QuestionSBA
QuestionChoice
Spinal braces are useful in immobilising the spine and provide support and stability. They are used in unstable spinal fractures to promote healing and reduce further instability. In this patient, however, there is no mention of spinal instability
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Attach a spinal brace
QuestionChoice
This will almost certainly be done while an inpatient to determine the progression of this patient's prostate cancer. However given this patient's new neurology findings, he requires urgent therapy to relieve his spinal cord compression to prevent permanent neurological damage
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Staging CT scan to identify extra-spinal metastases
QuestionChoice
Given this patient's new neurology findings he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. While dexamethasone is a crucial part of management of MSCC and cauda equina syndrome, we should not wait for a trial of dexamethasone as there is a risk of permanent neurological damage if the cord is not decompressed
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Review neurology twice daily for 48hrs to asses response to dexamethasone, and then consider radiotherapy if abnormal neurology persists beyond 48 hours
QuestionChoice
Given this patient's new neurology findings he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. While dexamethasone is a crucial part of management of MSCC and cauda equina syndrome, we should not wait for a trial of dexamethasone as there is a risk of permanent neurological damage if the cord is not decompressed
33231
d
Urgent physiotherapy to prevent further deconditioning
QuestionChoice
This patient has metastatic spinal cord compression (MSCC) and cauda equina syndrome secondary to a metastatic deposit in the lumbar spine which is impinging on the spinal cord. High dose dexamethasone is given to reduce inflammation around the tumour. Given this patient's new neurology findings, however, he should have urgent radiotherapy within 24hrs to prevent permanent neurological damage. Radiotherapy to the tumour can reduce pressure on the cord through tumour shrinkage and can achieve local tumour control
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a
Urgent radiotherapy
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Notes don't match the title 
22174
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Myopathy Kinase
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Damn they got me 
24730
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Medgyal
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The longest answer failed me
26783
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subscriber
Big mo
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Does radiotherapy count as conservative mx?
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Kinase Complement
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# 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)
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Emergency management of suspected acute spinal cord compression
Topic
34
Neurology
Urgent radiotherapy
6646
Metastatic spinal cord compression requires urgent radiotherapy to prevent permanent neurological damage and alleviate symptoms caused by spinal cord compression.
A 72-year-old man with prostate cancer and spinal metastases presents to the emergency department with 12 hours of painful urinary retention, 3 days of worsening lower limb weakness, and a flare of his chronic back pain. 
A urinary catheter is inserted, which drains 1200mL of clear urine.


Neurological exam shows normal tone, reduced power (4/5) in both legs, reduced knee and ankle reflexes, upgoing plantars, and normal coordination. He has saddle anaesthesia and decreased anal tone on rectal examination.

MRI spine shows severe metastatic spinal cord compression from L1 to L3.

The neurosurgery team opts for conservative management, and 16mg dexamethasone is prescribed.

Which of the following is the best next step in the management of this patient?
a