Overview

Spinal Cord Compression

Quick Reference

Critical Alerts

Neurological deficits are often irreversible - time-critical diagnosis
Most common cause is metastatic cancer - lung, breast, prostate
MRI entire spine is the gold standard
Dexamethasone early if high suspicion
Ambulatory status at treatment predicts ambulatory status after

Key Diagnostics

MRI entire spine with contrast (gold standard)
Plain X-rays (insensitive, may show bony lesions)
CT myelography (if MRI contraindicated)
Labs: CBC, BMP, calcium, tumor markers if indicated

Emergency Treatments

Dexamethasone: 10-16 mg IV bolus, then 4-6 mg q6h
Pain control: Opioids as needed
Urgent consultation: Oncology, radiation oncology, spine surgery
Definitive treatment: RT, surgery, or both
VTE prophylaxis: High risk in cancer patients

Definition

Spinal cord compression (SCC) occurs when the spinal cord or cauda equina is compressed by a mass lesion, leading to neurological dysfunction. Metastatic spinal cord compression (MSCC) is an oncologic emergency and the most common cause in adults.

Etiology

Category	Causes	Frequency
Metastatic cancer	Lung, breast, prostate, renal, myeloma, lymphoma	60-70%
Primary spine tumors	Chordoma, osteosarcoma, chondrosarcoma	5-10%
Infection	Epidural abscess, osteomyelitis, TB	10-15%
Degenerative	Disc herniation, spinal stenosis	Variable
Trauma	Fracture, dislocation	Variable
Hematoma	Epidural hematoma (anticoagulation)	Rare
Other	Sarcoidosis, extramedullary hematopoiesis	Rare

Epidemiology

Incidence (MSCC): 5-10% of cancer patients
First presentation: 20% of MSCC is first cancer presentation
Location: Thoracic (70%), lumbosacral (20%), cervical (10%)
Prognosis: Ambulatory at diagnosis → 75% remain ambulatory; non-ambulatory → <30%

Pathophysiology

Mechanisms of Compression

Extradural (Most Common - 95%)

Vertebral body metastasis with posterior expansion
Paraspinal tumor extending through neural foramen
Direct compression of cord/thecal sac

Intradural Extramedullary

Meningioma, schwannoma
Drop metastases from CNS tumors

Intramedullary

Primary cord tumors (ependymoma, astrocytoma)
Rare cord metastases

Pathophysiology of Cord Injury

Mass effect on spinal cord
            ↓
Venous congestion → Edema
            ↓
Arterial compromise → Ischemia
            ↓
Demyelination and axonal injury
            ↓
Neurological dysfunction (reversible early)
            ↓
Cord infarction (irreversible)

Why Time Is Critical

Early decompression before infarction = best outcomes
Motor function at diagnosis predicts motor function after treatment
Complete paraplegia for >24-48 hours rarely recovers

Common Primary Cancers

Cancer	% of MSCC
Lung	20-25%
Breast	15-20%
Prostate	15-20%
Renal cell	5-10%
Multiple myeloma	5-10%
Lymphoma	5%
Unknown primary	10-15%

Clinical Presentation

Symptoms

Pain (Most Common - 90%)

Type	Description
Local	Constant, aching, worsens over weeks
Mechanical	Worse with movement, coughing, Valsalva
Radicular	Band-like, dermatomal, shooting
Nocturnal	Worse lying down (venous congestion)

Motor Symptoms

Sensory Symptoms

Autonomic Symptoms (Late)

Physical Examination

Key Findings

Finding	Significance
Motor weakness	UMN pattern (spasticity, clonus) or mixed
Sensory level	Level of compression
Hyperreflexia	UMN lesion above
Extensor plantars (Babinski)	UMN lesion
Decreased rectal tone	Severe involvement
Urinary retention	Often late finding
Spine tenderness	Over compressed level

Grading Motor Function

Grade	Description
Ambulatory	Walking independently or with aid
Paraparetic	Weak but some movement
Paraplegic	Complete paralysis

Prognostic importance: Ambulatory at treatment → likely to remain ambulatory

Weakness in legs (or arms if cervical)

Common presentation.

Difficulty walking

Common presentation.

Gait unsteadiness

Common presentation.

Red Flags (Life-Threatening)

Urgent Evaluation Required

Red Flag	Concern	Action
Cancer + new back pain	MSCC	MRI entire spine
Motor weakness + back pain	Cord compression	Emergent MRI
Sensory level	Cord pathology	Emergent MRI
New bladder/bowel dysfunction	Late cord compression	Emergent MRI
Rapid progression	Unstable lesion	Urgent intervention
Bilateral symptoms	Cord (not root) level	Emergent imaging

"Can't Miss" Presentations

Known cancer + back pain = MRI
Back pain + bilateral leg weakness = MRI urgently
Back pain + urinary retention = MRI emergently
New sensory level = MRI emergently

Differential Diagnosis

Spinal Cord Compression vs Other Causes

Condition	Distinguishing Features
Cauda equina syndrome	Below conus (L1-L2); LMN; areflexia
Transverse myelitis	Inflammatory; younger; MRI cord changes
Guillain-Barré syndrome	Ascending; areflexia; LP elevated protein
Spinal cord infarction	Sudden onset; vascular territory
Multiple sclerosis	Young; demyelinating lesions; relapses
Vitamin B12 deficiency	Gradual; posterior columns; low B12
Peripheral neuropathy	Distal; symmetric; sensory > motor

Cord Compression vs Cauda Equina

Feature	Cord Compression	Cauda Equina
Level	Above L1-L2	Below L1-L2
Motor	UMN (spasticity, hyperreflexia)	LMN (flaccid, areflexia)
Sensory	Level at or below lesion	Saddle distribution
Bladder	Spastic, reflex	Areflexic, retention
Babinski	Positive	Absent

Diagnostic Approach

Clinical Assessment

Key History

Cancer history (past or suspected)
Onset and progression of symptoms
Pain characteristics (local, radicular)
Motor and sensory symptoms
Bladder/bowel function
Recent trauma or procedures

Imaging

MRI Entire Spine with Contrast (Gold Standard)

Why entire spine?
- Multiple levels involved in 30%
- Skip lesions possible
- Guides radiation field
- Identifies primary if unknown

Findings:
- Epidural mass compressing thecal sac/cord
- Cord edema (T2 hyperintensity)
- Vertebral body involvement
- Level(s) of compression

Plain X-rays

Low sensitivity (miss early lesions)
May show vertebral collapse, pedicle erosion
Cannot visualize cord

CT Spine

Better bony detail than MRI
Used for surgical planning
CT myelography if MRI contraindicated

CT Myelography

Alternative if MRI not available/contraindicated
Invasive (requires LP)
Shows block but less detail than MRI

Laboratory Studies

Test	Purpose
CBC	Infection, myeloma
BMP	Renal function, electrolytes
Calcium	Hypercalcemia of malignancy
LDH	Lymphoma marker
PSA	Prostate cancer (if suspected)
SPEP/UPEP	Myeloma
ESR/CRP	Infection, inflammation

Treatment

Immediate Management

Step 1: Dexamethasone

If cord compression suspected or confirmed:
- Dexamethasone 10-16 mg IV bolus
- Then 4-6 mg IV/PO q6h
- Reduces cord edema
- Improves neurological outcomes

Note: Optimal dose debated; high-dose (96 mg) shows no additional benefit

Step 2: Pain Control

IV opioids as needed
Pain is severe and undertreated

Step 3: Urgent Consultation

Oncology (for cancer patients)
Radiation oncology
Spine surgery (orthopedic or neurosurgery)

Definitive Treatment Options

Radiotherapy (RT)

Indication	Details
Standard of care for most MSCC	Palliative, reduces tumor
Radiosensitive tumors	Lymphoma, myeloma, small cell lung
Non-surgical candidates	Poor prognosis, multiple levels

Surgery + RT

Indication	Details
Single level compression	Better outcomes than RT alone
Structural instability	Spinal stabilization needed
Radioresistant tumors	Renal, melanoma
Rapid neurological decline	Urgent decompression
Unknown histology	Need tissue diagnosis
Recurrence after RT	Prior radiation limits re-irradiation

Patchell Trial (2005): Surgery + RT superior to RT alone for motor outcomes

Selection Criteria for Surgery

Life expectancy >3 months
Single area of compression
Reasonable performance status
Neurological deficit <48 hours old

Non-Malignant Causes

Epidural Abscess

IV antibiotics + surgical drainage
See epidural abscess topic

Disc Herniation

Urgent surgical decompression if severe

Epidural Hematoma

Reverse anticoagulation
Surgical evacuation

Disposition

Admission Criteria

All patients with confirmed or highly suspected spinal cord compression require admission

Oncology/neurosurgery/orthopedic spine service
Monitoring for neurological decline
Definitive treatment planning

Monitoring

Parameter	Frequency
Neurological exam	Q4-6h initially
Motor strength	Serial documentation
Sensory level	Serial documentation
Bladder function	Monitor I&O, PVR

Urgent vs Emergent Surgery

Urgency	Indication
Emergent (<24h)	Rapid neurological decline, paraplegia <24h
Urgent (24-48h)	Stable deficits, ambulatory patient
Semi-urgent	Stable, minor deficits

Prognosis

Factor	Better Prognosis
Ambulatory at treatment	Most important predictor
Single site	vs multiple
Slow progression	vs rapid
Radiosensitive tumor	Lymphoma, myeloma
No visceral metastases	vs extensive disease

Patient Education

Understanding Spinal Cord Compression

A tumor or other lesion is pressing on your spinal cord
This causes weakness, numbness, and sometimes bladder problems
Treatment aims to remove the pressure and prevent permanent damage
The outcome depends on how much function remains before treatment

What to Expect

Steroids to reduce swelling
Likely radiation therapy and/or surgery
Physical therapy during recovery
Close monitoring for changes

Warning Signs

Contact medical team immediately for:

Worsening weakness
New numbness or tingling
Inability to urinate or new incontinence
Increasing back pain

Special Populations

Unknown Primary Cancer

MSCC may be first presentation
Biopsy may be needed for diagnosis
CT chest/abdomen/pelvis for primary
Tumor markers, SPEP/UPEP

Patients on Anticoagulation

Consider epidural hematoma
Reverse anticoagulation if hematoma
Surgery more complex

Lymphoma/Myeloma

Often very radiosensitive
May respond dramatically to steroids + RT
Chemotherapy also important

Breast, Prostate (Hormone-Sensitive)

May respond to hormonal therapy
Still need local treatment for cord compression

End-Stage Cancer

Goals of care discussion essential
Palliative RT for pain relief
Surgery generally not appropriate if life expectancy <3 months

Quality Metrics

Performance Indicators

Metric	Target
MRI within 24 hours of suspicion	>0%
Dexamethasone within 2 hours of diagnosis	100%
Oncology/spine surgery consultation same day	>0%
RT or surgery within 24-48 hours for severe	>0%
Motor exam documented with level	100%

Documentation Requirements

Detailed motor and sensory exam with levels
Time of symptom onset
Neurological progression documented
Dexamethasone timing and dose
MRI findings with levels of compression
Consultation times
Treatment plan
Prognosis discussion

Key Clinical Pearls

Diagnostic Pearls

Cancer + back pain = MRI until proven otherwise
Sensory level is key - localizes the lesion
Entire spine MRI - 30% have multiple levels
First cancer presentation in 20% of MSCC
Ambulatory status is the most important prognostic factor

Treatment Pearls

Dexamethasone early - reduces edema, buy time
Time is function - don't delay treatment
Surgery + RT > RT alone for selected patients
Paraplegic >48h rarely recover ambulation
Radiosensitive tumors may respond dramatically

Disposition Pearls

All cord compression patients are admitted
Serial neuro exams are essential
Goals of care discussion for end-stage patients
Multidisciplinary approach - oncology, RT, surgery
VTE prophylaxis - high risk in immobile cancer patients

References

Patchell RA, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer. Lancet. 2005;366(9486):643-648.
Loblaw DA, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression. J Clin Oncol. 2005;23(9):2028-2037.
Rades D, et al. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol. 2005;23(15):3366-3375.
NICE Guideline. Spinal metastases and metastatic spinal cord compression (CG75). 2008.
George R, et al. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev. 2015;9:CD006716.
Klimo P, et al. Treatment of metastatic spinal disease: a meta-analysis. Neurosurgery. 2005;57(5):891-903.

Version History

Version	Date	Changes
1.0	2025-01-15	Initial comprehensive version with 14-section template