Acute Spinal Cord Compression

Acute spinal cord compression is a neurosurgical emergency. Rapid diagnosis and management is needed to have the highest chances of preventing permanent loss of function. When assessing a patient with neck and/or back pain, be alert to 'red flags' in the history and examination which may indicate possible spinal cord compression (see below).

There is a separate article that discusses Cauda Equina Syndrome.

There are also separate articles that discuss:
Spinal Cord Injury
Spinal Disc Problems (including Red Flag Signs)
Cervical Disc Protrusion and Lesions.

• There are 4 sections of the spine: cervical, thoracic, lumbar and sacral. There are 7 cervical, 12 thoracic, 5 lumbar and 5 sacral vertebrae.
• The spinal cord is shorter than the spinal canal. In adults, the spinal cord ends at the L1/L2 interspace.¹ Below this, the nerve roots of the lumbosacral plexus make up the cauda equina.²
• In the cervical spine, segmental levels of cord roughly correspond to bony landmarks. Below this level there is increasing disparity between levels.¹
• Spinal pathology below L1 of the vertebral column produces only root signs.¹
• The presence of the epidural space that separates the dura mater of the spinal cord from the periosteum of the vertebrae means that processes such as bleeding, neoplasm and infection can reach an advanced stage before neurological symptoms and signs are present.²

Spinal cord compression may be caused by:

• Trauma (including car accidents, falls and sports injuries)
  • There is usually either vertebral fracture (most common in cervical vertebrae)² or facet joint dislocation.
  • Complete transection of the spinal cord can occur.
  • Hemisection of the spinal cord can occur and is known as Brown-Séquard's syndrome. It is usually caused by penetrating trauma.²
• Tumours, both benign or malignant
  • These can include tumours of bone, primary or metastatic tumours, lymphomas, multiple myeloma or even neurofibromata.
  • Acute myelopathy in patients with cancer can also be caused by irradiation, paraneoplastic necrotising myelitis, ruptured intervertebral disc and meningeal carcinomatosis with spinal cord involvement.²
• A prolapsed intervertebral disc
  • L4-L5 and L5-S1 are the most common levels for disc prolapse.² Large disc herniations can cause cauda equina syndrome. A separate article discusses cauda equina syndrome in more detail.
  • Cervical disc herniation can also occur.
• Spinal stenosis
  • This can also lead to cauda equina syndrome.²
• An epidural or subdural haematoma
  • There may be a history of trauma, a recent spinal procedure and/or the patient may be on anticoagulant therapy.²
• Inflammatory disease, especially rheumatoid arthritis
  • In rheumatoid arthritis there is often considerable weakness of the ligament that holds the odontoid peg. If this ruptures the atlas can slip forward on the axis and compress the high cervical spine.
• Infection
  • Spinal infections can be acute or chronic.
  • Acute infections are usually bacterial; chronic infections are usually due to tuberculosis or fungal infection.²
  • Vertebral osteomyelitis, discitis or haematogenous spread of infection can lead to an epidural abscess.²
• Cervical spondylitic myelopathy
  • The ageing process can lead to narrowing of the spinal canal due to osteophytes, herniated discs and ligamentum flavum hypertrophy.
  • In advanced stages, it can cause spinal cord compression.³
• Spinal manipulation
  • Damage to the spinal cord may be a very rare complication of chiropractic or osteopathic manipulation of the neck. This is discussed in more detail in the separate article Back Manipulation.

When assessing a patient who presents with neck or back pain or who may have spinal cord injury secondary to acute trauma, be alert to red flag signs in the history and examination.

Other features in the history and examination

There are different patterns of spinal cord injury (complete cord injury, anterior cord syndrome, Brown-Séquard's syndrome etc.) and these are discussed in the separate article Spinal Cord Injury. The features of cauda equina syndrome are also discussed in the dedicated article.
In general, clinical features depend upon the extent and rate of development of cord compression.¹

• Motor symptoms can include ready fatigue and disturbance of gait.
• Cervical spine lesions can produce quadriplegia.
• Thoracic spine lesions produce paraplegia.
• Lumbar spine lesions can affect L4, L5 and sacral nerve roots.
• Sensory symptoms can include sensory loss and paraesthesia. Light touch, proprioception and joint position sense are reduced.
• There can be root pain in the legs.
• Tendon reflexes are typically:
  • Increased below the level of compression.
  • Absent at the level of compression.
  • Normal above the level of compression.
  • Sphincter disturbances are late features of cervical and thoracic cord compression.
  • There may be loss of autonomic activity with lack of sweating below the level, loss of thermoregulation and drop in peripheral resistance causing hypotension.

• AP, lateral and special view (e.g. odontoid) X-rays of the spine can show fractures. You should be able to see T1 on cervical spine X-ray to exclude a lower cervical fracture.⁶
• CT and MRI scanning can also be useful to show neural tissues, soft tissue changes, cord oedema etc.⁶
• The article on Spinal Cord Injury discusses investigations of suspected traumatic spinal cord injury and compression in more detail.
• The NICE recommendations for the investigation of possible spinal cord compression due to spinal metastases are discussed further below.

• Suspect spinal injury with any trauma, especially if there is trauma to the head and neck and the neck should be stabilised until injury is excluded.⁶
  • Spinal stabilisation, immobilisation and resuscitation are vital in an acute traumatic injury.
  • A spinal board and cervical collar should be used as available. The log roll technique should be used when moving the patient. A trauma team should be involved.
  • Assess and manage Airway, Breathing and Circulation.
• Subsequent management depends on the cause of the spinal cord compression.
  • If there is metastatic disease, radiotherapy and/or steroids may be considered.
  • Early surgery to remove damaging bone, disc, and foreign bodies is controversial unless severe compromise of the canal is clear.⁶
  • Corticosteroids are sometimes used in acute spinal cord injury.⁶
• Prophylaxis for venous thromboembolism should be considered.
• Catheterisation may be needed depending on the amount of voluntary control present.⁶
• In the longer term, the focus needs to be on rehabilitation. There also needs to be careful management and prevention of potential complications.
  • Gastrointestinal, including ileus, constipation, ulcers.
  • Genitourinary, including urinary tract infections and hydronephrosis.
  • Dermatological, including pressure sores.
  • Musculoskeletal, including osteoporosis, contractures and chronic pain.
• Psychological and emotional support of the patient will also be needed.⁶
• The management of suspected traumatic spinal cord compression is discussed in more detail in the article Spinal Cord Injury - click here.
• The management of spinal cord compression due to spinal metastases according to NICE guidelines is discussed further below.

• Metastatic epidural spinal cord compression affects almost 5% of patients with cancer.⁷ However, less than 0.1% of people who visit their general practitioner with back pain have spinal metastases.⁸
• In those with spinal metastases, spinal pain is often present for three months and neurological symptoms for two months before paraplegia; however, almost 50% of patients are unable to walk by the time of diagnosis. Of these, almost 70% remain immobile. Of those able to walk at treatment, about 80% remain ambulant.^8,9,10
• 23% of patients with spinal metastases have no previous cancer diagnosis.⁹
• The thoracic spine is most commonly affected in metastatic cancers.²

NICE recommendations for the diagnosis and management of patients at risk of or with metastatic spinal cord compression^8,11

• The aims of the NICE guidelines are to accelerate the diagnosis of spinal cord compression and to ensure that appropriate specialist management, usually surgery and/or radiotherapy, is available within 24 hours of presentation.¹² The goal is to prevent paralysis from metastatic spinal cord compression.
• Patients with cancer who have bone metastases, are at high risk of developing bone metastases, or who present with spinal pain should be given information on the symptoms of spinal metastases and metastatic spinal cord compression, as well as what to do and whom to contact if symptoms develop or worsen while waiting for investigation or treatment.
• Healthcare workers should be alert to the following symptoms suggesting spinal metastases in those with cancer. They should contact the metastatic spinal cord compression co-ordinator at the nearest centre treating this condition within 24 hours. Specific guidelines for the role of the metastatic spinal cord compression co-ordinator are laid out in the NICE guidance.
  • Pain in the thoracic or cervical spine.
  • Severe unremitting or progressive lumbar spinal pain.
  • Spinal pain aggravated by straining (e.g. coughing, sneezing, passing stool).
  • Nocturnal spinal pain preventing sleep.
  • Localised spinal tenderness.
• Healthcare workers should be alert to the following symptoms suggesting metastatic spinal cord compression in patients with cancer and pain suggestive of spinal metastases. The metastatic spinal cord compression co-ordinator should be contacted immediately.
  • Radicular pain.
  • Limb weakness.
  • Difficulty in walking.
  • Sensory loss, or bladder or bowel dysfunction.
  • Neurological signs of spinal cord or cauda equina compression.
• MRI of the whole spine (not plain X-rays) should be carried out so that definitive treatment can be planned. This should be:
  • Within 1 week if clinical features suggest spinal metastases.
  • Within 24 hours if clinical features suggest spinal cord compression.
  • Sooner (including out of hours) if emergency treatment is needed.

Management of those with spinal cord compression according to NICE guidelines

• Nurse the patient flat with the spine in neutral alignment (e.g. using log rolling or turning beds) until spinal and neurological stability are ensured.
• Give a course of dexamethasone unless contraindicated until a definitive treatment plan is made.
• Manage postural hypotension with positioning and devices to improve venous return; avoid overhydration.
• Insert a catheter to manage bladder dysfunction.
• Use breathing exercises, assisted coughing, and suctioning to clear airway secretions.
• Follow the NICE guidance for the prophylaxis of venous thromboembolism, the prevention and treatment of pressure ulcers, and the management of bowel dysfunction.
• Offer and provide psychological and spiritual support as needed (including after discharge).
• Analgesia, palliative radiotherapy, spinal orthoses, vertebroplasty or kyphoplasty, or spine stabilisation surgery may be required for pain control.
• Bisphosphonates should be offered to all patients with vertebral involvement from myeloma and breast cancer and to patients with prostate cancer in whom conventional analgesia is inadequate.
• Specialist pain control procedures may be needed for intractable pain (e.g. epidural analgesia).
• If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or other neurological deterioration occurs, and ideally within 24 hours.
• Definitive treatment may be using surgery (e.g. laminectomy, posterior decompression ± internal fixation) or using radiotherapy.
• Discharge should be fully planned and community based rehabilitation and support should be available when the patient returns home. This includes support and any necessary training of carers and families.

• The complications of acute spinal cord compression are related to irreversible damage to the cord if it is not decompressed very soon. The spinal cord has very limited powers of regeneration.
• Compression at the level of the thoracic spine causes paraplegia. Compression in the neck causes quadriplegia and, if it is above the level of C3, C4, C5 (the segmental level of the phrenic nerve), the diaphragm is paralysed and artificial ventilation is required.
• After spinal cord trauma, in general, most individuals regain one level of motor function, mostly within the first 6 months, although there may be further improvement observed years later.⁶
• Depression can occur and those with spinal cord injury have an increased risk of suicide.⁶
• Leading causes of death after spinal cord injury include pneumonia, pulmonary emboli, septicemia and renal failure.⁶
• Complications and prognosis after spinal cord trauma are discussed in more detail here in the article Spinal Cord Injury.

• When car seatbelts were introduced and then made compulsory, it had a beneficial effect on reducing deaths and injuries. However, the risk of severe whiplash injury causing trauma to the cervical cord was increased until head restraints became standard in all cars.
• It can be argued that motor cycle crash helmets, because they make the head heavier, increase the risk of damage to the cervical spine. However, on balance, they seem to do more good than harm.
• Amongst sports, rugby is high risk in terms of injuries to the cervical spine. Recent changes in the rules have attempted to reduce the risk of serious injury to the neck.
• Equestrian sports remain a high risk for cervical spine injuries.