Spinal Cord Compression

Treat suspected spinal cord or cauda equina compression as a time-sensitive syndrome rather than a diagnosis. Immediate concern is warranted for new focal or radicular spinal pain with progressive weakness, gait disturbance, sensory change, urinary retention or incontinence, fecal dysfunction, or a new sensory level. In cancer, back pain is the most common presenting symptom of metastatic spinal cord compression (MSCC), and motor deficits or sphincter dysfunction usually indicate more advanced disease.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

Cancer history substantially raises the pretest probability, but compression may be the first manifestation of malignancy. In patients without known cancer, symptoms suggesting compression plus constitutional features or otherwise unexplained persistent axial pain should prompt urgent investigation for malignancy as well as nonmalignant causes.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

Perform and document a focused neurologic examination before treatment when this does not delay stabilization: limb power, tone, reflexes, plantar responses, sensory level, gait when safe, perineal sensation, anal tone when clinically indicated, and postvoid residual when cauda equina dysfunction is suspected. A normal plain radiograph or absence of fever does not exclude epidural tumor, abscess, hematoma, or compressive disc disease.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

MRI of the whole spine with gadolinium is the preferred study for suspected MSCC because noncontiguous epidural disease can occur. For suspected MSCC, guidance supports MRI as soon as possible and within 24 hours; whole-spine sagittal T1 and T2 sequences with axial imaging through abnormalities help define metastases, epidural disease, and degree of neural compression.BMJ+1BMJMalignant spinal cord compression - Symptoms, diagnosis and treatment | BMJ Best Practicenice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

Use CT myelography when MRI is contraindicated or unavailable. CT is useful for vertebral destruction, collapse, retropulsion, and operative planning but is less sensitive than MRI for epidural soft tissue and cord pathology. Plain radiographs are inadequate to diagnose cord compression.PubMed+1PubMedSpinal Cord Compression - StatPearls - NCBI Bookshelfnice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

For suspected spinal epidural abscess, obtain blood cultures and inflammatory markers while arranging MRI, but do not let laboratory testing delay imaging or surgical evaluation in a patient with neurologic deficit. Leukocytosis is absent in a substantial minority of cases; in one diagnostic study, ESR greater than 20 mm/hour plus one or more risk factors had high sensitivity but limited specificity for epidural abscess.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

MSCC most often arises from vertebral metastasis extending into the epidural space or from vertebral collapse. Thoracic involvement is most common. Pretreatment ambulatory function strongly predicts post-treatment ambulation; delayed diagnosis after loss of walking ability is associated with poor neurologic recovery.ScienceDirect+2ScienceDirectMetastatic Epidural Spinal Cord Compression - an overviewPubMedSpinal Cord Compression - StatPearls - NCBI BookshelfPubMedMetastatic Spinal Cord Compression - NCBI Bookshelf

Give dexamethasone promptly for MSCC with neurologic signs or symptoms while definitive treatment is arranged. A commonly cited standard-dose regimen is a 10 mg IV bolus followed by 4 mg every 6 hours; high-dose strategies such as 96 mg daily are associated with psychosis, gastrointestinal ulceration or perforation, and other serious toxicity without demonstrated neurologic superiority over standard-dose treatment.PubMed+1PubMedTreatment of metastatic spinal cord compression: cepo review ...PubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf Monitor glucose and gastrointestinal risk, and taper after definitive treatment or when MSCC is excluded.nice org uknice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

Definitive treatment should be selected in a multidisciplinary discussion incorporating neurologic trajectory, epidural compression, mechanical stability, tumor radiosensitivity, performance status, systemic disease burden, anticipated survival, and patient goals. Prognostic and stability scores can structure assessment but should not determine treatment in isolation.nice org uknice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

Spinal epidural abscess is often diagnostically delayed because the classic combination of fever, pain, and neurologic deficit is uncommon early. Bacteremia risk, diabetes, injection drug use, immunosuppression, recent spinal intervention, or contiguous infection should lower the threshold for contrast-enhanced MRI. Management generally includes IV antimicrobial therapy and urgent decompression for neurologic deficit, sepsis, or failure of nonoperative management.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

Spinal epidural hematoma should be considered in acute spinal pain followed by weakness or sphincter dysfunction, particularly after neuraxial procedures or in patients receiving anticoagulants. Severe or progressive deficits require urgent surgical decompression; outcome worsens with delayed recognition.PubMedPubMedSpinal Cord Compression - StatPearls - NCBI Bookshelf

Acute traumatic compression requires spinal motion restriction, resuscitation, CT-based characterization of fracture or dislocation, and MRI when it informs decompression, disc/hematoma management, or ligamentous stability. Early decompression within 24 hours may improve neurologic outcomes and is recommended as an option when clinically feasible.PubMed+1PubMedA Clinical Practice Guideline for the Management of Acute Spinal Cord Injury: Introduction, Rationale, and ScopePubMedSpinal Cord Injuries - StatPearls - NCBI Bookshelf

Repeat motor, sensory, gait, and sphincter assessments at clinically appropriate intervals during acute evaluation and after intervention. Escalating pain, new weakness, declining ambulation, or new bladder/bowel dysfunction should trigger reassessment for progression, instability, treatment failure, recurrent compression, infection, or hematoma.PubMed+1PubMedSpinal Cord Compression - StatPearls - NCBI Bookshelfnice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

In MSCC, formal assessment of spinal stability and prognosis can improve communication and documentation. The Spinal Instability Neoplastic Score (SINS) may be useful as an adjunct, particularly to help rule out instability at lower scores, but evidence is limited and it should not replace expert clinical and radiologic assessment.nice org uk+1nice org ukSpinal metastases and metastatic spinal cord compressionnice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE

Communicate prognosis without presenting a score as determinative. Baseline ambulation, tumor biology, visceral disease, performance status, neurologic deficit, and response options influence outcomes; patient goals may reasonably favor surgery, radiotherapy, symptom-focused care, or a combination.PubMed+1PubMedTreatment of metastatic spinal cord compression: cepo review ...nice org ukRationale and impact | Spinal metastases and metastatic spinal cord compression | Guidance | NICE