spinal cord compression; compressive myelopathy

Etiology

• epidural compression by metastatic tumor
  • lung cancer
  • breast cancer
  • prostate cancer
  • multiple myeloma
  • renal cell carcinoma
  • germ cell tumor
• compression from local nodal involvement & tumor infiltration through intervertebral foramina
  • lymphoma, leukemia
• trauma
• epidural abscess
• epidural hematoma

Pathology

• thoracic compression (70%)
• lumbar compression (20%)
• cervical compression (10%)
• involvement of multiple non-contiguous levels (10-40%)

Clinical manifestations

• pain (90%)
  • localized spinal or radicular pain
  • pain may be aggravated by coughing, sneezing or straight-leg raising
  • cervical pain may radiate down arm
  • thoracic pain radiates around rib cage or abdominal wall
    • may be described as a compressing band bilateral around chest or abdomen
  • lumbar pain may radiate into the groin or down the leg
• fever & focal pain & tenderness suggest epidural abscess
• paresthesias
• sensory loss, especially perineal
• muscle weakness, motor deficits, paralysis
  • motor deficits at the time of diagnosis predicts neurologic outcome
• abnormal reflexes, arreflexia, Babinski sign
• autonomic manifestations
  • urinary incontinence
  • fecal incontinence
• clinical syndromes of acute spinal cord compression
  • transverse myelopathy
  • spinal shock
  • central cord syndrome
  • hemicord syndrome (Brown-Sequard syndrome)
  • conus medullaris syndrome
  • cauda equina syndrome
• upper motor neuron signs
  • spasticity, hyperreflexia, extensor plantar response
• occasionally lower motor neuron signs
  • atrophy, hyporeflexia

Radiology

• magnetic resonance imaging (MRI) with gadolinium contrast of entire spine
  • > 1 site of spinal cord compression is common
• plain radiograph of little value
• bone scan of little value

Differential diagnosis

• fever: epidural abscess
• anticoagulation: epidural hematoma
• cancer: metastases
• trauma: vertebral fracture
• elderly with chronic back &/or leg pain: spinal stenosis

Management

• acute spinal cord compression is a medical emergency
• establish diagnosis before neurologic deficits occur
  • avoid permanent disability
  • special case of epidural abscess
• dexamethasone immediately
  • initial: 10-100 mg IV
  • then: 4 mg IV QID
  • taper as indicated
  • of no benefit if due to hematoma
  • avoid if due to infection
• surgery
  • indications
    • surgical decompression
      • prior to radiation therapy for metastatic cancer* - < 65 years, single area of compression, paraplegia < 48 hours, predicted survival > 6 months - leukemia, lymphoma, multiple myeloma, germ cell tomors may be treated urgently with radiation therapy
    • spine instability
    • tolerance to spinal cord irradiation
    • progressive neurologic decline despite radiation
  • surgical decompression may have better outcomes
• radiation therapy to involved areas
  • leukemia, lymphoma, multiple myeloma, germ cell tomors
  • plasmacytoma, including spinal extradural solitary plasmacytoma
  • other radiosensitive tumors should have radiation therapy after surgery
• opiates for pain
• chemotherapy for sensitive tumors
  • lymphoma
  • breast cancer
• prognosis:
  • neurologic status is the most important predictor of prognosis in neoplastic spinal cord compression
    • ambulatory patients tend to remain ambulatory with treatment
    • nonambulatory patients generally remain nonambulatory

* except as per radiation therapy to involved areas

More general terms

• spinal cord injury (SCI)

Additional terms

• cauda equina syndrome
• spinal stenosis