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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.

Weakness
  • […] signs and segmental sensory loss in the arms; upper motor neuron signs in the legs Respiratory (intercostal) weakness Thoracic Spastic paraplegia with a sensory level at the trunk Weakness of the legs, sacral loss of sensation and extensor (upward) plantar[dundeemedstudentnotes.wordpress.com]
  • A case is described in a 45-year-old male with renal cell carcinoma in which the presentation of the MSCC was atypical with principally proximal left leg weakness with no evidence of bone metastasis.[ncbi.nlm.nih.gov]
  • We present a case of 50 year old male who came to the hospital with back pain and progressive bilateral lower limb weakness for the past 6 months. Imaging studies revealed enhancing lesions on dorsal spines.[ncbi.nlm.nih.gov]
  • As we age, our bones become more brittle and weak, putting strain on the surrounding nerves.[intermountainhealthcare.org]
  • Abstract A 4-year-old Cambodian male presented to the emergency room with 2 weeks of gradually increasing leg weakness until he could no longer stand. He was also reported to have a deformity on his back, intermittent fevers and cough.[ncbi.nlm.nih.gov]
Difficulty Walking
  • Cervical myelopathy is a syndrome of difficulty walking, hand clumsiness, arm weakness, and/or numbness/tingling caused by compression of the spinal cord.[uncmedicalcenter.org]
  • Spinal cord compression can cause neurologic symptoms—such as pain, numbness, or difficulty walking. Your spinal cord is the conduit that enables communication between your brain and body.[spineuniverse.com]
  • New difficulty walking or climbing stairs; reduced power (motor weakness), Sensory impairment or altered sensation in limbs. Bowel or bladder disturbance; loss of sphincter control is a late sign with a poor prognosis.[palliativecareguidelines.scot.nhs.uk]
Falling
  • Patients with MESCC should receive surgery before the preoperative ASIA Impairment Scale grade falls below grade C.[ncbi.nlm.nih.gov]
  • Causes of spinal cord compression include trauma (such as auto accidents, falls, sports injury, epidural injection), spinal abscess, tumor, hematoma or blood clot, ruptured or herniated disk, and spinal stenosis. .[medicalmalpracticeinquirer.com]
  • Accidents and injuries such as car accidents, falls, and contact sports, can injure the neck and cause spinal cord compression. The most severe neck injuries are neck fractures or dislocations.[thespinehealthinstitute.com]
  • An injury to the neck—such as from a car accident, sports, or a fall—may also lead to myelopathy.[orthoinfo.aaos.org]
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]
  • 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 and/or urinary retention.[en.wikipedia.org]
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]
  • RESULTS: Pre-operative back pain was 7.2 on a visual analogue scale.[ncbi.nlm.nih.gov]
  • Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC.[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]
Low Back Pain
  • 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]
  • Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):228-39. (Level II evidence).[imagingpathways.health.wa.gov.au]
  • Red flags See also separate Neck Pain (Cervicalgia) and Torticollis and Low Back Pain and Sciatica articles. Red flags that suggest spinal compression include: Insidious progression.[patient.info]
  • back pain, pain in leg, Sherman Mau diseases Lumbago, sciatica and lumbodynia Lumbar disc disease (herniated disc, bulging disc) Meningovascular syphilis or syphilitic myelopathy (tabes dorsalis) Cervicocranial syndrome and whiplash neck injury Neck[minclinic.ru]
Muscle Weakness
  • Symptoms, such as back pain, abnormal sensations, muscle weakness, or impaired bladder and bowel control, may be mild or severe.[msdmanuals.com]
  • Mild compression may lead to a prickling or tingling sensation, backache, muscle weakness and erectile dysfunction.[symptoma.com]
  • After the corticosteroids injections in two days the severity of the legs muscle weakness (paraparesis) in patients often decreases. In some early partial spinal cord transverse lesion syndromes, neurosurgical treatment may be advisable.[minclinic.ru]
Spine Pain
  • Treatment of a SCC differs in those patients whose spine is unstable compared to those with a stable spine.[austinpublishinggroup.com]
Lordosis
  • VAS was significantly improved postoperatively ( p p  0.002), with improvements in lumbar lordosis (8.3   7.3 degrees) and thoracic kyphosis (2.4   7.1 degrees) postoperatively.[ncbi.nlm.nih.gov]
Tingling
  • Mild compression may lead to a prickling or tingling sensation, backache, muscle weakness and erectile dysfunction.[symptoma.com]
  • Cervical myelopathy is a syndrome of difficulty walking, hand clumsiness, arm weakness, and/or numbness/tingling caused by compression of the spinal cord.[uncmedicalcenter.org]
  • Neurology, Weill Cornell Medical College; Attending Neurologist and Director, Neuromuscular Service and EMG Laboratory, New York Presbyterian Hospital-Cornell Medical Center Injuries and disorders can put pressure on the spinal cord, causing back pain, tingling[msdmanuals.com]
  • Symptoms that may be associated with cervical myelopathy include: Neck pain and stiffness Tingling Numbness Weakness Find yourself dropping things Hand clumsiness (eg, buttoning a shirt) Balance problems Difficulty walking Possible Causes There are many[spineuniverse.com]
Limb Weakness
  • We present a case of 50 year old male who came to the hospital with back pain and progressive bilateral lower limb weakness for the past 6 months. Imaging studies revealed enhancing lesions on dorsal spines.[ncbi.nlm.nih.gov]
  • PATIENT CONCERNS: A 28-year-old man presented with intermittent dorsodynia and bilateral lower-limb weakness and numbness. A magnetic resonance scan (MRI) showed an extradural lesion of the T6-T9 thoracic spine that lead to cord compression.[ncbi.nlm.nih.gov]
  • We report neurologic improvements, no sphincter disorder, persistent spasticity, and lower limbs weakness not affecting full ambulation.[ncbi.nlm.nih.gov]
  • METHODS: We present the case of a 33-year-old Caucasian woman with a 10-day history of thoracic back pain and a 1-day history of sudden-onset bilateral lower limb weakness and paresthesia from below the level of the umbilicus (American Spinal Injury Association[ncbi.nlm.nih.gov]
  • We report a 7-year-3-month-old girl who suffered from neck pain with restricted movement, poor appetite, body weight loss, mild right limbs weakness, and a non-tender neck mass.[ncbi.nlm.nih.gov]
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. Diagnosis is by X-rays but preferably magnetic resonance imaging (MRI) of the whole spine.[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]
  • Upper motor neurone signs in the lower limbs (Babinski's sign: up-going plantar reflex, hyperreflexia, clonus, spasticity). Lower motor neurone signs in the upper limbs (atrophy, hyporeflexia).[patient.info]
Paresthesia
  • METHODS: We present the case of a 33-year-old Caucasian woman with a 10-day history of thoracic back pain and a 1-day history of sudden-onset bilateral lower limb weakness and paresthesia from below the level of the umbilicus (American Spinal Injury Association[ncbi.nlm.nih.gov]
  • 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]
  • We herein report a case of periosteal chondroma in a 41-year-old male who presented with gait disturbance and paresthesia of both lower extremities.[ncbi.nlm.nih.gov]
  • Neck flexion can produce paresthesia (altered sensations), usually in the back, but sometimes into the extremities.[necksolutions.com]
  • Then develop a syndrome of transverse myelopathy with paresthesias, alternating with loss of sensitivity. Motor paresis starts in the toes and feet and rises to the spinal cord compression level.[minclinic.ru]
Unable to Walk
  • 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]
  • […] 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]
  • . • Poor prognosis • Lung or melanoma primary • Multiple spinal metastases • Visceral metastases • Unable to walk • Severe weakness • Recurrence after radiotherapy. 36.[slideshare.net]
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]
  • 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 and/or urinary retention.[en.wikipedia.org]
  • 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]

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].

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