Approach to the Patient: Spinal Cord Compression

Initial symptoms of focal neck or back pain may evolve over days to weeks; followed by combinations of paresthesias, sensory loss, motor weakness, and sphincter disturbance evolving over hours to several days. Partial lesions may selectively involve one or more tracts and may be limited to one side of the cord. In severe or abrupt cases, areflexia reflecting spinal shock may be present, but hyperreflexia supervenes over days to weeks. With thoracic lesions, a sensory level to pain may be present on the trunk, indicating localization to the cord at that dermatomal level.

In pts with spinal cord symptoms, the first priority is to exclude treatable compression by a mass. Compression is more likely to be preceded by warning signs of neck or back pain, bladder disturbances, and sensory symptoms prior to development of weakness; noncompressive etiologies such as infarction and hemorrhage are more likely to produce myelopathy without antecedent symptoms.

MRI with gadolinium, centered on the clinically suspected level, is the initial diagnostic procedure. CT myelography can be helpful in pts who have contraindications to MRI. It is important to image the entire spine to search for additional clinically silent lesions. Infectious etiologies, unlike tumor, often cross the disc space to involve adjacent vertebral bodies.