Acute spinal cord compression

Neoplastic disease
• Most common presentation is metastatic lesion(lung/prostate/breast > renal/gastrointestinal/lymphoma)

Mechanical/structural abnormalities
• Traumatic/bony injury
• Osteoporosis/pathological fracture
• Degenerative joint disease
• Postsurgical complication

Infectious causes
• Extradural spinal abscess (IVDU, HIV, tuberculosis, immunosuppression)
• Diskitis/osteomyelitis

Vascular causes
– Ischemic
– Hemorrhagic (anticoagulation)

Inflammatory disease
– Rheumatoid arthritis (C1/2 dislocation)

Presentation

Classic presentation

Neck or back pain
- May be acute, subacute, or chronic in development.
- May be associated with symptoms of the underlying disease process (e.g., fever).
Neurological signs and symptoms
- Associated with limb weakness/paresthesias in more advanced cases.
- Neurogenic bladder and/or bowel.
- Autonomic dysfunction is expected if the lesion is cervical/thoracic in origin.
- Gait abnormality.

Critical presentation

Spinal shock
- Characterized by a loss of spinal cord function below the level of the lesion.
- Cervical and thoracic level lesions may be associated with respiratory compromise.
- Results in a disruption of sympathetic innervation causing unopposed parasympathetic tone, which may also cause hypotension and bradyarrhythmias (neurogenic shock).
- Flaccid paralysis, anesthesia distal to the lesion, and loss of bladder/bowel control are characteristic.
- Priapism may also be present, caused by loss of sympathetic innervation below the level of the lesion.

Diagnosis and evaluation

The diagnosis of acute spinal cord compression is suggested by history and physical examination, and confirmed by radiography or surgical intervention. Clinical presentations may vary depending on the level of neurological injury.
CBC, ESR, CRP, chemistries, venous lactate.
Coagulation studies, liver function tests.
Urinalysis, ± beta-hCG.
ECG, chest radiography.
Spinal imaging:
- Plain radiographic films may show bony destruction in the case of infectious or metastatic disease, or fracture in the setting of trauma. However, plain films may be falsely negative in up to 20% of cases.
- CT scan of the spine provides improved delineation of bony structures.
- Emergent spine MRI: MRI is preferred over CT because it can better evaluate soft tissue structures such as the spinal cord and ligamentous pathology.
- CT myelography is useful for identifying spinal canal compromise in those patients unable to undergo MRI. However, it does not provide distinction between the various soft tissue lesions such as hematoma, epidural abscess, etc.