Spinal Cord Compression

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Spinal Cord Compression

• Dr. Wayne Hoskins

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Spinal Cord Anatomy

• Medulla --gt exiting nerve roots
• Surrounded by meninges dura, arachnoid, pia
• Ends at L1/2
• Protected by bony vertebral column

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Spinal Cord Function

• Transmits neural signals and contains neural
  circuits that control reflexes
• Three major functions
• Motor
• Sensory
• Reflex

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Spinal Tracts
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Causes of Compressions
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Causes of Compressions

• Trauma - vertebral fracture
• Inter-vertebral disc / spinal stenosis
• Tumor Lung, breast, prostate, RCC, thyroid,
  lymphoma, MM
• Epidural abscess

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UMNL vs. LMNL
Sign UMNL LMNL
Tone ? ?
Power --gt ? ? ? ?
Atrophy Mild due to disuse Yes
Fasciculation's No Yes
Reflexes ? ?
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Case

• 76 yo F - LBP lateral RgtL leg pain
• Insidious onset 2/12 ago
• PMHx Colon Ca 2008 - APR
• Presented to ED DVT excluded - D/C
• Represents with worsening pain
• Denies weakness, numbness, parathesia, cauda
  equina Sx, fever

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Red Flags
Fracture Major trauma in elderly, osteopenic, on long term steroids
Infection Constitutional symptoms fever, chills, unexplained weight loss Recent bacterial infection Risk factors for infection underlying disease process, immunosuppression, IVDU
Tumor Age gt 50 or lt20 History of Ca Constitutional symptoms such as weight loss Pain at multiple sites Pain worse at rest, at night, wakes at night Failure to improve with treatment Persists gt 6 weeks
Significant neurological deficit Severe or progressive sensory alteration or weakness Bladder or bowel dysfunction Neurological deficit in in legs, arms, perineum
AAA Age gt60 Pulsating mass in abdomen Absence of aggravating factors
Spondylo-arthritis Age lt 45, morning stiffness improved with exercise Oligo-arthritis, polyarthritis, rash, diarrhea, eye symptoms
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Exam Ix

• Lumbar-pelvic pain on palpation
• Normal neuro exam
• SLR negative
• FBE, CMP, LFT NAD
• CEA 3.7

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Lumbar-pelvic x-ray

• Sclerosis in left
• sacral alar
• suspicious of
• healing
• insufficiency
• fracture

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NM Bone study SPECT

• Increased
• uptake LgtR
• sacral alar
• consistent with
• arthritis

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MRI
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Metastatic SCC

• Spinal cord or cauda equina compression by
  direct pressure /or induction of vertebral
  collapse or instability by metastatic spread or
  direct extension that threatens or causes
  neurological disability
• - 5-10 all Ca patients
• - Initial manifestation in 20
• - Median survival 3-6/12

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Early detection

• View as oncological emergency if
• - neuro symptoms radicular pain, any limb
  weakness, difficulty in walking, sensory loss or
  bowel/bladder dysfn
• - neuro signs of spinal cord or cauda equina
  compression

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Imaging

• Whole spine MRI lt1/52 to plan definitive
  treatment and lt24/24 if neurological symptoms
• Sensitivity and specificity gt90
• CT only to assess stability, plan surgery, biopsy
  guidance
• - CT myelopgraphy if MRI contra
• Do not perform plain radiographs

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Treatment

• Goals palliative, pain control, preserve or
  restore ambulation,neuro stability
• Start definitive treatment ideally within 24/24
  of Dx
• Carefully plan surgery consider fitness,
  prognosis, preferences
• Urgent lt24/24 RT for definitive treatment if
  unsuitable for surgery

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Treatment

• Analgesia Conventional by WHO pain relief
  ladder, ?specialist pain care
• Bisphosphonates myeloma or breast Ca and
  prostate if analgesia has failed not for others
• Corticosteroids 16mg loading dexameth
• - 16mg/d, over 5-7/7 after RT or surgery
• - complications sepsis, bowel perforation
• Biopsy stage (no., sites, extent)

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Treatment

• RT if non-mechanical pain
• Vertebroplasty/kyphoplasty - consider if no MSCC
  or instability
• - mechanical pain resistant to analgesia
• - vertebral body collapse
• Surgery consider urgently if spinal instability,
  mechanical pain resistant to analgesia
• - external spinal support (halo, orthosis) if
  unsuitable for surgery

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Surgery

• RT if non-mechanical pain
• Vertebroplasty/kyphoplasty - consider if no MSCC
  or instability
• - mechanical pain resistant to analgesia
• - vertebral body collapse
• Surgery consider urgently if spinal instability,
  mechanical pain resistant to analgesia
• - external spinal support (halo, orthosis) if
  unsuitable for surgery

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Radiotherapy

• Urgent lt24/24 if definitive treatment or
  unsuitable for surgery unless
• - tetraplegia or paraplegia gt24/24 and pain
  controlled overall poor prognosis
• Fractionated RT definitive Tx if no neuro
  impairment, pain or instability
• No pre-operative RT
• Post-operative RT offered when wound healed

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Thromboprophylaxis

• All patients thigh length TEDS and/or
  intermittent pneumatic compression or foot
  impulse devices
• High risk LMWH and mechanical thromboprophylaxis

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CSM

• Natural history slow deterioration in stepwise
  fashion, with worsening symptoms of gait
  abnormalities, weakness, sensory changes and
  often pain
• Dx Hx, Exam, XR - CT/MRI to confirm

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Management

• Minimal symptoms without hard evidence of gait
  disturbance or pathological reflexes warrant
  nonoperative treatment
• Demonstrable myelopathy and spinal cord
  compression are candidates for operative
  intervention

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Surgery

• Anterior and posterior approaches

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ACDF
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Thank You
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Diagnosis

• X-ray
• Preferably MRI urgently - whole spine if cancer
  implicated

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Treatment

• Dexamethasone - 16mg/d may reduce edema around
  lesion
• Surgery - indicated in local compression and if
  hope of regaining functions

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Surgical Considerations

• Speed of onset
• Red flags