NEURO - Spinal cord compression

Question 1

(3) types of locations of compressing lesion in the spine

Answer 1

Extradural (80%)

Intradural / extramedullary (15%)

Intramedullary (5%)

Question 2

The most common pathological causes of spinal cord compression

Answer 2

–Tumour
•Primary, metastatic

–Degenerative
•Disc prolapse, osteoporosis, spondylosis

–Infection
•Vertebral body, disc space, extradural, intradural

–Haematoma
•Spontaneous, trauma, AVM

–Developmental
•Syrinx, AVM, arachnoid cyst

Question 3

Most common compressions of spinal cord

• extradural
• intradural, extramedullary
• intramedullary

Answer 3

–Extradural compression: by metastatic tumour, abscess or degenerative spinal disease

–Intradural, extramedullary compression: by a meningioma, schwannoma or myxopapillary ependymoma

–Intramedullary compression: by a glioma (astrocytoma or ependymoma) or a syrinx

Question 4

2 Px of compressions of spinal cord

Answer 4

–Pain

–Neurological deficit

Question 5

Describe “cervical myelopathy”

Answer 5

–Predominantly lower motor neuron signs in the upper limbs
–Spastic paraparesis (upper motor neuron) in the lower limbs

In an older patient with neck pain, slow symptom onset, no fever and no history of cancer, this is most likely to be due to degenerative cervical canal stenosis

Question 6

Px of lumbar spinal canal stenosis

Answer 6

sciatica and neurogenic claudication due to cauda equina compression

Question 7

Causes of spinal canal stenosis

Answer 7

–Spondylosis with hypertrophy and osteophytes of the facet joints
–Hypertrophy of ligamentum flavum
–Bulging or prolapsed intervertebral discs and associated osteophytes
–Excessive mobility
–Often on a background of a congenitally narrow canal

Question 8

Neurological symptoms in spinal canal stenosis result from:

Answer 8

–Direct pressure on the neural structures

–Ischaemia of the neural structures

Question 9

Rx of degenerative canal stenosis

Answer 9

•Conservative management may be indicated for
–Mild, non-progressive disease
–The very elderly (>80)
–Those unfit for surgery due to co-morbidities

•Surgical treatment indicated for moderate, severe or progressive disease

• posterior approach: laminectomy
• anterior approach: discectomy, vertebrectomy

Question 10

DDx of Intradural, extramedullary, well-defined lesion in a young patient

Answer 10

• Schwannoma
• Myxopapillary ependymoma
• Dermoid or epidermoid cyst
• Metastasis (rare)

Question 11

Describe sphincter disturbance

Answer 11

–Occurs with compression in any region, but particularly the conus medullaris and cauda equina
–Difficulty initiating urination is usually the first symptom followed be urinary retention or incontinence
–Subsequent constipation and faecal incontinence

Question 12

Common causative cancers of malignant spinal cord compression & most common spinal level affected

Answer 12

Lung, breast, prostate, kidney, lymphoma, myeloma

Thoracic spine

Question 13

Rx of malignant spinal cord compression

Answer 13

•Commence dexamethasone

–Palliation/symptom control only
•If death from primary cancer is imminent or if deficit has been present for more than a few days and is fixed

–Radiotherapy
•In radiosensitive tumours and only if neurological deficit is mild and non-progressive, without significant neural compression on imaging
•After surgical decompression

–Surgery

Question 14

Describe spinal abscess

• common site
• causes

Answer 14

thoraco-lumbar region

Haematogenous spread to disc/epidural space from distant infected site

Direct spread from adjacent infection (v. body, decubitus ulcer, paraspinal/psoas abscess)

Staph aureus most common (45-70%)

Question 15

Px of spinal abscess

Answer 15

–Severe local spinal pain
–Rapidly progressive neurological deficit
–Systemic features of infection

Spinal cord compression due to inflammatory swelling and pus
–Most commonly extradural

Rapid & irreversible neurological deterioration: cord ischaemia from thrombosis of arteries or veins

Question 16

Rx of spinal abscess

Answer 16

• Emergency surgical decompression

* Broad spectrum antibiotics until micro-organism isolated and sensitivities known