Spinal cord compression (non-traumatic)

Background

Most often from cancer
- Multiple myeloma, lymphoma, prostate, lung, breast
Site of Compression: Thoracic > Cervical > Lumbar
The cauda equina (Latin for "horse's tail") begins at the 2nd Lumbar space extending down to the beginning of the sacral nerves. It is distal to the tapered end of the spinal cord, or conus medularis.[1]

Syndrome	Spinal cord compression	Conus medullaris syndrome	Cauda equina syndrome
Location of lesion		Lesions at vertebral level L2
Spontaneous pain		Unusual and not severe; bilateral and symmetrical in perineum or thighs	Often very prominent and severe, asymmetrical, radicular
Motor findings	Deficits usually affect both legs but are often asymmetric	Not severe, symmetrical; rarely twitches	May be severe, asymmetrical, fibrillary twitches of paralyzed muscles are common
Sensory findings	Weakness in lower extremities, paresthesias/sensory deficits, gait difficulty	Saddle distribution, bilateral, symmetrical, disassociated sensory loss (impaired pain and temperature with sparing of tactile)	Saddle distribution (75% pts), may be asymmetrical, no dissociation of sensory loss
Reflex changes		Achilles reflex may be absent	Patellar and Achilles reflexes may be absent
Sphincter disturbance	Bladder and rectal sphincter paralysis usually reflect involvement of S3-S5 nerve roots	Early and marked (both urinary and fecal)	Late and less severe (60-80% pts)
Male sexual function		Impaired early	Impairment less severe
Onset		Sudden and bilateral	Gradual and unilateral
Other			Urinary retention with or without overflow incontinence (Sn 90%, Sp 95%)

Emergent MRI
- If considering compression due to neoplasm obtain scan of entire spine
Consider Bladder scan/ultrasound for bladder volume (post-void residual)

Consult neurosurgery and/or rad onc
Corticosteroid therapy
- Extremely controversial and perhaps no longer indicated in nontraumatic compression[3][4]
- Consider emergent radiation, surgical intervention, and/or chemo therapy

Dexamethasone: at least 16 mg IV as soon as possible after assessment[5]
- Note: dexamethasone can be used to reduce compressive edema from epidural metastases, but is more likely to worsen an infection from spinal epidural abscess.
Consult spine service
Consider foley for bladder decompression

Cohen MS, Wall EJ, Kerber CW, et al. The Anatomy of the Cauda Equina on CT Scans and MRI. J Bone Joint Surg Br 1991; 73 (3): 381-84.
Bradley WG. Neurology in Clinical Practice: Principles of diagnosis and management. P363
Coleman WP, et al: A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury. J Spinal Disord 2000; 13:185.
Hurlbert RJ: Methylprednisolone for acute spinal cord injury: An inappropriate standard of care. J Neurosurgery 2000; 93(1 Suppl):1
Metastatic spinal cord compression: Diagnosis and management of patients at risk of or with metastatic spinal cord compression. Full Guideline. November 2008. Developed for NICE by the National Collaborating Centre for Cancer. ©2008 National Collaborating Centre for Cancer

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