Ch. 15 - Spinal cord compression Flashcards
What are the 3 types of spinal cord compression?
Extradural, intradural/extramedullary, intramedullary
Most common intrathecal tumor
Schwannoma (neurofibroma)
Most common causes of malignant spinal cord compression
Lung CA > breast CA > prostate CA > kidney CA > lymphoma > myeloma
What is the most common type of spinal cord compression?
Extradural (80%) - most from metastases
What are the most common causes of extradural spinal cord compression?
Metastatic tumor, extradural abscess
What are the most common causes of intradural/extramedullary spinal cord compression?
Schwannoma > meningioma
What are the most common causes of intramedullary spinal cord compression?
Glioma (ependymoma > astrocytoma), syrinx
What 2 major presenting features are the hallmarks of spinal cord compression?
- Pain (common early feature)
- Neurologic deficit (esp. sensory level)
Describe ‘girdle’ pain
Pain radiating around chest wall 2/2 thoracic cord compression, with involvement of thoracic nerve roots
Lhermitte’s sign
Flexion or extension of neck causing ‘electric shock’ or tingling radiating down through body to extremities; associated with cervical cord involvement
What do the neurological features of spinal cord compression consist of?
Progressive weakness, sensory disturbance, sphincter disturbance
Describe the pattern of weakness in spinal cord compression
‘Pyramidal’ pattern with flexor movements most severely affected and extensor movements (e.g. hip extension, knee extension, plantar flexion) preserved
What nerve root weakness will be demonstrated by a mass below T1 in the thoracic area?
NO clinically demonstrable weakness!
What pattern of weakness is seen with conus medullaris involvement? Cauda equina compression?
Conus medullaris – mixture of LMN and UMN signs
Cauda equina – LMN signs
At what level does the T4 dermatome lie? T7? T10?
T4 – nipples
T7 – xiphisternum
T10 – umbilicus
Brown-Sequard syndrome
Hemisection causing contralateral impairment of pain and temperature sensation, with ipsilateral pyramidal weakness and impairment of joint position sense, vibration, and fine touch
Clinical signs of sphincter disturbance
Enlarged, palpable bladder (2/2 urinary retention), diminished perianal sensation, and decreased anal tone
Best imaging modality for spinal cord compression
MRI
Tx of spinal cord compression
Urgent decompression except for some malignant tumors (high-dose steroids and radiotherapy)
Surgical tx options for malignant spinal cord compression
Decompressive laminectomy (posterior approach) OR vertebrectomy and fusion (anterior approach)
Why are glucocorticoids often used prior to spinal cord decompression?
Reduce local edema
A poor prognosis for neurological recovery is suggested by how many hours of complete paraplegia?
36 hours
‘Dumb-bell’ tumor
Intrathecal tumor (e.g. schwannoma) extending through intervertebral foramen
Population most commonly affected by spinal meningiomas
Middle-aged or elderly with marked FEMALE predominance
Most common site for spinal meningioma
Thoracic region
Most common site for ependymoma
Filum terminale leading to compression of cauda equina
Cauda equina compression sxs
Low back and leg pain, progressive leg weakness, saddle anesthesia, sphincter disturbance
Spinal cord ependymoma tx? Astrocystoma?
Ependymoma – macroscopic excision
Astrocytoma – NOT resectable; radiotherapy only
Central posterior cervical disc herniation presentation? Most common levels?
Sudden onset of severe neck pain with rapidly progressive paralysis (LMN features at level of compression and UMN below); usually C5/6 or C6/7
Why is the low thoracic region considered a ‘watershed’ area?
T8-L2 often largely supplied by a single unilateral radicular vessel (artery of Adamkiewicz); can contribute to disc degeneration
Etiology of spinal epidural abscess?
Hematogenous spread from distant or occult infection OR direct spread from adjacent intervertebral disc or vertebral column (esp. pedicle or neural arch)
Most common site of primary infection causing epidural spinal abscess?
Skin/soft tissue > respiratory tract
Most common causative organism of epidural spinal abscess?
Staphylococcus aureus >> Streptococcus sp.
Tx of epidural abscess?
Urgent laminectomy + complete evacuation of abscess + high-dose abx
Pott’s disease
Spinal tuberculosis (osteomyelitis) affecting 2 or more adjacent vertebral bodies with destruction of intervening disc space
Spinal AVMs more common in males or females?
Males 4x more likely than females
‘Steal’ phenomenon seen with spinal AVMs
AVM steals blood from normal neural tissue causing local spinal cord hypoxia
Subarachnoid hemorrhage associated with sudden severe back pain. What is the diagnosis?
Spinal AVM (15% of patients present with subarachnoid hemorrhage)
What causes cervical myelopathy?
Cervical cord compression 2/2 narrow cervical vertebral canal
DDx for cervical myelopathy
Spinal tumor, multiple sclerosis, motor neuron disease, syringomyelia, subacute combined degeneration of cord
Identify the lesion
Pott’s disease
Identify the lesion
Epidural abscess
Spinal column region most commonly affected by mets?
Thoracic
Is meningitis more common with epidural or subdural abscesses?
Subdural
