Evaluating and Managing Spinal Cord Compression: The Bullet Points

March 10th, 2025

Introduction

Spinal cord compression is a medical emergency requiring rapid diagnosis and intervention to prevent permanent neurologic deficits. Diagnosing this condition can be challenging, as low back pain is a common complaint, but only a small percentage of cases result from spinal cord compression.

Common Causes:

• Degenerative disc disease (herniation, stenosis)
• Metastatic cancer (lung, prostate, breast)
• Spinal epidural abscess
• Spinal epidural hematoma (trauma, coagulopathy)
• Fractures
• Ligamentous injury

Key red flags include:

• New-onset motor/sensory deficits
• Bowel or bladder dysfunction (e.g., retention or incontinence)
• History of cancer, intravenous drug use, immunosuppression

Diagnosis

Clinical Evaluation

• Neurologic exam (motor, sensory, reflex testing)
• Rectal exam (assess anal tone in cauda equina syndrome)
• Post-void residual bladder scan (>100 mL suggests dysfunction)

Imaging

• Magnetic resonance imaging (MRI) (gold standard) → Best for evaluating soft tissue, nerve roots, and spinal cord compression
• Computed tomography (CT) scan → Useful for detecting bony abnormalities but may miss soft tissue causes
• CT myelography → Alternative if MRI is contraindicated

Management Based on Etiology

Degenerative Disc Disease & Herniation

• Symptoms: Progressive radiculopathy, new motor deficits
• Imaging: MRI for herniation, stenosis, CT for visualizing vertebral anatomy and preoperative planning
• Treatment:
  • Mild cases: Conservative management
  • Severe cases: Surgical decompression

Metastatic Spinal Cord Compression

• Symptoms: Progressive pain (worse at night), weakness, ataxia, autonomic dysfunction
• Imaging: MRI (entire spine; metastases often affect multiple levels), CT if MRI is contraindicated
• Treatment:
  • Corticosteroids (dexamethasone) to reduce inflammation
  • Surgical decompression (if prognosis allows)
  • Radiation therapy for palliative care
  • Spine Instability Neoplastic Score (SINS) guides surgical decision-making

Spinal Epidural Abscess

• Risk factors: Diabetes, intravenous drug use, spinal procedures
• Symptoms: Back pain, fever, neurologic deficits (late finding)
• Diagnosis:
  • MRI with contrast (gold standard)
  • Lab tests: Leukocytosis, erythrocyte sedimentation rate/C-reactive protein, blood cultures
• Treatment:
  • IV antibiotics (vancomycin, ceftriaxone, cefepime)
  • Surgical drainage if neurologic symptoms present

Spinal Epidural Hematoma

• Risk factors: Trauma, anticoagulation, vascular malformations
• Diagnosis: MRI preferred over CT
• Treatment:
  • Surgical decompression
  • Reversal of coagulopathy if present

Traumatic Spinal Cord Compression

• Mechanism: motor vehicle collisions, falls, penetrating injuries
• Diagnosis:
  • CT (first-line for fractures, dislocations)
  • MRI (gold standard for soft tissue injury, ligamentous damage)
• Management:
  • Surgical decompression and stabilization
  • Methylprednisolone is NOT recommended for acute spinal cord injury

Cauda Equina Syndrome

• Symptoms:
  • Leg weakness
  • Saddle anesthesia
  • Urinary retention
• Diagnosis: MRI of the lumbar spine
• Treatment: Urgent decompression surgery

Conclusion

• Spinal cord compression requires urgent diagnosis and intervention.
• MRI is the gold standard for evaluation.
• Surgical decompression is necessary in most cases.
• Early recognition improves neurologic outcomes. Delays in treatment can lead to permanent disability, making early detection and rapid management critical.

For a more complete look at evaluating and managing spinal cord compression, click here.