QuestionSBA
QuestionChoice
This may be required if the patient is not a candidate for neurosurgery and is found to have MSCC, however this is not the most appropriate next step in management.
10015765
e
External beam radiotherapy
QuestionChoice
This may be required following the MRI whole spine, but not before dexamethasone is given.
10015764
d
Refer to neurosurgery
QuestionChoice
An urgent MRI whole spine will be required, but waiting for this before administering dexamethasone is not appropriate. The most important next step is to give dexamethasone.
10015762
b
MRI spinal cord
QuestionChoice
An MRI brain (looking for metastases) may be required if the MRI spine does not yield a diagnosis, however the most likely cause is MSCC given the bilateral symptoms and saddle anaeshesia.
10015763
c
MRI brain
QuestionChoice
The likely diagnosis is metastatic spinal cord compression. 16mg dexamethasone (either PO or IV) should be administered without delay, as per NICE guidelines. After this, the maintenance dose is 8mg BD.
10015761
a
Dexamethasone
QuestionComment
fair play
33669
User
subscriber
Acute Botox
QuestionComment
you sneaky ma, good question
36753
User
subscriber
Neoplasia JAK
Concept
Chapter
# Summary

Spinal cord compression (SCC) is a medical emergency that can lead to permanent neurological disability. It causes symptoms of weakness and sensory disturbance below the level of the compression, back pain deep and bladder and bowel involvement (incontinence, constipation or retention). Upper motor neurone signs are seen. Causes include trauma, malignancy (especially metastatic spinal cord compression), disc prolapse or compression by an abscess or epidural haematoma. An MRI of the whole spine is the key investigation. Management depends on the underlying cause; high dose steroids and referral to neurosurgery for consideration of decompression are key. 


# Definition

Spinal cord compression (SCC) is a form of myelopathy caused by pressure on the cord by a variety of causes. It causes an upper motor neurone lesion, unlike the lower motor neurone signs seen in cauda equina syndrome, where compression is below the level of L1. 


# Epidemiology

- Spinal cord injury affects approximately 15.4 million people globally
- Trauma causes the most cases worldwide, with falls, road traffic accidents and violence being the most common precipitants
- In the UK, there are around 4400 new cases of spinal cord injury per year
- Metastatic spinal cord compression (MSCC) is the leading cause in the UK 
- In around a quarter of patients, MSCC is their first presentation of malignancy 


# Aetiology

- **Trauma** - typically due to vertebral fractures or dislocation of facet joints; the cord may be severed in significant trauma
- **Malignancy i.e. MSCC** - either due to pathological collapse of vertebrae or compression by growing tumours
- **Infection** including abscess formation and chronic infections such as tuberculosis 
- **Epidural haematoma** where blood accumulates in the epidural space, compressing the cord
- **Intervertebral disc prolapse** although this is much more rare than lumbar disc prolapses causing cauda equina syndrome




# Signs and Symptoms

**Symptoms include:**


- Back pain, which is typically:
- Severe
- Progressive
- Aggravated by straining e.g. coughing
- Difficulty walking
- Weakness below the level compressed (typically bilateral and symmetrical)
- Numbness below the level compressed
- Urinary or faecal incontinence
- Urinary retention
- Constipation


**Signs seen (below the level of the lesion):**


- Hypertonia
- Hyperreflexia (although reflexes may be absent at the level compressed)
- Clonus
- Upgoing plantars
- Sensory loss (a "sensory level")


Symptoms and signs of an underlying cause may also be present, e.g. weight loss and fatigue in a patient with MSCC, fevers in a patient with tuberculosis. 


# Differential Diagnosis

- **Transverse Myelitis** causes inflammation of the cord that presents similarly to SCC; it may be seen in the context of chronic demyelinating diseases such as Multiple Sclerosis or Neuromyelitis Optica (where other manifestations e.g. optic neuritis may be present)
- **Cauda Equina Syndrome** is usually caused by herniation of a lumbar disc compressing the cauda equina; bowel and bladder disturbances may be present but signs are lower motor neurone (e.g. flaccid rather than spastic paralysis)
- **Peripheral Neuropathy** also causes symptoms of weakness and sensory loss, signs are lower motor neurone rather than upper and distribution differs depending on aetiology (e.g. symptoms often unilateral in compression neuropathies)
- **Spinal metastases** and other causes of back pain (e.g. musculoskeletal), especially if the predominant symptom is pain with minimal neurological symptoms and signs
- **Sciatica** refers to pain in the lower back, buttocks and posterior legs caused by nerve root compression usually secondary to disc herniation in the lumbar spine; weakness can also occur but MRI will differentiate this from SCC


# Investigations

An **MRI whole spine** is the key investigation


- The whole spine should be imaged as there may be compression at multiple levels
- In cases of suspected MSCC, this should be done within 24 hours as per NICE guidelines
- Patients with suspected spinal metastases (e.g. back pain) with no neurological signs or symptoms suggestive of MSCC should have their MRI within 1 week


In some cases other imaging modalities may be used, e.g. **whole-body CT** in the context of major trauma. CT may also be used in patients for whom MRI is contraindicated.


Other investigations indicated depend on the presentation and suspected aetiology:


- Do a **bladder scan** if suspected urinary retention 
- An **ECG** and **baseline blood tests** should be done in anticipation of possible emergency surgical decompression (including a **group and save** and **clotting**)
- In cases where MSCC is the first presentation of malignancy, further investigations are required to determine where the primary cancer is (guided by history and examination)
- This may include further imaging e.g. a CT of the chest, abdomen and pelvis
- Bloods may be done for tumour markers e.g. PSA in men
- Biopsy is usually required to confirm the diagnosis

# Management

- Management depends on the underlying cause as well as the patient's background 
- Patients with traumatic spinal cord injuries should be transferred to a major trauma centre
- General principles include:
- Immobilise the patient and nurse with spinal precautions (e.g. log-rolling)
- Regular repositioning to prevent pressure ulceration in immobile patients
- Analgesia for pain
- VTE prophylaxis 
- Catheterise if in urinary retention
- Counselling and rehabilitation is key, with multidisciplinary input (e.g. physiotherapy) 

**Using MSCC as an example:**

- Start high-dose steroids (usually 16mg dexamethasone initially) in patients with suspected MSCC - this reduces oedema helping to relieve compression
- A proton pump inhibitor (PPI) should also be given to prevent peptic ulceration caused by steroids
- Blood glucose should be monitored for hyperglycaemia secondary to steroids
- Refer to neurosurgery urgently for consideration of surgical decompression (other options include vertebroplasty or kyphoplasty)
- Patients unsuitable for surgery may have radiotherapy for spinal metastases - this can also be used as an adjuvant after surgery
- Spinal braces may be used in patients not suitable for surgery to help with pain management and spinal stability
- Oncology input is key both for diagnosis in patients without a known malignancy and for ongoing management (e.g. chemotherapy)


# NICE Guidelines


[NICE - Spinal injury: assessment and initial management](https://www.nice.org.uk/guidance/ng41/)


[NICE - Spinal metastases and metastatic spinal cord compression](https://www.nice.org.uk/guidance/ng234)


# References

[Patient UK - Spinal Cord Compression](https://patient.info/doctor/spinal-cord-compression)


[World Health Organisation - Spinal Cord Injury](https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury)
209
2100
Spinal Cord Compression
Topic
25
Oncology and Palliative Care
Condition
611
Spinal cord compression
UkmlaTopic
1
Acute and emergency
Condition
612
Spinal cord compression
UkmlaTopic
3
Cancer
Condition
614
Spinal cord compression
UkmlaTopic
16
Musculoskeletal
Condition
615
Spinal cord compression
UkmlaTopic
17
Neurosciences
15696
In cases of suspected metastatic spinal cord compression, prompt administration of dexamethasone is essential to reduce inflammation and prevent further damage.
Presentation
71
Back pain
UkmlaTopic
12
General practice and primary healthcare
Presentation
72
Back pain
UkmlaTopic
16
Musculoskeletal
Presentation
73
Back pain
UkmlaTopic
17
Neurosciences
Presentation
74
Back pain
UkmlaTopic
21
Perioperative medicine and anaesthesia
A patient with prostate cancer is referred to hospital by his GP due to severe back pain. On examination, he has altered perineal sensation and global hyperreflexia in both lower limbs.

Which is the most important next step in management?
a