Spinal cord compression (N) Flashcards
Define spinal cord compression.
An injury to the spinal cord resulting from processes that compress or displace arterial, venous and CSF spaces, as well as the cord itself
What are some causes of spinal cord compression? (6)
- infection - discitis, TB, epidural abscess
- trauma
- vertebral compression fractures - low energy trauma in patients with osteoporosis/osteomyelitis/elderly
- vertebral metastases - lung, breast, prostate, renal
- tumours - primary sarcoma, CNS tumours, multiple myeloma
- intervertebral disc disease - rupture of the nucleus pulposus in the intervertebral space, through the fibres of the annulus fibrosis
What infections can cause spinal cord compression? (3)
By external pressure or by direct involvement of the cord:
- discitis
- TB (Pott’s disease of the spine)
- epidural abscess
What are vertebral compression fractures (spinal cord compression)?
Low energy trauma in patients with weakened bone e.g. osteoporosis/osteomyelitis/elderly
Which cancers can cause vertebral metastases (spinal cord compression)? (4)
- lung
- breast
- prostate
- renal
What is intervertebral disc disease (spinal cord compression)?
- rupture of the nucleus pulposus in the intervertebral space, through the fibres of the annulus fibrosis
- herniation may cause 1+ fragments of the nucleus pulposus to compress/irritate adjacent nerve roots
- Sx of paraesthesia, pain and weakness are indicative of lumbar radiculopathy or sciatica
- MRI shows evidence of disc protrusion or extrusion, nerve root impingement, or thecal sac compression
What is the most common cause of spinal cord compression?
Metastatic spinal cord compression
Which causes of spinal cord compression are more common in acute cases? (2)
- trauma
- disc herniation
Which causes of spinal cord compression are more common in chronic cases? (3)
- malignancy
- osteoporosis
- osteomyelitis
What are the most common causes of spinal cord compression by age group? (3)
- 16-30y = trauma
- 30-50y = herniation (disc disease)
- 40-75y = malignancy
Define cauda equina syndrome (SCC).
Lumbosacral nerve roots that extend below the spinal cord are compressed
What is cauda equina syndrome (SCC) commonly caused by?
Disc herniation - L4/L5 or L5/S1
What are the clinical features of cauda equina syndrome (SCC)? (6)
- decreased reflexes
- saddle anaesthesia
- faecal incontinence
- urinary incontinence
- bilateral sciatica - leg weakness
- decreased anal tone
How do we investigate and treat cauda equina syndrome (SCC)?
Urgent MRI spine and then possible surgical decompression
What type of condition is acute spinal cord compression?
Medical emergency - prevent irreversible spinal cord injury and long term disability
What are the clinical features of spinal cord compression? (6)
- back pain - earliest and most common Sx
- paraesthesia or numbness/sensory loss AT level of lesion
- weakness or paralysis bilaterally BELOW affected level of spinal cord
- loss of tone BELOW affected level of spinal cord
- bladder/bowel dysfunction - urinary/faecal incontinence
- hyperreflexia
What is a red flag feature of back pain for a tumour or growth in spinal cord compression?
Back pain worse when lying down or coughing
Where do we see UMN vs LMN signs in spinal cord compression?
- UMN signs below level of lesion
- LMN signs at level of lesion
Where is paraesthesia/numbness/sensory loss seen in spinal cord compression?
At level of lesion
Where is weakness/paralysis seen in spinal cord compression?
Bilaterally below affected level of SC
Where is loss of tone seen in spinal cord compression?
Below affected level of SC
What might we see in central cord syndrome (spinal cord compression)?
(Hyperextension + cervical spondylosis) - greater loss of UL function vs LL, including vestibulospinal tract
What might we see in Brown-Sequard syndrome (spinal cord compression), and posterior cord syndrome?
- (hemisection) - unilateral spastic paralysis ipsilaterally
- as well as ipsilateral loss of vibration and proprioception
- with pain and temperature being lost from contralateral side beginning 1/2 segments below lesion
What might we see in anterior cord syndrome (spinal cord compression)?
- loss of motor function below level of injury
- loss of sensation carried by anterior columns of SC (pain and temperature)
- preservation of sensation carried by posterior columns of SC (fine touch and proprioception)
What are some risk factors for spinal cord compression? (4)
- Hx of trauma including MVA, and high-risk occupation or sports
- osteoporosis
- IVDU
- immunosuppression
What are the first-line investigations for spinal cord compression? (4)
- MRI spine
- gadolinium-enhanced MRI spine
- plain spine XR
- CT spine
What is the first-line investigation for spinal cord compression?
MRI of whole spine within 24h of presentation - may see disc displacement or mass effect
What may we see on MRI whole spine in spinal cord compression? (4)
- disc displacement
- mass effect
- epidural enhancement
- T2 cord signal
What might we see on spine XR in spinal cord compression? (4)
- decreased disc space height (disc compression)
- tumour/infection - loss of bony detail
- trauma - misalignment of vertebral elements
- infection - loss of end-plate definition
What are some differential diagnoses for spinal cord compression? (9)
- transverse myelitis
- Guillain-Barre syndrome - Hx gastroenteritis (C. jejuni) or influenza-like illness, ascending paralysis
- HIV-related myelopathy
- ALS (UMN&LMN, muscle stiffness and atrophy, hyperreflexia)
- MS
- diabetic neuropathy
- peripheral neuropathy
- polymyositis
- hereditary muscular dystrophy
How do we prevent VTE in spinal cord compression? (2)
- enoxaparin (LMWH)
- compression stockings
How do we manage traumatic spinal cord compression? (3)
- immobilisation (cervical collar or backboard/head strap)
- decompressive surgery (/stabilisation surgery)
- IV corticosteroids (e.g. dexamethasone)
How do we manage cauda equina syndrome (intervertebral disc compression)?
Decompressive laminectomy
How do we manage malignancy causing spinal cord compression?
High-dose oral dexamethasone
Surgery
Radiation therapy
How do we manage an epidural abscess (spinal cord compression)?
Vancomycin, metronidazole, cefotaxime and surgery
What are some complications of spinal cord compression? (4+3)
- pressure ulcers
- UTI
- DVT
- PEs
- (discectomy-related complications)
- (post-operative autonomic complications)
- (MRSA infections)
Describe the prognosis of spinal cord compression.
Depends on cause - patient can live with SCC but livelihood may be affected
