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Spinal Cord Compression

Compressions Spinal Cord

The term spinal cord compression refers to a state of pressure exertion on the spinal cord due to various causes, including tumors or traumatic injuries.


Presentation

Symptoms related to spinal cord compression vary and depend on the extent of the compression present. Mild compression may lead to a prickling or tingling sensation, backache, muscle weakness and erectile dysfunction. The painful sensation of the back may extend to the back of the leg and reflexes may be affected too, either in terms of weakened or exaggerated reflexes.

If the compressive cause is not removed or repaired, continual pressure exerted on the spine can lead to more severe symptoms, such as urinary retention or loss of bowel and bladder control, considerably weakened muscles and numbness. The most severe symptoms that can arise from SCC are paralysis and a complete loss of sensory function.

Cervical Lymphadenopathy
  • Rosai-Dorfman disease (RDD) is a rare benign histiocytic disease that is commonly characterized by massive painless cervical lymphadenopathy and systemic manifestations.[ncbi.nlm.nih.gov]
Chronic Cough
  • He had no history of trauma nor did he have chronic cough, night sweats or fevers. He has been treated several times for alcohol dependence. On examination he was wasted, power 0/5 in both lower limbs and a sensory level at T12.[ncbi.nlm.nih.gov]
Sulfur Granules
  • Histopathology of the neck mass revealed sulfur granules of actinomyces. Since actinomycosis was strongly suspected, she was treated with high dose of parenteral penicillin G followed by oral penicillin with complete recovery.[ncbi.nlm.nih.gov]
Fecal Incontinence
  • Spinal cord compression usually causes decreased sensation and paralysis of limbs below the level of compression, urinary and fecal incontinence, and/or urinary retention, which brings great suffering to the patients and usually requires surgical intervention[ncbi.nlm.nih.gov]
  • Signs and symptoms [ edit ] Symptoms suggestive of cord compression are back pain , a dermatome of increased sensation, paralysis of limbs below the level of compression, decreased sensation below the level of compression, urinary and fecal incontinence[en.wikipedia.org]
  • Other symptoms may occur: Reduced sexual response, including erectile dysfunction in men Retention of urine Loss of bladder control (urinary incontinence) Loss of bowel control (fecal incontinence) Loss of reflexes in the knee and ankle People who have[merckmanuals.com]
Hepatomegaly
Back Pain
  • Several rare yet potentially devastating causes of acute back pain are deserving of consideration when approaching back pain in the ED setting; SSH is among them.[ncbi.nlm.nih.gov]
  • Most patients had a history of hyperuricemia or peripheral tophus, the most common symptoms are back pain, when the pain stone compression spinal cord or nerve root, there will be the corresponding neurological symptoms or signs.[ncbi.nlm.nih.gov]
  • Pre-operative back pain was 7.2 on a visual analogue scale. Back pain was reduced to 4.4 at discharge and 2.0 at the latest follow-up with a mean follow-up of 12 months (p 0.001). The Frankel score remains constant or improved from D to E.[ncbi.nlm.nih.gov]
  • We describe a case of EMH in a 21-year-old man with β-thalassemia intermedia presenting with progressive low back pain, worsening paraparesis and sphincter disturbance.[ncbi.nlm.nih.gov]
  • Bowel and bladder dysfunction and neck or back pain may also be part of the clinical presentation, but are not uniformly present.[ncbi.nlm.nih.gov]
Spine Pain
  • Treatment of a SCC differs in those patients whose spine is unstable compared to those with a stable spine.[austinpublishinggroup.com]
Muscle Spasticity
  • One of those, according to the University of Maryland Medical Center, is muscle spasticity. Muscle spasticity can cause spasms in the legs or make them more difficult to control.[livestrong.com]
Hyperreflexia
  • Physical examination revealed hyperreflexia and a T11 sensory level. MRI revealed a pseudomeningocele compressing the thoracic spinal cord. The patient underwent surgical drainage of the cyst.[ncbi.nlm.nih.gov]
  • Lhermitte's sign (intermittent shooting electrical sensation) and hyperreflexia may be present.[en.wikipedia.org]
  • Hyperreflexia . Heightened deep tendon reflexes in the knee and ankle are potential indicators of spinal cord compression and dysfunction. Clonus . Upon forcing the ankle to extend, the patient's foot rapidly beats up and down. Babinski reflex .[spine-health.com]
  • […] retardation) – 1 Serious urination difficulty (residual urine, dysuria) – 0 Urine retention Additional findings associated with myelopathy: Muscular tone in the legs will be increased, Deep tendon reflexes in the knee and ankle will be accentuated (hyperreflexia[necksolutions.com]
Spastic Paraplegia
  • Examination revealed functional upper extremities with spastic paraplegia of bilateral lower extremities. The patient's neurologic function was cautiously monitored, but he deteriorated to a bed-bound state, preoperatively.[ncbi.nlm.nih.gov]
  • The cord symptoms were often noted to progress rapidly to a flaccid paraplegia, although a slowly progressive spastic paraplegia could occur.[medlink.com]
  • paraplegia with a sensory level at the trunk Weakness of the legs, sacral loss of sensation and extensor (upward) plantar reflexes Specific syndromes associated with cord compression (often traumatic/hyperacute causes) Cord transection i.e. complete[dundeemedstudentnotes.wordpress.com]
  • ., metastatic tumors), subacute combined degeneration of the spinal cord (vitamin B 12 deficiency), hereditary spastic paraplegia, normal pressure hydrocephalus and spinal cord infarction ( Table 4 ) . 10 Most of these conditions can easily be distinguished[aafp.org]
Unable to Walk
  • […] to walk III Sensory function (same in upper and lower limbs, and trunk) – 2 Normal – 1 Slight sensory disturbance or numbness – 0 Distinct sensory disturbance IV Bladder function – 3 Normal – 2 Slight urination difficulty (pollakisuria, retardation)[necksolutions.com]
  • Spinal pain is often present for three months and neurological symptoms for two months before paraplegia, but almost 50% of patients are unable to walk by the time of diagnosis. Of these, almost 70% remain immobile.[patient.info]
  • . • Poor prognosis • Lung or melanoma primary • Multiple spinal metastases • Visceral metastases • Unable to walk • Severe weakness • Recurrence after radiotherapy. 36.[slideshare.net]
Radiculomyelopathy
  • Electroencephalogr Clin Neurophysiol 84: 433–439 PubMed CrossRef Google Scholar Fouyas IP, Statham PF, Sandercock PA et al. (2001) Surgery for cervical radiculomyelopathy (Cochrane Review).[link.springer.com]
  • Compression may often involve a radicular component (radiculomyelopathy).[neuroanatomy.wisc.edu]
Decreased Proprioception
  • We present a case of an osteochondroma of the spine presenting with spinal cord compression. 27-year-old male presented with lower extremity weakness and paresthesia, decreased lower extremity sensation, and decreased proprioception.[ncbi.nlm.nih.gov]
  • Table 1 – Signs/symptoms of cord compression New or worsening back pain Weakness Loss of sensation in affected limbs Decreased proprioception Numbness / tingling / coldness Urinary retention / constipation Ataxia / spasticity Bowel / bladder incontinence[oncolink.org]
Urinary Retention
  • Spinal cord compression usually causes decreased sensation and paralysis of limbs below the level of compression, urinary and fecal incontinence, and/or urinary retention, which brings great suffering to the patients and usually requires surgical intervention[ncbi.nlm.nih.gov]
  • Retention Constipation Treatment It is a medical emergency Can be difficult to differentiate a chronic from an acute cause, particularly if pain and sensory level are ambiguous.[almostadoctor.co.uk]
  • retention Bowel constipation Typically, there are a mixture of upper and lower motor neuron signs Below the level of compression there are usually upper motor neuron signs i.e. brisk reflexes and spasticity At the level of compression there are usually[dundeemedstudentnotes.wordpress.com]
  • Loss of bladder control results in urinary retention, frequent small voids, overflow or incontinence. Loss of bowel control such as the urge to defecate, may lead to constipation or incontinence.[myvmc.com]
Urinary Incontinence
  • Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%).[ncbi.nlm.nih.gov]
  • When urinary incontinence starts or when patients become dependent on a wheel chair for long period of time, the chance that surgery will help decreases.[spinedoctormiami.com]
  • In general, clinical signs include paresis or paralysis, but depending on the level of the spinal cord involved and the type of lesion present there may also be urinary incontinence, loss of sensation, Horner's syndrome, and in acute lesions, spinal shock[medical-dictionary.thefreedictionary.com]
  • Other symptoms may occur: Reduced sexual response, including erectile dysfunction in men Retention of urine Loss of bladder control (urinary incontinence) Loss of bowel control (fecal incontinence) Loss of reflexes in the knee and ankle People who have[merckmanuals.com]
Overflow Incontinence
  • There may be overflow incontinence when the bladder cannot physically hold any more urine.[neuroanatomy.wisc.edu]

Workup

The suspicion of spinal cord compression must be followed by prompt workup, due to the devastating and potentially irreversible consequences of paralysis and sensory loss.

The first step towards a diagnosis includes a plain radiograph of the spinal column, in order to detect fractured vertebral bodies or a dislocation [7]. Following the radiographic imaging, a magnetic resonance imaging (MRI) scan is the test of choice in order to illustrate the spinal cord and its surrounding structures. Herniated discs, tumors, abscesses or hematomas can all be detected via MRI; if the procedure cannot be performed for lack of availability, a myelography can be done instead. A potential infection of the spinal tract can be ruled out via a lumbar puncture. In the case that a tumor is discovered, further evaluation including a biopsy will be required, in order to confirm malignancy [8].

Mediastinal Mass
  • Because of these nonspecific symptoms, it is difficult to suspect a mediastinal mass. A posterior mediastinal tumor causing spinal cord compression is an important example of an oncologic emergency arising from a neurogenic tumor.[ncbi.nlm.nih.gov]
ST Elevation
  • She was diagnosed with pulmonary oedema and a non-ST-elevation myocardial infarction following chest X-ray, ECG and high sensitivity troponin levels.[ncbi.nlm.nih.gov]

Treatment

Partial or acute spinal cord compression must be addressed at once; successful identification of the condition and proper treatment will relieve the spinal cord of the extreme pressure and sensory and/or motor function will be restored, since irreversible damage to the nerves requires time in order to develop. Surgical intervention is the treatment of choice in such cases.

Apart from surgery, SCC induced by other causes may require different types of treatment as well. Should a hematoma or tumor be the cause of SCC, dexamethasone or methylprednisolone may help to restore the amount of pressure exerted on the spinal cord [9]. Corticosteroids target the inflammation caused by the tumor and the latter can then be surgically excised or treated with radiation therapy [10] [11].

Abscesses can cause extra pressure to the spinal cord; if that is the cause, surgical excision is the method of choice, followed by the administration of antimicrobial agents [12]. In the absence of any neurological sequelae, the abscess open link may be solely drained, possibly followed by antibiotic coverage. Surgical drainage is also the method most doctors prefer in cases of hematomas. Should an individual suffer from a coagulation disorder, vitamin K injections and plasma transfusions are opted for, in order to reduce the risk of bleeding and hematoma recurrence.

Prognosis

With regard to the most common cause of SCC, trauma, only a small percentage of the patients are expected to experience a relapse, due to a certain instability of the spinal cord or because they do not refrain from the activity that caused the traumatic injury. 1/3 of the patients who experience loss of limb motion are expected to regain mobility and almost 80% of the individuals will require urinary catheterization for the rest of their lives [5].

SCC that is a result of malignancy is expected to reappear at a rate of up to 10% and when the condition arises due to cauda equina syndrome, recurrence is exhibited at a rate of up to 15% [6].

Etiology

Spinal cord compression has multiple etiologic factors [2]. The most common cause is cancer, and particularly metastatic cancer usually originating from the lungs, brain, prostate or lymphatic tissue. A tumor that originally appears on the spine can also cause compression, but this is not usually observed in daily clinical practice. Another common cause is osteoporosis, which leads to frequent fractures of the skeleton; the dislocated bones can either lead to compression or exacerbate an already existing case of compression.

Secondarily, any mass or lesion in the vicinity of the spine can put pressure on the spinal cord. For these reasons, hematomas and abscesses pose a threat to the functionality of the spinal cord. Hematomas can arise as a result of anti-coagulant medications, arteriovenous malformations or congenital deficiency of clotting factors. Herniated discs can also press the spinal cord, as can any type of dysregulated growth of the skeleton, such as cervical spondylosis. Fibrosis of the connective tissue that envelopes the spinal cord can also restrain the cord itself and cause neurological symptoms due to compression.

Depending on the causes, spinal compression can either appear acutely and suddenly, or develop in a more gradual fashion over a longer period of time.

Epidemiology

Spinal cord compression is a condition that is frequently diagnosed on an international level. Nevertheless, scarce data is available concerning its prevalence worldwide and the numbers presented here are estimations obtained from USA studies. According to these studies, the prevalence of SCC amounts to 4 per 100,000 individuals per year [3]. and the relative majority of the affected patients belong to the age group of 16 to 30 years old [4]. It is believed that the frequency of SCC has been on a steady rise during the past years, with trauma being the most common cause of acutely arising spinal cord compression.

Sex distribution
Age distribution

Pathophysiology

Extending from the foramen magnum to the first two lumbar vertebrae, the spinal cord consists of grey and white matter, encased within a sac of three layers of meninges for reasons of protection. The innermost membrane is the pia mater and the middle membrane is the arachnoid mater; between the two, in the space called the subarachnoid space, the cerebrospinal fluid flows, providing minimal friction and additional protection to the spinal cord. On the external part of the dura, which is the outermost of the three meninges, the skeletal vertebral column encloses the spinal cord and the meninges.

At various levels in the route of the spinal cord, nerve roots serving both motor and sensory functions enter the structure, alongside vessels that provide the necessary perfusion. Any cause that leads to an increased amount of pressure to the cord, nerves and vessels can lead to neurological sequelae, such as tingling sensations, inability to feel temperature, abnormal pain sensations and even motor dysfunction and paralysis.

Acute spinal cord compression is most frequently caused by trauma or herniated discs. Fractured vertebral bodies and spinal subluxation can also lead to the same clinical picture. The condition can also arise in a more slow fashion, due to a tumor, degeneration or infection; these are the chronic types of SCC. Irrespective of the cause, the common denominator between both acute and chronic SCC is the loss of spinal cord and nerve root function. Any type of compressive injury to the vascular system responsible for the perfusion of the spinal cord also causes the same symptoms: the corticospinal and spinocerebellar tracts are the two most prone to compressive malfunction.

Prevention

Concerning the occupations that are accompanied by an augmented risk of sustaining traumatic injuries of the spinal cord or disc herniation, adequate measures have to be taken by employers in order to educate the employees regarding self-protection and safe practice. Adequate safety measures should also be provided for by employers, such as restraint systems. Jobs with a such a higher risk include:

  • Firefighters
  • Military personnel
  • Professional drivers
  • People employed in the agriculture
  • Seamen
  • Construction workers

Any type of recreational activity that is organized should also abide by the same rules.

Summary

Compression of the spinal cord is a condition in which the spinal cord is subject to an abnormal amount of pressure.

The most common cause of spinal cord compression (SCC) is malignancy. In fact, 1 out of 20 cancer patients do exhibit this condition as a complication. Compression of the spine and, subsequently, spinal cord, is the second most common complication stemming from brain cancer [1]. There are two distinct pathways by which spinal cord compression induced by malignancy can occur. The first one involves a primary tumor of the spine, wherein the initial location of the cancerous tumor is on the spine itself, therefore exerting excessive pressure on the nervous tissue. A second pathway is metastatic cancer, wherein particularly malignancies of the lungs, prostate and breast have increased possibility of metastasizing to the spinal cord and pressing the nerves and roots. The first type of spinal cord compression, caused by a primary tumor of the spine, is termed malignant spinal cord compression and the latter is termed metastatic spinal cord compression.

Except for malignant causes, various other conditions can subject the spinal cord to increased pressure and related sequelae, including infectious diseases, spine trauma, hematomas, abscesses and osteoporotic damage.

The diagnosis of spinal cord compression can be achieved via a radiographic depiction of the spine, that will help to detect potential fractures, and a magnetic resonance imaging scan, that can delineate various tissue alterations in the vicinity of the spine, such as a hematoma, a tumor or a herniated disc. Treatment depends on the cause and may involve surgery, radiation therapy, chemotherapy or drainage. Treatment should be as prompt as possible, in order to prevent long-lasting pressure from being exerted on the spine, which will inadvertently lead to nerve damage that may be irreversible.

Patient Information

The spinal cord is a thin column that is made up of gray and white matter, exactly like the brain. It extends from the lower parts of the skull until the lumbar region and is encased in three membranes, a sac containing fluid and the spinal column, which consists of the vertebral skeleton. All three structures protect the vulnerable spinal cord from injuries, pressure and friction.

The spinal cord is a valuable organ, because it is responsible for sensory and motor functions. Nerves penetrate various locations of the organ and transmit vital information concerning movement and sensations (temperature, touch, pain, etc.). It should by all means be protected, because damage to it may be irreversible and can lead to devastating consequences and disability.

Various circumstances lead to an increased amount of pressure sustained by the spinal cord. Traumatic injuries, herniated discs, tumors, collections of pus or blood around the spinal region, as well as infection of the spine and fractured vertebrae can all lead to the condition known as spinal cord compression. Depending on the degree of compression, a person may experience strange tingling sensations, lose the ability to feel temperature or pain, feel numb and, in extreme cases, lose the ability to move and control their bladder and bowel.

The condition is diagnosed via X-rays of the back, and MRI or myelography and a lumbar puncture, if necessary. Treatment may be surgical or pharmacological and the results depend on the cause of the compression and the time that has passed between its development and the point of therapy.

References

Article

  1. DeVita VT Jr, Hellman S, Rosenberg SA. Cancer Principles & Practice of Oncology. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2001.
  2. Arce D, Sass P, Abul-Khoudoud H. Recognizing spinal cord emergencies. Am Fam Physician. 2001 Aug 15; 64(4):631-8.
  3. Furlan JC, Sakakibara BM, Miller WC, et al. Global incidence and prevalence of traumatic spinal cord injury. Can J Neurol Sci. 2013; 40:456-464.
  4. Sekhon LH, Fehlings MG. Epidemiology, demographics, and pathophysiology of acute spinal cord injury. Spine. 2001; 26(24S):S2-S12.
  5. Findlay GF. Adverse effects of the management of spinal cord compression. J Neurol Neurosurg Psychiatry. 1984; 47:761-768.
  6. Bucholtz JD. Metastatic epidural spinal cord compression. Semin Oncol Nurs. 1999;15:150-159.
  7. Babar S, Saifuddin A. MRI of the post-discectomy lumbar spine. Clin Radiol. 2002; 57:969-981.
  8. Richards PJ. Cervical spine clearance: a review. Injury. 2005 Feb; 36(2):248-69; discussion 270.
  9. Held JL, Peahota A. Nursing care of the patient with spinal cord compression. Oncol Nurs Forum. 1993; 20:1507-1514.
  10. Johnson BL, Gross J. Handbook of Oncology Nursing. 3rd ed. Sudbury, Mass: Jones and Bartlett; 1998.
  11. Rades D, Blach M, Nerreter V, et al. Metastatic spinal cord compression. Influence of time between onset of motoric deficits and start of irradiation on therapeutic effect. Strahlenther Onkol. 1999; 175:378-381.
  12. Lenehan B, Fisher CG, Vaccaro A, et al. The urgency of surgical decompression in acute central cord injuries with spondylosis and without instability. Spine (Phila Pa 1976). 2010; 35(21):S180-S186.

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Last updated: 2018-06-21 23:29