Spinal Cord Compression Flashcards
Why is prompt diagnosis and treatment for spinal cord compression essential?
Neurosurgical emergency
Avoid permanent neurological disability
What categories of lesions can compress the spinal cord and the cauda equina?
Extradural = 80% Intradural/extramedullary = 15% Intramedullary = 5%
What is the most common intradural lesion causing spinal cord compression?
Nerve root lesions
What is an intramedullary lesion?
Lesion from inside spinal cord itself
How can you tell if the image a T2 MRI?
CSF white
What are the most common pathological causes of spinal cord compression?
Tumour Degenerative - Disc prolapse - Osteoporosis - Spondylosis Infection - Vertebral body - Disc space - Extradural - Intradural Haematoma - Spontaneous - Trauma - AV malformation Developmental - Syrinx - AV malformation - Arachnoid cyst
What are the most common extradural causes of spinal cord compression?
Metastatic tumour
Abscess
Degenerative spinal disease
What are the most common intradural causes of spinal cord compression?
Meningioma
Schwannoma
Myxopapillary ependymoma
What are the most common intramedullary causes of spinal cord compression?
Glioma
Syrinx
What are the two major presenting features of spinal cord compression?
Pain
Neurological deficit
What does the order of symptom presentation in spinal cord compression suggest about the cause?
If presents with pain as 1st symptom, most likely extramedullary
- If pain slow, slow growing
If neurological deficits 1st, most likely intramedullary
If both present at same time, acutely, probably from outside and rapid
What structures are the source of pain in spinal cord compression?
Periosteum
Dura
Nerve roots
What structures are the source of neurological deficit in spinal cord compression?
Nerve roots
Spinal cord itself
What is the most likely diagnosis in
- Older patient
- Neck pain
- Slow symptom onset
- No fever
- No Hx of cancer
Degenerative cervical canal stenosis
What are the differential diagnoses for degenerative canal stenosis?
Spinal tumour - Primary - Metastatic Spinal infection Inflammatory/neurodegenerative disease - MS - Motor neuron disease - Syringomyelia - Subacute combined degeneration of spinal cord
Where are the most clinically significant places that degenerative spinal canal stenosis can occur?
Cervical spine
Lumbar spine
What symptoms does degenerative spinal cervical canal stenosis cause?
Cord compression > cervical myelopathy
What symptoms does degenerative spinal lumbar canal stenosis cause?
Cauda equina compression > sciatica and neurogenic claudication
What causes degenerative spinal canal stenosis?
Spondylosis with hypertrophy and osteophytes of facet joints
Hypertrophy of ligamentum flavum/posterior spinal ligament
Bulging/prolapsed intervertebral discs and associated osteophytes
Excessive mobility
Often on background of congenitally narrow canal
What are the neurological symptoms in degenerative spinal canal stenosis due to?
Direct pressure on neural structures
Ischaemia of neural structures
What damage does degenerative spinal canal stenosis cause?
Degeneration and loss of nerve cells Spinal cord cavitation Glial cell proliferation Demyelination Wallerian degeneration of tracts above and below level of compression
When is conservative management of degenerative spinal canal stenosis indicated?
Mild, non-progressive disease
Very elderly
Unfit for surgery due to comorbidities
When is surgical treatment indicated for degenerative canal stenosis?
Moderate/severe/progressive disease
Why is surgical treatment indicated for degenerative canal stenosis?
To stop further disability - presenting neurological deficits may be irreversible
What can be removed in surgery for degenerative spinal canal stenosis?
Lamina = laminectomy
Disc = discectomy
Vertebral body = vertebrectomy
What is the gold standard investigation for cauda equina compression?
MRI of lumbosacral spine
What are the differential diagnoses for an intradural, extramedullary, well-defined lesion in a young patient?
Schwannoma
Myxopapillary ependymoma
Dermoid/epidermoid cyst
Metastasis - rare
What sort of pain can occur in spinal cord compression?
Diffuse, dull, burning
Sciatica in lower limbs
Brachalgia in upper limbs
“Girdle” pain radiating around chest wall
What are the sensory levels on the trunk?
C4 = right above T2 T2 = sternal angle T4 = nipple level T7 = xiphisternum T10 = umbilicus L1 = inguinal region
What is Brown-Sequard syndrome?
Happens when only 1/2 of cord involved Contralateral impairment of - Pain - Temperature sensation Ipsilateral - Weakness - Impairment of - Proprioception - Vibration - Light touch
What is the sensory disturbance in intrinsic lesions of the central spinal cord and syringomyelia?
Cape-like loss of pain and temperature
What is a syrinx?
Dilatation of central canal
What is syringomyelia?
Cord compression due to syrinx
What is the sensory disturbance in lesions of the cauda equina and conus medullaris?
Saddle anaesthesia
At what spinal level is the conus medullaris?
L1/L2
At what spinal level do you not get upper motor neuron signs?
Below L2
When does sphincter disturbance occur?
Compression in any region
Particularly compression of
- Conus medullaris
- Cauda equina
What symptoms does a sphincter disturbance cause?
Urinary hesitancy > urinary retention > urinary incontinence > constipation > faecal incontinence
What are the most common causative cancers of malignant spinal cord compression?
Lung carcinoma Breast carcinoma Prostate carcinoma Renal carcinoma Lymphoma Myeloma
What spinal level is most commonly affected by metastasis?
Thoracic
What are the principles of treatment of malignant spinal cord compression?
Urgent Ix and Rx to avoid severe permanent disability
- Start dexamethasone
Prompt decision regarding treatment modality
- Palliation/symptom control only
- Radiotherapy
- Surgery
In which region of the spine is a spinal abscess most common?
Thoraco-lumbar region
What can cause a spinal abscess?
Haematogenous spread to - Disc - Epidural space Direct spread from adjacent infection - Vertebral body - Decubitus ulcer - Paraspinal abscess - Psoas abscess
What is the most common causative organism of spinal abscesses?
Staph aureus
What is the presentation of a spinal abscess?
Severe local spinal pain
Rapidly progressive neurological deficit
Systemic features of infection
What causes spinal cord compression with a spinal abscess?
Inflammatory swelling
Pus
What causes spinal cord ischaemia with a spinal abscess?
Thrombosis of arteries and veins
What are the principles of treatment of a spinal abscess?
Emergency Ix and transfer for neurosurgical assessment
Emergency surgical decompression
Broad spectrum Abx until micro-organism isolated and sensitivities known
What are yellow flags?
Psychosocial reasons that prevent improvement of back pain
