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Spinal Cord Compression

Spinal Cord Compression. Dr. Wayne Hoskins. Spinal Cord Anatomy. Medulla --> exiting nerve roots Surrounded by meninges: dura, arachnoid, pia Ends at L1/2 Protected by bony vertebral column. Spinal Cord Function. Transmits neural signals and contains neural circuits that control reflexes

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Spinal Cord Compression

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  1. Spinal Cord Compression Dr. Wayne Hoskins

  2. Spinal Cord Anatomy • Medulla --> exiting nerve roots • Surrounded by meninges: dura, arachnoid, pia • Ends at L1/2 • Protected by bony vertebral column

  3. Spinal Cord Function • Transmits neural signals and contains neural circuits that control reflexes • Three major functions: • Motor • Sensory • Reflex

  4. Spinal Tracts

  5. Causes of Compressions

  6. Causes of Compressions • Trauma - vertebral fracture • Inter-vertebral disc / spinal stenosis • Tumor: Lung, breast, prostate, RCC, thyroid, lymphoma, MM • Epidural abscess

  7. UMNL vs. LMNL

  8. Case • 76 yo F - LBP & lateral R>L leg pain • Insidious onset 2/12 ago • PMHx: Colon Ca 2008 - APR • Presented to ED: DVT excluded - D/C • Represents with worsening pain • Denies weakness, numbness, parathesia, cauda equina Sx, fever

  9. Red Flags

  10. Exam & Ix • Lumbar-pelvic pain on palpation • Normal neuro exam • SLR negative • FBE, CMP, LFT NAD • CEA 3.7

  11. Lumbar-pelvic x-ray Sclerosis in left sacral alar suspicious of healing insufficiency fracture

  12. NM Bone study & SPECT Increased uptake L>R sacral alar consistent with arthritis

  13. MRI

  14. Metastatic SCC Spinal cord or cauda equina compression by direct pressure & /or induction of vertebral collapse or instability by metastatic spread or direct extension that threatens or causes neurological disability - 5-10% all Ca patients - Initial manifestation in 20% - Median survival 3-6/12

  15. Early detection • View as oncological emergency if: - neuro symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss or bowel/bladder dysfn - neuro signs of spinal cord or cauda equina compression

  16. Imaging • Whole spine MRI: <1/52 to plan definitive treatment and <24/24 if neurological symptoms • Sensitivity and specificity >90% • CT only to assess stability, plan surgery, biopsy guidance - CT myelopgraphy if MRI contra • Do not perform plain radiographs

  17. Treatment • Goals: palliative, pain control, preserve or restore ambulation,neuro & stability • Start definitive treatment ideally within 24/24 of Dx • Carefully plan surgery: consider fitness, prognosis, preferences • Urgent <24/24 RT for definitive treatment if unsuitable for surgery

  18. Treatment • Analgesia: Conventional by WHO pain relief ladder, ?specialist pain care • Bisphosphonates: myeloma or breast Ca and prostate if analgesia has failed; not for others • Corticosteroids: 16mg loading dexameth - 16mg/d, over 5-7/7 after RT or surgery - complications: sepsis, bowel perforation • Biopsy & stage (no., sites, extent)

  19. Treatment • RT: if non-mechanical pain • Vertebroplasty/kyphoplasty - consider if no MSCC or instability &: - mechanical pain resistant to analgesia - vertebral body collapse • Surgery: consider urgently if spinal instability, mechanical pain resistant to analgesia - external spinal support (halo, orthosis) if unsuitable for surgery

  20. Surgery • RT: if non-mechanical pain • Vertebroplasty/kyphoplasty - consider if no MSCC or instability &: - mechanical pain resistant to analgesia - vertebral body collapse • Surgery: consider urgently if spinal instability, mechanical pain resistant to analgesia - external spinal support (halo, orthosis) if unsuitable for surgery

  21. Radiotherapy • Urgent <24/24 if definitive treatment or unsuitable for surgery unless: - tetraplegia or paraplegia >24/24 and pain controlled; overall poor prognosis • Fractionated RT definitive Tx if no neuro impairment, pain or instability • No pre-operative RT • Post-operative RT offered when wound healed

  22. Thromboprophylaxis • All patients thigh length TEDS and/or intermittent pneumatic compression or foot impulse devices • High risk: LMWH and mechanical thromboprophylaxis

  23. CSM • Natural history: slow deterioration in stepwise fashion, with worsening symptoms of gait abnormalities, weakness, sensory changes and often pain • Dx: Hx, Exam, XR - CT/MRI to confirm

  24. Management • Minimal symptoms without hard evidence of gait disturbance or pathological reflexes warrant nonoperative treatment • Demonstrable myelopathy and spinal cord compression are candidates for operative intervention

  25. Surgery Anterior and posterior approaches

  26. ACDF

  27. Thank You

  28. Diagnosis • X-ray • Preferably MRI urgently - whole spine if cancer implicated

  29. Treatment • Dexamethasone - 16mg/d may reduce edema around lesion • Surgery - indicated in local compression and if hope of regaining functions

  30. Surgical Considerations • Speed of onset • Red flags

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