Spinal Cord Compression

Aetiology

Acute spinal cord compression

• Trauma
• High energy injury
• Particularly affects the mobile segments of the spine i.e. cervical

• Tumours - haemorrhage or collapse
• Extradural - usually metastasis e.g. lung, breast, prostate
• Intradural - extramedulary meningioma, schwannoma
• Intramedullary - astrocytoma, ependymoma

• Infection
• Epidural abscess - bloodborne staph, TB
• Post surgery/trauma

• Spontaneous haemorrhage
• Epidural, subdural, intramedullary
• Trauma, bleeding diathesis, anticoagulants, aterio-venous malformations

• Prolapsed intervertebral disc
• L4-L5 and L5-S1 are the most common levels for disc prolapse - both will cause sciatica
• Large disc herniations can cause cauda equina syndrome

Chronic spinal cord compression

• Degenerative disease, mainly spinal canal stenosis
• Osteophyte formation, bulging of intervertebral discs, facet joint hypertrophy, subluxation

• Tumours

• Rheumatoid arthritis

Clinical presentation

Symptoms

• Motor, sensory and autonomic dysfunction can occur

• Cervical spine lesions can produce quadriplegia

• Thoracic spine lesions produce paraplegia

• Lumbar spine lesions can affect L4, L5 and sacral nerve roots

• Sensory symptoms can include sensory loss and paraesthesia; light touch, proprioception and joint position sense are reduced
• The sensory level is usually 2-3 dermatome levels below the level of anatomical compression

Signs

• Upper motor neurone signs: increased tone, brisk reflexes, pyramidal/corticospinal pattern of weakness

• Pyramidal weakness below the level of the lesion
• Cervical: arms and legs
• Thoracolumbar: legs

Specific patterns of pathology

• Complete lesion - all motor and sensory modalities affected

• Sensory and motor level

• Initially a flaccid arreflex paralysis - 'spinal shock'

• Upper motor neurone signs appear later

• Ipsilateral motor level and dorsal column sensory level - loss of motor function, deep touch and position on ipsilateral side

• Contralateral spinothalamic sensory level - loss of pain, temperature and light touch on contralateral side

• Hyperflexion or extension injury to already stenotic neck

• Predominantly distal upper limb weakness

• 'Cape-like' spinothalamic sensory loss

• Lower limb power preserved

• Dorsal columns preserved

• Upper motor neurone signs tend to predominate

Investigations

• MRI is the imaging technique of choice

Management

Trauma

• Immbolise

• Investigate - X-ray/CT, MRI

• Decompress and stabilise - surgery, traction, external fixation

Metastatic cord compression

• Depends on patient and tumour

• Dexamethasone

• Chemo/radiotherapy

• Surgical decompression and stabilisation

Primary tumours

• Surgical excision

Infection

• Antimicrobial therapy

• Surgical drainage of abscess

• Stabilisation where required

Haemorrhage

• Reverse anticoagulation

• Surgical decompression

Degenerative disease

• Surgical decompression +/- stabilisation