View source for Spinal cord compression (non-traumatic)

==Background==
*Compression of the spinal cord from non-traumatic etiology
*A '''neurologic emergency''' — neurologic deficits may become permanent if not promptly treated
*Most common cause: metastatic cancer ('''malignant epidural spinal cord compression''') — affects 5-10% of cancer patients<ref name="loblaw">Loblaw DA, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression. ''J Clin Oncol''. 2005;23(9):2028-2037. PMID 15774794.</ref>
*Other causes: [[Epidural abscess]], epidural hematoma, disc herniation, degenerative stenosis
*Thoracic spine is the most commonly affected level in malignancy (60%)

==Etiology==
*'''Malignancy''': lung, breast, prostate, renal cell, lymphoma, multiple myeloma
*[[Epidural abscess]]: hematogenous spread or direct extension; risk factors include IVDU, immunosuppression, recent spinal procedure
*Epidural hematoma: anticoagulation, post-procedural, coagulopathy
*Disc herniation: central disc causing cord compression (thoracic or cervical)
*Degenerative spinal stenosis with myelopathy
*Vertebral compression fracture (osteoporotic or pathologic)

==Clinical Features==
*Back pain (present in >90% of malignant cases) — often worse at night, worse supine
*Progressive weakness (upper motor neuron signs below level of compression)
**Hyperreflexia, spasticity, positive Babinski sign
**May present as difficulty walking or frequent falls
*Sensory level — band-like numbness at level of compression
*Bowel/bladder dysfunction — urinary retention, incontinence (late finding; poor prognostic sign)
*Fever + back pain + neurologic deficit = epidural abscess until proven otherwise
*Vertebral tenderness to palpation

==Differential Diagnosis==
*[[Cauda equina syndrome]] (lower motor neuron findings)
*[[Transverse myelitis]]
*[[Guillain-Barré syndrome]]
*[[Spinal cord infarction]]
*Vertebral compression fracture without cord compromise
*[[Multiple sclerosis]] relapse

==Evaluation==
*'''MRI of entire spine with and without gadolinium''' — imaging of choice<ref name="quraishi">Quraishi NA, et al. Metastatic spinal cord compression. ''BMJ''. 2015;350:h2539. PMID 26037491.</ref>
**Entire spine because multifocal disease is common with malignancy
**Emergent MRI — do not delay
**CT myelography if MRI unavailable or contraindicated
*Labs
**If infection suspected: CBC, ESR, CRP, blood cultures (ESR >20 has high sensitivity for epidural abscess)
**If malignancy: LDH, calcium, alkaline phosphatase
**Coagulation studies if epidural hematoma suspected
*X-rays of spine: may show vertebral body destruction, but cannot rule out cord compression

==Management==
===Malignant Cord Compression===
*'''[[Dexamethasone]]''' — give immediately when suspected (before imaging if high suspicion)
**'''10 mg IV bolus''', then 4 mg IV/PO q6h<ref name="george">George R, et al. Interventions for the treatment of metastatic extradural spinal cord compression in adults. ''Cochrane Database Syst Rev''. 2015;(9):CD006716. PMID 26337716.</ref>
*Emergent radiation oncology and/or neurosurgery/spine surgery consultation
*Surgical decompression + radiation therapy superior to radiation alone for selected patients
*Pain management: opioids, consider PCA

===Epidural Abscess===
*Broad-spectrum IV antibiotics: Vancomycin + Ceftriaxone (or Cefepime)
*Blood cultures before antibiotics (if does not delay treatment)
*Emergent neurosurgical consultation for drainage
*See [[Epidural abscess]] for detailed management

===Epidural Hematoma===
*Reverse anticoagulation immediately
*Emergent neurosurgical consultation for possible decompression

==Disposition==
*Admit all cases of spinal cord compression
*New neurologic deficits require emergent evaluation and treatment
*Ambulatory status at presentation is the strongest predictor of outcome

==See Also==
*[[Cauda equina syndrome]]
*[[Epidural abscess]]
*[[Low back pain]]
*[[Transverse myelitis]]

==References==
<references/>

[[Category:Neurology]]
[[Category:Hematology and Oncology]]