Spinal cord compression (incl. cauda equina) Flashcards
Describe the dermatomes of the lower limbs.
What are the most common causes of spinal cord compression?
- Trauma - leading cause of acute SCC (e.g. falls, RTA)
- Vertebral compression fractures - weakened bone fractures with low-level trauma
- Intervertebral disc disease
- Tumours
- Infection - discitis, TB, epidural abscess
How does intervertebral disc disease cause spinal cord compression?
Disc herniation = rupture of nucleus pulposus –> through fibres of annulus fibrosis –> into intervertebral space –> compresses nerve roots
Symptoms = paraesthesia, pain, power reduced indicative of lumbar radiculopathy/sciatica
List 3 types of tumours which can cause SCC.
- Primary sarcoma
- CNS tumours e.g. ependymoma, meningioma, glioma
- Multiple myeloma
- Metastatic breast, prostate, renal, small cell lung cancers
List 3 causes of acute compression of cauda equina.
- Bony metastasis
- Myeloma
- Epidural abscess
- Disc prolapse
- Epidural haematoma
- Primary sacral tumour e.g. chordoma
What is TB causing spinal compression called?
Pott’s disease of the spine
List 5 red flag symptoms for lower back pain, suggesting SCC.
- Bilateral sciatica
- Bladder dysfunction
- Perineal paraesthesia
- Gait disturbance
- Lower limb weakness
- Erectile dysfunction
What are the motor, sensory and autonomic symptoms of incomplete spinal cord compression?
Sensory - altered sensation below certain level/ hemisensory loss
Motor - hemiplegia/paresis (sparing face) [or para or tetra]
Autonomic
- constipation
- urinary retention
- dizziness (due to hypotension)
- cold, shivering, drowsiness (due to hypothermia)
- ED
- abdominal pain and distension (due to ileud)
- syncope (due to bradycardia)
PAIN is also common - often sharp, radicular pain.
Which 4 tumours commonly metastasise to the spine and can contribute to SCC?
- Small cell lung cancer
- Non-small cell lung cancer
- Breast cancer
- Prostate cancer
- Renal cancer
What are the signs and symptoms of cauda equina syndrome? What is a common cause of cauda equina syndrome?
Commonly due to disc compression and stenosis of the spinal canal.
Symptoms:
- Low back pain
- Bilateral sciatica
- Bladder retention/incontinence
- Saddle anaesthesia (perineal)
- Leg weakness
Signs:
- Sensory loss in lumbosacral distribution
- Reduced tone in legs (flaccid)
- Reduced power in legs
- Reduced reflexes (!!)
- Anal sphincter tone loss
List 2 differences between the examination of cauda equina compression and cord compression.
BOTH cause power loss and sensory loss
- Cauda equina causes flaccid paralysis and loss of reflexes
- SCC causes spastic paralysis and brisk reflexes
What are the early signs of spinal shock and how do these progress in SCC?
Spinal shock - areflexia and hyporeflexia
This is later replaced by increased tone, hyper-reflexia and +ve Babinski
NB: bilateral signs are uncommon in disc herniation.
What causes Brown-Sequard’s syndrome? What are the clinical signs/symptoms?
BSS = hemisection lesion of the spinal cord and most commonly seen after trauma
Signs/symptoms:
- Ipsilateral below level of lesion:
- segmental anaesthesia
- paralysis
- loss of vibration
- loss of proprioception
- hyper reflexia
- Contralateral below level of lesion:
- loss of pain
- loss of temperature sensation
How is cauda equina syndrome managed?
Urgent spinal surgical admission same day - must be done within hours and even waiting until the next day may allow irreversible damage and paralysis to occur.
What is the difference between anterior and posterior cord syndrome?
Anterior cord syndrome - anterior spinal tracts affected, including vestibulospinal tract –> loss of pain/temperature sensation + paralysis below level of lesion (spares touch, proprioception, vibration)
Posterior cord syndrome (rare) - posterior spinal tracts affected usually due to posterior spinal artery occlusion –> loss of pain, position, vibration below level of lesion.
What investigations would you do for SCC?
MRI/CT (1st line) - anteroposterior, lateral and special views required to show alignment of bones. Gandolinum-enhanced MRI can exclude infection including osteomyelitis/epidural abscess.
Plain spine x-ray - helpful in trauma combined with CT
Other:
- Clotting studies - pre-op
- FBC - pre-op
- Electrolytes
- CSF analysis - not diagnostic but may be useful for excluding non-traumatic causes of SCI e.g. transverse myelitis, HIV myelopathy, infection.
- ESR/CRP
Define spinal cord compression.
Spinal cord compression occurs when there is compression of the spinal cord or cauda equina at any level secondary to the effects of a malignancy.
What are the causes of spinal cord compression?
- Trauma e.g. car accident, falls, diving
- Vertebral compression fracture
- Intervertebral disc herniation
- rupture of the nucleus pulposus in the intervertebral space, through the fibres of the annulus fibrosis
- Primary or secondary metastatic spinal tumour
- Infection e.g. discitis, TB (Pott’s), epidural abscess
This can include metastatic infiltration to the vertebral column causing instability or pathological fractures as well as direct pressure from malignancy to the spinal cord.
How common is spinal cord compression?
Affects 15% of cancer patients
More common in lung, prostate and breast cancers
But 20% occurs in those without cancer diagnosis
What are the signs and symptoms of spinal cord compression?
- Back pain (predates neurological symptoms by 7 weeks)
- usually in thoracic region
- worse when lying flat or coughing/straining
- worse at night
- continuous in nature
- Numbness, sensory disturbance
- Motor weakness (late)
- Bladder and bowel dysfunction (late)
What examination should be done in suspected spinal compression?
- Give analgesia as full examination of upper and lower limbs will be needed.
- PR exam
- Bladder scan (pre and post void) for signs of urinary retention
What investigations should be done to diagnose spinal compression?
-
MRI whole spine - GOLD STANDARD and must be done within 24hrs
- CT scan if MRI is contraindicated
What is the management of spinal cord compression?
-
Loading dose dexamethasone 16mg immediately - unless contraindications e.g. 10mg stat then 16mg daily with PPI cover.
- contraindicated if there is suspicion of lymphoma
- Analgesia
- VTE prophylaxis (cancer increases risk)
- Inform local oncology centre + discuss possible transfer of care
- Refer to neurosurgery
Other management options:
- Radiotherapy
- Surgery
- Nurse patent in neutral alignment, insert catheter, bisphosphonates in all cancer patients with bone mets
Where does the spinal cord end?
From foramen magnum to L1/L2
NB: umbilicus is L3/4, PSIS is S2
What are the most common levels of disc prolapse?
L4-L5 and L5-S1
Large disc herniations can cause cauda equina syndrome
Define cauda equina syndrome.
Compression of the nerve roots caudal to the level of the spinal cord, causing one or more of the following:
- bladder and/or bowel dysfunction,
- reduced sensation in the saddle (perineal) area,
- and sexual dysfunction,
- with possible neurological deficit in the lower limb (motor/sensory loss, reflex change)
What cauda equina red flags should have early referral according to NICE CKS?
- Bilateral sciatica
- Severe or progressive bilateral neurological deficit of the legs, such as major motor weakness with knee extension, ankle eversion, or foot dorsiflexion
- Difficulty initiating micturition or impaired sensation of urinary flow, if untreated this may lead to irreversible urinary retention with overflow urinary incontinence
- Loss of sensation of rectal fullness, if untreated this may lead to irreversible faecal incontinence
- Perianal, perineal or genital sensory loss (saddle anaesthesia or paraesthesia)
- Laxity of the anal sphincter.
How common is CES?
CES is reported in approximately 0.04% of all patients presenting with low back pain.
Occurs in approximately 2% of cases of herniated lumbar discs
What is the most common cause of CES? What are the other causes of CES?
Most common: compression from lumbar herniation at L4/L5, L5/S1
- Tumours - bony mets or sacral tumour e.g. chondrome
- Myeloma
- Trauma –> disc prolapse
- Infection e.g. epidural abscess
- Congenital
- Spondylolisthesis
- Late stage ankylosing spondylitis
- Postoperative epidural haematoma
What are the clinical features of CES?
- Usually sudden onset within hours-days
- Low back pain
- Sensory abnormality (may be unilateral)
- Usually asymmetrical weakness with loss of reflexes
- Bowel/bladder dysfunction
- Saddle and perineal anaesthesia
- Urinary dysfunction e.g. retention, difficulty starting/stopping
- Faecal incontinence and constipation
- Erectile dysfunction
Investigations done as for spinal cord compression.
What is the management of CES?
- Refer immediately to neurosurgery - arrange urgent spinal admission that day
- Must be done same day as waiting until next day may allow irreversible damage and paralysis to occur
- Surgery - to decompress or for lesion debulking
- Radiotherapy - if surgery cannot be performed
- Analgesia
What are some differentials for a spastic paraparesis?
demyelination
MND
cerebral tumour
syrinx (syringomyelia) - cysts form within the spinal cord
subacute combined cord degeneration
Which signs differentiate cord compression from cauda equina?
Cauda equina compression causes flaccid paralysis with loss of reflexes.
Cord compression usually causes spastic paralysis with brisk reflexes.
Both cause sensory and power loss.
