Acute spinal compression
Theory
Either acute or chronic compression on the spine results in neurological disturbances to the upper limbs, lower limbs, saddle area and also results in bowel and bladder dysfunction.
Management focuses on recognising the condition and adequate treatment, which is nearly always urgent surgical decompression.
Immediate intern management
Suspect the diagnosis. Any patient complaining of upper or lower limb neurological symptoms needs to have acute spinal cord compression ruled out.
Thorough history and examination, including full neurological examination
- Obtain IV access and commence gentle IV fluids.
- Send off basic blood tests.
- Analgesia for back pain.
- Strict rest in bed and spinal precautions.
Notify unit registrar and surgical registrar and discuss findings.
- Organise urgent MRI (CT) scan.
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Clinical features
History
- Back pain
- Neurological symptoms
- Weakness arms, legs
- Numbness arms/buttocks/legs
- Bladder and bowel dysfunction
- Incontinence
- Urinary retention
- Trauma
- Known cancer/myeloma
- Recent spinal/epidural
Examination
- Neurological examination
- UMN signs in limbs clonus, increased tone, weakness, hyperreflexia, upgoing plantars
- Sensory change
- Saddle anaesthesia
- PR
Causes
Acute
- Disc prolapse
- Trauma
- Fractures
- Epidural haematoma/abscess
Acute or chronic
- Bony metastases
- Myeloma
- Abscess
- Spinal cord tumour
- Spondylolisthesis
- Tuberculosis
- Pregnancy
- Degenerative spinal disease
Investigations
MRI is the gold standard but may not be available at all centres.
Acute spinal cord compression is an absolute indication for an urgent MRI.
Imaging
- CT scan spine
- MRI spine
Associated tests
- Basic blood tests
- X-Match
- CXR
- ECG
Screening tests
- ESR
- PSA
- Tumour markers
- Bone scan (tumour hot spots)
- Inflammatory markers
Definitive management
Urgent neurosurgical evaluation is required
- Urgent spinal decompression – laminectomy
- Resection of tumour or disc prolapse
- Corticosteroids (dexamethasone) have an urgent role in limiting cord oedema (use following discussion with neurosurgery)
Other considerations
- Consider radiotherapy for known metastasis to the spine
- Treatment of myeloma/TB
- Pressure care if sensory disturbance
- IDC for urinary retention
- Specimen cultures if evidence fever/sepsis. A septic patient developing segmental nerve or cord features has spinal abscess with no time to lose.
- Cauda equine syndrome will give LMN signs in the lower limbs.
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