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Information ⬇

[Section Outline]
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.

Neoplastic Spinal Cord Compression !!navigator!!

Occurs in 5-10% of pts with cancer; epidural tumor may be the initial manifestation of malignancy. Most neoplasms are epidural in origin and result from metastases to the adjacent spinal bones. Almost any malignant tumor can metastasize to the spinal column, with lung, breast, prostate, kidney, lymphoma, and plasma cell dyscrasia being particularly frequent. The thoracic cord is most commonly involved; exceptions include prostate and ovarian tumors, which preferentially involve the lumbar and sacral segments from spread through veins in the anterior epidural space. Urgent MRI is indicated when the diagnosis is suspected; up to 40% of pts with neoplastic cord compression at one level are found to have asymptomatic epidural disease elsewhere, thus, imaging of the entire length of the spine is important to define the extent of disease. Plain radiographs will miss 15-20% of metastatic vertebral lesions.

TREATMENT

Neoplastic Spinal Cord Compression

  • Glucocorticoids to reduce edema (typically dexamethasone, 10 mg intravenously) can be administered before the imaging study if the clinical suspicion is high, and continued at a lower dose (4 mg every 6 h orally) until radiotherapy (generally 30-40 Gy administered in 8-10 fractions) and/or surgical decompression is completed.
  • Early surgery, either decompression by laminectomy or vertebral body resection, followed by radiotherapy is more effective than radiotherapy alone for pts with a single area of spinal cord compression by extradural tumor. Surgery also indicated when cord compression worsens despite radiotherapy, when maximum dose of radiotherapy has been delivered previously to the site, or when a vertebral fracture or spinal instability contributes to cord compression.
  • Newer techniques such as stereotactic radiosurgery can deliver high doses of focused radiation with similar rates of response compared to traditional radiotherapy; these are increasingly being used, particularly for pts with radioresistant tumors or requiring re-irradiation.
  • Time is of the essence; fixed motor deficits (paraplegia or quadriplegia) established for >12 h do not usually improve, and beyond 48 h the prognosis for substantial motor recovery is poor.
  • Biopsy is needed if there is no history of underlying malignancy; a simple systemic workup including chest imaging, mammography, measurement of prostate-specific antigen (PSA), and abdominal CT usually reveals the diagnosis.

Spinal Epidural Abscess !!navigator!!

Presents as a triad of pain, fever, and progressive limb weakness. Aching pain is almost always present, either over the spine or in a radicular pattern. The duration of pain prior to presentation is generally <2 weeks but may be several months or longer. Fever is usually present along with elevated white blood cell count, sedimentation rate, and C-reactive protein. Risk factors include an impaired immune status (diabetes mellitus, HIV, renal failure, alcoholism, malignancy), intravenous drug abuse, and infections of skin or other soft tissues. Most cases are due to Staphylococcus aureus; other causes include gram-negative bacilli, Streptococcus, anaerobes, fungi, and tuberculosis. Methicillin resistant Staphylococcus aureus (MRSA) is an additional consideration, and therapy should be tailored to this possibility.

MRI localizes the abscess. Lumbar puncture (LP) is required only if encephalopathy or other clinical signs raise question of associated meningitis, a feature found in <25% of cases. The level of the LP should be planned to minimize risk of meningitis due to passage of the needle through infected tissue.

TREATMENT

Spinal Epidural Abscess

  • Decompressive laminectomy with debridement combined with long-term antibiotic treatment.
  • Surgical evacuation is unlikely to improve deficits of more than several days duration.
  • Broad-spectrum antibiotics (typically vancomycin 15-20 mg/kg q12h (staphylococcus including MRSA, streptococcus), ceftriaxone 2 gm q24h (gram-negative bacilli), and when indicated metronidazole 30 mg/kg/d divided into q6h intervals (anaerobes) should be started empirically before surgery, modified on the basis of culture results, and continued for 6-8 weeks.
  • With prompt diagnosis and treatment, up to two-thirds of pts experience significant recovery.

Spinal Epidural Hematoma !!navigator!!

Hemorrhage into the epidural (or subdural) space causes acute focal or radicular pain followed by variable signs of a spinal cord disorder. Therapeutic anticoagulation, trauma, tumor, or blood dyscrasia is a predisposing condition; rarely, hematomas complicate LP or epidural anesthesia. Treatment consists of prompt reversal of any underlying bleeding disorder and surgical decompression.

Outline ⬆

Section 2. Medical Emergencies