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Cord compression

Up ADEM Brain abscess Brain death Cerebral oedema Cerebral tumours CVT CVA Coma Cord compression Delirium Encephalitis Guillain Barre syndrome ICU acquired weakness ICH Meningitis Myasthenia gravis Periodic paralysis Nerve lesions SAH Status epilepticus Subdural empyema SjO2 Tick paralysis Transverse myelitis Weakness


Spinal cord compression

Key points:
Early diagnosis and decompression important because prognosis depends primarily on severity of neurological deficit and duration of deficit before decompression.
Signs and symptoms are those of a myelopathy but the common feature of "structural" lesions is pain. Spine or root pain in the presence of myelopathic symptoms strongly implies a surgically remediable cause.

Trauma

- in selected circumstances internal fixation and fusion has a role to play and does impart advantages to the patient, his spine and his rehabilitation. However, neurological outcome is not improved. (More on traumatic cord injury).

Inflammatory conditions

  • most important is rheumatoid arthritis.

  • acute cord compression is not common in rheumatoid but there are anecdotal reports of patients collapsing and dying due to gross odontoid subluxation. Usually patients develop symptoms over weeks-months but a few patients develop neurological signs and deteriorate witha progressive myelopathy over a short period of days. A clear history is of paramount importance as widespread joint disease makes accurate clinical examination difficult.

  • vertical subluxation of the odontoid process makes it possible that the patient will develop lower cranial nerve signs

  • most common form of C1/2 dislocations is anterior subluxation of C1 on C2. Less frequent abnormalities include posterior subluxation, rotational deformities or lateral subluxations

  • post-operative mortality and morbidity greatest in those who are most severely afffected neurologically pre-op. (ie quadraparetic and unable to walk) Systemic effects of RA, especially interstitial pneumonitis may adversely affect postsurgical recovery

Infective lesions

  • infections of spine uncommon

  • can be classified into vertebral osteomyelitis (more common) or intraspinal infection

  • incidence of intraspinal infection 1/million/yr in UK. Extradural, subdural or intramedullary in order of frequency). Usually due to Staph in UK, TB in Asia and Africa

  • spinal extradural neurosurgical emergency. Outstanding clinical feature is spinal pain associated with marked local tenderness of the spine at the level of abscess formation

  • commonest organisms causing vertebral osteomyelitis: Staph, Strep, E coli, TB. Occasionally due to unusual organisms such as salmonella or brucella. May be complicated by the development of an extradural abscess

  • investigation of choice: MRI. CT myelography is 2nd best

Degenerative disease

  • usually due to disc prolapse +/- canal stenosis

  • for those patients who develop an acute myelopathy due to hyperextension forces superimposed on a narrow spinal canal there is little, if any, convincing evidence that surgical decompression improves neurological recovery

  • for patients who present with an acute disc prolapse causing cauda equina syndrome prognosis for recovery is based on the severity of the pre-decompression neurological deficit rather than the duration of neurological symptoms. Same is likely to apply to recovery from cervical or thoracic disc induced myelopathy

Neoplasms

  • usually due to secondaries

  • multiple levels involved in 17%

  • most secondaries found in thoracic spine and multiple lesions may be non-contiguous

  • in most cases myelopathy develops over days to weeks

  • pain in 90% of patients

  • acute cord compression does occur if tumour enlarges very rapidly due to haemorrhage or if a vertebral body suddenly collapses

  • tissue diagnosis important if primary cannot be identified

  • management depends on a number of factors including histology, tumour load, number of secondaries, estimate of life expectancy

  • severity of neurological deficit has the greatest influence on prognosis for neurological recovery following decompressive surgery

  • radiotherapy may take several days to have its optimum effect

  • urgent surgery is treatment of choice where compression is due to collapsed vertebra

Haematoma

  • distinctly uncommon

  • substantial number occur for no particular reason

  • produce combination of spinal pain and root pain followed by progressive myelopathy over 1-2 days

  • diagnosis confirmed by MRI or CT myelography

  • treatment: laminectomy at level of cord compression

Further reading

Johnstone RA. The management of acute spinal cord compression. J Neurol Neurosurg Psychi 1993; 56:1046-1054


©Charles Gomersall, February, 2015 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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