Spinal Cord Compression
Dr. Wayne Hoskins
Spinal Cord Anatomy
• Medulla --> exiting
nerve roots
• Surrounded by
meninges: dura,
arachnoid, pia
• Ends at L1/2
• Protected by bony
vertebral column
Spinal Cord Function
• Transmits neural signals and contains
neural circuits that control reflexes
• Three major functions:
– Motor
– Sensory
– Reflex
Spinal Tracts
Causes of Compressions
Causes of Compressions
• Trauma - vertebral fracture
• Inter-vertebral disc / spinal stenosis
• Tumor: Lung, breast, prostate, RCC,
thyroid, lymphoma, MM
• Epidural abscess
UMNL vs. LMNL
Sign
UMNL
LMNL
Tone


Power
-->   

Atrophy
Mild due to disuse Yes
Fasciculation's No
Reflexes

Yes

Case
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76 yo F - LBP & lateral R>L leg pain
Insidious onset 2/12 ago
PMHx: Colon Ca 2008 - APR
Presented to ED: DVT excluded - D/C
Represents with worsening pain
Denies weakness, numbness,
parathesia, cauda equina Sx, fever
Red Flags
Fracture
Major trauma in elderly, osteopenic, on long term steroids
Infection
Constitutional symptoms: fever, chills, unexplained weight loss
Recent bacterial infection
Risk factors for infection: underlying disease process, immunosuppression, IVDU
Tumor
Age > 50 or <20
History of Ca
Constitutional symptoms such as weight loss
Pain at multiple sites
Pain worse at rest, at night, wakes at night
Failure to improve with treatment
Persists > 6 weeks
Significant neurological
deficit
Severe or progressive sensory alteration or weakness
Bladder or bowel dysfunction
Neurological deficit in in legs, arms, perineum
AAA
Age >60
Pulsating mass in abdomen
Absence of aggravating factors
Spondylo-arthritis
Age < 45, morning stiffness improved with exercise
Oligo-arthritis, polyarthritis, rash, diarrhea, eye symptoms
Exam & Ix
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Lumbar-pelvic pain on palpation
Normal neuro exam
SLR negative
FBE, CMP, LFT NAD
CEA 3.7
Lumbar-pelvic x-ray
Sclerosis in left
sacral alar
suspicious of
healing
insufficiency
fracture
NM Bone study & SPECT
Increased
uptake L>R
sacral alar
consistent with
arthritis
MRI
Metastatic SCC
Spinal cord or cauda equina compression by
direct pressure & /or induction of vertebral
collapse or instability by metastatic spread or
direct extension that threatens or causes
neurological disability
- 5-10% all Ca patients
- Initial manifestation in 20%
- Median survival 3-6/12
Early detection
• View as oncological emergency if:
- neuro symptoms: radicular pain, any
limb weakness, difficulty in walking,
sensory loss or bowel/bladder dysfn
- neuro signs of spinal cord or cauda
equina compression
Imaging
• Whole spine MRI: <1/52 to plan
definitive treatment and <24/24 if
neurological symptoms
– Sensitivity and specificity >90%
• CT only to assess stability, plan surgery,
biopsy guidance
- CT myelopgraphy if MRI contra
• Do not perform plain radiographs
Treatment
• Goals: palliative, pain control, preserve
or restore ambulation,neuro & stability
• Start definitive treatment ideally within
24/24 of Dx
• Carefully plan surgery: consider fitness,
prognosis, preferences
• Urgent <24/24 RT for definitive
treatment if unsuitable for surgery
Treatment
• Analgesia: Conventional by WHO pain relief
ladder, ?specialist pain care
• Bisphosphonates: myeloma or breast Ca and
prostate if analgesia has failed; not for others
• Corticosteroids: 16mg loading dexameth
- 16mg/d, over 5-7/7 after RT or surgery
- complications: sepsis, bowel perforation
• Biopsy & stage (no., sites, extent)
Treatment
• RT: if non-mechanical pain
• Vertebroplasty/kyphoplasty - consider if no
MSCC or instability &:
- mechanical pain resistant to analgesia
- vertebral body collapse
• Surgery: consider urgently if spinal instability,
mechanical pain resistant to analgesia
- external spinal support (halo, orthosis) if
unsuitable for surgery
Surgery
• RT: if non-mechanical pain
• Vertebroplasty/kyphoplasty - consider if no
MSCC or instability &:
- mechanical pain resistant to analgesia
- vertebral body collapse
• Surgery: consider urgently if spinal instability,
mechanical pain resistant to analgesia
- external spinal support (halo, orthosis) if
unsuitable for surgery
Radiotherapy
• Urgent <24/24 if definitive treatment or
unsuitable for surgery unless:
- tetraplegia or paraplegia >24/24 and pain
controlled; overall poor prognosis
• Fractionated RT definitive Tx if no neuro
impairment, pain or instability
• No pre-operative RT
• Post-operative RT offered when wound
healed
Thromboprophylaxis
• All patients thigh length TEDS and/or
intermittent pneumatic compression or
foot impulse devices
• High risk: LMWH and mechanical
thromboprophylaxis
CSM
• Natural history: slow deterioration in
stepwise fashion, with worsening
symptoms of gait abnormalities,
weakness, sensory changes and often
pain
• Dx: Hx, Exam, XR - CT/MRI to confirm
Management
• Minimal symptoms without hard
evidence of gait disturbance or
pathological reflexes warrant
nonoperative treatment
• Demonstrable myelopathy and spinal
cord compression are candidates for
operative intervention
Surgery
Anterior and
posterior
approaches
ACDF
Thank You
Diagnosis
• X-ray
• Preferably MRI urgently - whole spine if
cancer implicated
Treatment
• Dexamethasone - 16mg/d may reduce
edema around lesion
• Surgery - indicated in local compression
and if hope of regaining functions
Surgical Considerations
• Speed of onset
• Red flags