Definition
Spinal cord injury 2’ to external pressure = injury to white matter and grey matter in cord resulting in loss of sensory and motor function
Types of spinal cord compression
Acute
Sub-acute
Chronic
When is spinal cord compression classed as cauda equina syndrome
L1/L2
Aetiology
- Trauma: car accidents, sport injuries, knife injury
- Vertebral compression fractures: osteoporosis, osteomalacia, spinal subluxation
- Intervertebral disc disease: disc herniation, disc protrusion
- Tumours: metastatic disease, primary sarcoma, CNS tumours
- Infection: discitis, epidural abscess, TB (Pott’s disease), osteomyelitis
Epidemiology
- Trauma (MC) - 16-30 year olds
- High risk sporting activity: horse-riding, motor racing, diving
- High risk occupation: construction, military, firefighting
- Malignancy: breast, prostate, renal, lung, multiple myeloma mets
- Age
- Immunosuppression: osteomyelitis, discitis, epidural abscess
- IV drug use: osteomyelitis, discitis, epidural abscess
Signs
UMN weakness below lesion
- loss of muscle power
- increased tone
- hyperflexia
Sensory deficit: pinprick, fine touch, vibration, temperature, joint-position sense
Spinal shock:
- hypo- or areflexia below the level of injury
- motor paralysis below the level of injury
Neurogenic shock:
- typically cervical/high thoracic injury
- bradycardia
- peripheral vasodilation
- poikilothermia
- decreased cardiac output
- priapism
Symptoms
- Acute onset: more likely trauma or disc herniation
- Insidious onset: more likely malignancy, osteoporosis
- Back pain
- Paresthesia
- Weakness
- Bladder or bowel dysfunction
Complete spinal cord injury
All motor and sensory function below the SCI level lost
E.g. high cervical cord level
- quadriplegia
- respiratory insufficiency
- loss of bladder and bowel function
- neurogenic shock
Central cord syndrome
- Usually involves cervical spine
- Weakness in upper extremities > weakness in lower extremities
- Variable sensory loss below the level of injury
- Most common pattern of incomplete SCI
Anterior cord syndrome
- Disruption of anterior spinal cord or anterior spinal artery
- Loss of motor function below the level
- Loss of pain and temperature sensation (anterior column)
- Preservation of fine touch and proprioception (posterior column)
Posterior cord syndrome
- Disruption of posterior spinal cord or posterior spinal artery (rare)
- Motor function retained
- Loss of fine touch and proprioception (posterior column)
- Preservation of pain and temperature sensation (anterior column)
Brown-sequard syndrome
- Hemisection lesion of the spinal cord
- Unilateral spastic paralysis
- Ipsilateral loss of vibration and proprioception
- Contralateral loss of pain and temperature sensation
Diagnosis
FIRST LINE:
- Full neurological examination: tone, power, sensation, reflexes, proprioception
- GOLD STANDARD = MRI whole spine
= Rarely spinal cord injury without radiographic abnormality (SCIWRA) may occur.
Consider:
- Blood cultures: osteomyelitis suspected
- CSF culture: epidural abscess or CNS infection
- CT thorax, abdomen and pelvis: sus met disease
Treatment MDT support
- VTE prophylaxis: due to reduced mobility
- Nutritional input: if dysphagia or reduced oral intake
- Blood pressure support: if neurogenic shock
- PPI cover : to prevent gastric stress ulceration
- Ventilatory support: if high cervical lesion affecting respiratory effort
- Physiotherapy
Acute traumatic SCC Tx
- Immediate immobilisation
- Surgical spinal cord decompression and stabilisation
- IV corticosteroids: not always used in traumatic SCC, CI in gunshot injury due to limited evidence
Malignanct SCC Tx
- Dexamethasone: reduce inflammation
- Radiotherapy: usually performed as a palliative measure in context of metastatic disease
- Surgery: depending on impact of radiotherapy, age and prognosis
Infective spinal cord compression
(e.g. epidural abscess)
- IV antibiotics
- Surgery: spinal cord decompression vs CT-guided needle aspiration if antibiotic therapy is insufficient
Complications
- Respiratory compromise
- CV dysfunction: bradycardia , AV block , SVT , cardiac arrest
- Autonomic dysfunction : orthostatic hypotension, heat intolerance, impaired bladder and bowel control
- Pressure ulcers: LOM
- Thromboembolism : reduced mobility
- UTI : increased risk with impaired bladder emptying
- Heterotopic ossification
- Depression
- Iatrogenic complications : haemorrhage, infection, nerve root injury during operation
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Essential tremor11
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Muscular dystrophies10
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Brain Abscess11
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Brain metastases9
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Acoustic neuroma12
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Bulbar Palsy7
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Cerebellar Syndrome6
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Cerebral Palsy12
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Spinal Cord Compression18
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Cauda equina syndrome9
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Spinal Cord Injury11
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Meniere's Disease9
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Delerium14
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Narcolepsy6
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Mononeuropathy - Meralgia Paraesthetica7
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Neurofibromatosis8
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Normal Pressure Hydrocephalus10
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GCS score4
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Idiopathic Intracranial Hypertension6
