes are likely to occur with spinal cord compression?
sensory loss and numbness
What is the pattern of weakness with acute spinal cord compression?
Lower limb weakness
How does whether signs are UMN or LMN in spinal cord compression depend on the level of the lesion?
- if above L1, usually UMN in legs, sensory level
- if below L1, usually cause LMN signs in legs and perianal numbness
How are tendon reflexes affected in relation to the level of spinal cord compression?
Lesions below the level are increased, but absent at level of lesion
What are 2 aspects of the management of neoplastic spinal cord compression?
- High-dose oral dexamethasone
- Urgent oncological assessment for consideration of radiotherapy or surgery
What are 2 examples of traumatic causes of acute spinal cord compression?
- Vertebral fracture
- Facet joint dislocation
Why is it relatively rare that disc prolapses cause spinal cord compression?
usually lumbar disc herniation causes compression of the cauda equina inferior to the spinal cord
How can inflammatory and degenerative conditions cause greater risk of developing acute spinal cord compression?
can predispose to a narrowed cord canal
What are 2 examples of inflammatory conditions which can predispose to acute spinal cord compression?
- Rheumatoid arthritis
- Ankylosing spondylitis
What are 2 examples of degenerative conditions that can predispose to acute spinal cord compression?
- Ligamentum flavum hypertrophy
- Osteophyte formation
Why is there hyperreflexia below the level of the lesion but absent reflexes at the level of the lesion?
the lower motor neurone within the ventral horn is compressed, so producing a lower motor neurone deficit
What are late stage features of acute spinal cord compression?
autonomic involvement e.g. bowel incontinence/constipation, urinary retention
also evidence of underlying cause e.g. malignant features: weight loss, tiredness
What are 3 key differentials for acute spinal cord compression?
- Lumbago: pain in lower back
- Sciatica
- Cauda equina syndrome
What are the features of lumbago that differentiate it from acute spinal cord compression?
causes pain solely aroun lower lumbar area with no radiation
What are the features of cauda equina syndrome that differentiate it from acute spinal cord compression?
typically caused by lumbar disc herniation; also presents with LMN signs and bladder/bowel disturbances
What are the features of sciatica that differentiate it from acute spinal cord compression?
lower back pain, spreading to the buttocks or lower limbs, depending on the dermatome affected
often caused by disc herniation pressing on exiting nerve, producing LMN signs
What are 2 types of investigations that can be performed for suspected ASCC?
- MRI of whole spine
- Routine blood tests - to help determine cause, and group & save + clotting screen as surgical intervention highly likely
Within what time frame should the whole spine MRI be carried out for suspected ASCC and what does it depend on?
- if suspected due to spinal metastases: within a week
- if believe cord is compressed: within a day
What are 2 groups that patients may need referral to for suspected ASCC?
- immediate referral to neurosurgery
- oncological opinion sough as required
What is the definitive treatment for metastatic spinal cord compression?
surgery
In addition to definitive surgery, what other treatments are available for the management of MSCC?
radiotherapy and chemotherapy may be started concurrently alongside surgery - depending on sensitivity of the tumour
What does the prognosis of MSCC depend on?
extent that disease has progressed before decompression and underlying cause; also mobility state at time of treatment
What is the survival rate for MSCC patients?
typically approximately 6 months after the onset
