Spinal Cord Compression

⚠️ Spinal cord compression is a neurological emergency. Delays in diagnosis and treatment can lead to irreversible paralysis, sphincter disturbance, and reduced survival in malignant cases.

ℹ️ About

• Occurs when the spinal cord is compressed by tumour, abscess, bone fragment, or disc herniation.
• Most common cause in adults = metastatic cancer (especially breast, lung, prostate, lymphoma, myeloma). 🦠
• Other causes: trauma, spinal infections (TB, abscess), degenerative disease, epidural haematoma.

🧬 Pathophysiology

• Compression → venous congestion + ischaemia → oedema → neuronal damage.
• Progressive cord injury if untreated → permanent motor, sensory, autonomic loss.
• In malignancy: epidural extension from vertebral metastasis is typical.

🩺 Clinical Features (Red Flags)

• Early: back pain (constant, nocturnal, worse on coughing/straining).
• Motor: limb weakness, heaviness, difficulty walking 🦵.
• Sensory: numbness, paraesthesia, sensory level.
• Autonomic: bladder retention, incontinence, constipation, sexual dysfunction 🚻.
• Exam: UMN signs below level (hyperreflexia, spasticity, Babinski), LMN at level.

⚖️ Common Causes

🔎 Investigations

• 🏥 Urgent whole-spine MRI – gold standard.
• 🧪 Bloods: FBC, CRP/ESR, calcium, PSA (if suspected malignancy), tumour markers.
• 🩻 Plain X-ray: may show vertebral collapse, lytic/blastic lesions, but low sensitivity.
• CT: useful if MRI unavailable/contraindicated.
• Biopsy (if malignancy suspected and diagnosis uncertain).

💊 Management (Emergency)

• 🚑 Immediate: high-dose corticosteroids (dexamethasone IV), analgesia, spinal immobilisation if unstable.
• 📞 Urgent referral to spinal/neurosurgical or oncology team.
• 🔬 Definitive treatment:
  • Malignant: radiotherapy ± surgical decompression (if unstable spine or radioresistant tumour).
  • Infective: IV antibiotics, surgical drainage if abscess.
  • Trauma: urgent surgical decompression + stabilisation.
• 🧾 Supportive: bladder catheterisation if retention, VTE prophylaxis, physiotherapy, palliative care input if advanced cancer.

📈 Prognosis

• Outcome depends on neurological function at diagnosis.
• Patients walking at presentation have better chance of retaining mobility.
• Delayed recognition → irreversible paralysis, sphincter loss.
• Malignant SCC: median survival ~3–6 months, but varies with tumour type and treatment response.

🎯 Exam Pearls

• Back pain + neurological symptoms in a cancer patient = malignant spinal cord compression until proven otherwise 🚨.
• Always MRI whole spine urgently – skip X-ray unless no MRI available.
• Dexamethasone IV = first-line emergency measure.
• On exam: UMN signs below lesion, LMN signs at lesion.
• Differentiate from cauda equina: cauda equina = LMN signs, saddle anaesthesia, areflexic bladder.

🧩 Case 1 — Malignant Spinal Cord Compression

A 68-year-old man with known prostate cancer presents with progressive back pain, worse at night and on coughing, followed by new-onset leg weakness and urinary hesitancy. Examination reveals lower limb weakness, brisk reflexes, and sensory loss below the umbilicus. 💡 Malignant spinal cord compression is most often due to vertebral metastases from prostate, breast, or lung cancer. It is an oncological emergency: high-dose corticosteroids should be started immediately, with urgent MRI spine and referral for neurosurgical or oncological intervention (radiotherapy or surgery).

🧩 Case 2 — Spinal Epidural Abscess

A 55-year-old man with poorly controlled diabetes presents with fever, severe mid-thoracic back pain, and rapidly progressive leg weakness. Examination shows paraparesis and saddle anaesthesia. 💡 Spinal epidural abscess causes cord compression from pus within the spinal canal, often due to Staphylococcus aureus. Classic triad is back pain, fever, and neurological deficit. Diagnosis is by urgent MRI, and management requires prompt IV antibiotics and surgical decompression to prevent permanent paralysis.

🧩 Case 3 — Traumatic Vertebral Fracture

A 35-year-old man is brought to A&E after a road traffic accident, complaining of severe lumbar pain and inability to move his legs. Examination shows flaccid paraplegia, absent reflexes, and loss of sensation below L1. 💡 Traumatic vertebral fracture with retropulsed bone fragments can directly compress the spinal cord. Immediate immobilisation, high-dose steroids (in some centres), and urgent neurosurgical assessment are essential. Long-term outcomes depend on the severity and completeness of the initial cord injury.