inpatient / neurology
Spinal Cord Compression
# Spinal Cord Compression
Assessment:
-- History: *** malignancy, IVDU, trauma, disc herniation, AC use
-- Clinical/Exam: *** back pain, LE weakness, saddle anesthesia, bowel/bladder dysfunction (incontinence, urgency, retention, loss of rectal tone), hyperreflexia and pos Babinski if chronic, loss of sensation below the affected level of cord
-- Data: *** MRI
-- Etiology/DDx: *** tumor/metastases, trauma, hematoma, vertebral fracture, epidural abscess
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- Imaging: *** STAT whole spine MRI with IV contrast
-- Consults: *** neurosurgery, radiation oncology
Treatment
-- Steroids: *** dexamethasone 10mg IV load, then 4mg q6; taper of 10-14 days, switch to PO when clinically stable
PDF coming soon!
If You Remember Nothing Else
If there is concern for cord compression from tumor (paresis, saddle anesthesia, bladder/fecal incontinence), get an MRI immediately and involve the neurosurgery and radiation therapy teams for guidance of steroids and the timing of surgery vs RT.
Clinical Pearls
- For tumors causing compression, surgery is generally the first choice with post-op RT, unless not a surgical candidate in which case palliative RT options are the best route; there is no role for chemo in the acute setting, as it has too slow an effect to lead to acceptable outcomes
- Adverse events associated with high dose steroids - bowel perf, bleeding, psychosis, infection; also watch for hyperglycemia, insomnia, gastritis
- Significant neurological improvements if steroids given within 8 hours of injury
- Cauda equina typically manifests with lower motor neuron signs whereas spinal cord compression and conus medullaris have lower motor neuron signs at level of compression and upper motor neuron signs below
- Cauda Equina - L3-S5, unilateral, gradual sxs, flaccid paresis, saddle anesthesia (anus, genitals, inner thighs)
- Conus Medullaris - T12-L2, sudden and bilateral sxs, hyperreflexia, early onset bladder/fecal incontinence
- Cauda Equina - L3-S5, unilateral, gradual sxs, flaccid paresis, saddle anesthesia (anus, genitals, inner thighs)
- Cauda Equina - L3-S5, unilateral, gradual sxs, flaccid paresis, saddle anesthesia (anus, genitals, inner thighs)
Trials and Literature
- Surgery + RT > RT alone for functional outcomes - most pronounced for helping those with ambulatory dysfunction to regain function; RT very effective at preventing progression of worsening ambulation if treated early, but alone not good at helping to regain already lost function
- Significant neurological improvements if steroids given within 8 hours of injury - Dexamethsone 10mg load with 16mg daily dose is non-inferior to 100mg load and 96mg daily (noting that 1mg dex is about equal to 5mg pred)
Other Resources
