Key Facts

Spinal cord compression is a time-critical emergency. Back pain with neurological deficit in a cancer patient is malignant cord compression until proven otherwise. Dexamethasone and urgent imaging should not be delayed.

Epidemiology

Malignant spinal cord compression (MSCC): ~4,000 cases/year in UK. Affects ~5% of cancer patients. Non-malignant: disc herniation is the commonest cause of non-malignant compression. Epidural abscess: ~1 per 10,000 hospital admissions.

Aetiology

Malignant (~70% of acute cord compression):

• Metastatic: lung, breast, prostate, renal, myeloma, lymphoma
• Vertebral body collapse/pathological fracture → posterior displacement into canal
• Direct epidural tumour extension

Non-Malignant:

• Disc herniation (usually cervical or lumbar; thoracic disc rare but dangerous)
• Epidural abscess (S. aureus most common; risk: IVDU, immunosuppression, spinal procedures)
• Epidural haematoma (anticoagulants, post-procedure, coagulopathy)
• Vertebral fracture (osteoporotic, traumatic)
• Degenerative: cervical spondylotic myelopathy (commonest cause of chronic cord compression)

Pathophysiology

Compression of the spinal cord causes mechanical damage + ischaemia (compression of spinal arteries and venous plexus) → oedema → further compression (vicious cycle). UMN signs develop below the level of compression. A sensory level corresponds to the dermatome at the level of the lesion. Sphincter dysfunction occurs late because autonomic fibres are in the central cord (protected until compression is severe). Speed of onset determines reversibility — acute complete cord syndromes have the worst prognosis.

Symptoms

• Back pain (90%): localised to level of compression; may be radicular (band-like around trunk); worse on coughing/straining/movement; progressive; often precedes neurological symptoms by weeks
• Limb weakness: progressive; initially subtle (leg heaviness, difficulty walking) → paraparesis/paraplegia
• Sensory loss: numbness, tingling below level; sensory level on examination
• Sphincter dysfunction (late): urinary retention (painless — overflow incontinence), constipation, loss of anal tone

Signs

• UMN signs below lesion: spasticity, hyperreflexia, upgoing plantars, clonus
• LMN signs AT level: wasting, fasciculations, reduced reflexes (anterior horn cells)
• Sensory level: pin-prick/temperature loss below level; posterior columns (vibration, proprioception) may be selectively affected depending on pathology
• Reduced anal tone and perianal sensation: loss of S2-S4 function

Red Flags (NICE NG149 — MSCC)

• Known cancer + new back pain + any neurological symptom → MSCC until proven otherwise
• Progressive bilateral leg weakness
• Urinary retention/incontinence with back pain
• Saddle anaesthesia
• Rapidly progressive symptoms (hours-days)

Imaging (Urgent)

• MRI whole spine with gadolinium: gold standard; must image ENTIRE spine (multiple levels affected in ~30% of MSCC)
• Identifies: site of compression, cause (tumour, disc, abscess, haematoma), extent, cord signal change
• Within 24 hours of suspected MSCC (NICE NG149); within 1 hour if rapidly progressive
• CT myelogram: if MRI contraindicated

Bloods

• FBC, CRP, ESR: infection (abscess)
• Coagulation: haematoma risk; before any spinal procedure
• PSA, myeloma screen (SPEP, urine BJP, calcium): if metastatic disease suspected
• Blood cultures: if epidural abscess suspected

Other

• CT chest/abdomen/pelvis: staging if new malignancy diagnosed
• Post-void residual bladder scan: urinary retention assessment
• Bone biopsy: if unknown primary with vertebral collapse

Malignant Cord Compression (NICE NG149)

• IV dexamethasone 16mg STAT → 16mg/day in divided doses (reduces vasogenic oedema around tumour); PPI cover; glucose monitoring
• Urgent MSCC coordinator contact: coordinate imaging and treatment
• Surgical decompression ± stabilisation: posterior decompressive laminectomy or anterior approach; best outcomes if walking at time of surgery (Patchell trial — surgery + RT superior to RT alone for single-level MSCC)
• Radiotherapy: alone if not surgical candidate; or adjuvant post-surgery; urgent (within 24 hours of confirmed MSCC)
• Oncological treatment: systemic therapy (chemo/immunotherapy/hormonal) for underlying malignancy

Non-Malignant Causes

• Disc herniation: urgent surgical decompression (discectomy) if progressive deficit
• Epidural abscess: emergency surgical drainage + IV antibiotics (flucloxacillin 2g QDS + ceftriaxone); 6 weeks antibiotics minimum
• Epidural haematoma: emergency surgical evacuation; correct coagulopathy
• Cervical spondylotic myelopathy: surgical decompression (anterior or posterior approach) if progressive

Supportive

• VTE prophylaxis (LMWH + compression stockings)
• Bladder catheterisation if retention
• Pressure area care
• Physiotherapy and rehabilitation
• Pain management (neuropathic: gabapentin/pregabalin; opioids for severe)

Referral Criteria

• All suspected cord compression: emergency neurosurgery/spinal surgery
• MSCC: MSCC coordinator, oncology
• Cancer team: for ongoing systemic treatment

Neurological status at treatment is the strongest predictor: ambulant at treatment → ~80% remain ambulant; paraparesis → ~40% regain walking; paraplegia >48 hours → <10% recover walking. Malignant cord compression: median survival 3-6 months (depends on primary). Epidural abscess: good outcomes if treated before established deficit. Cervical myelopathy: surgical decompression halts progression in most; recovery variable.

Spinal Cord Compression — Level Localisation

Patchell Trial (2005)