Rarely, back pain is caused by an epidural hematoma, resulting in a presentation similar to that of acute lumbar disc herniation.15 Patients with epidural hematoma usually have a history of recent spinal procedure or trauma. In this situation, motor weakness is present in both lower extremities, and the bladder and bowel can be paralyzed. Spinal cord compression is a surgical emergency and if unrecognised or untreated, can result in irreversible neurological damage and disability. DAISY ARCE, M.D., and PAMELA SASS, M.D., State University of New York Health Science Center at Brooklyn College of Medicine, Brooklyn, New York, HASSAN ABUL-KHOUDOUD, M.D., Pembina County Memorial Hospital and Wedgewood Manor, Cavalier, North Dakota. There are numerous causes of cord compression. Malignant spinal cord compression is a medical emergency. Emergency magnetic resonance imaging of cervical spinal cord injuries: clinical correlation and prognosis. Metastatic spinal cord compression. Acute spinal cord compression (SCC) is a medical emergency that requires swift diagnosis and treatment to prevent irreversible spinal cord injury and long-term disability. The physician should examine the entire spine for areas of redness, scars, blisters, lipomata, hairy patches, birthmarks and café-aulait spots. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. 1998;11:346–9. Petri R, Med Clin North Am. Spinal cord compression (SCC) is the most frequent neurological complication of systemic cancer. 1991 Feb;18(1):145-52. Tung GA, As a disc herniation becomes more central, more than one nerve root can be involved. Radiation therapy is the standard approach. 15. Metastatic spinal cord compression (MSCC) is a medical emergency which necessitates immediate assessment and treatment.. 1998;17:111–20. Spine. Gimbel R. If the spinal roots below the conus medullaris are involved, it is termed cauda equina syndrome.. Because MRI is noninvasive, does not involve radiation, covers a large area of the spine and can show changes within the disc and vertebral body, it has become the imaging modality of choice in the diagnosis of radiculopathy, spinal cord abscesses, spinal cord tumors, spinal stenosis and nontraumatic vascular lesions.8–12 Using the magnetic resonance images in the fast sequence results in a myelography-like appearance that allows rapid screening of the spinal canal with high sensitivity for epidural masses.9 Chelated gadolinium further enhances MRI studies. Acute nontraumatic spinal epidural hematomas. Copyright © 2020 American Academy of Family Physicians. In an emergency situation, it should be assumed that the person has a spinal cord injury if they have had a traumatic accident. Spinal cord compression is a palliative care emergency that can affect people with cancer. Spinal cord compression can occur anywhere from your neck down to your lower spine and cause symptoms, such as numbness, pain, and weakness. Low back pain: an algorithmic approach to diagnosis and management. In the emergency room, a doctor may be able to rule out a spinal cord injury by careful inspection and examination, testing for sensory function and movement, and by asking some questions about the accident.But if the injured person complains of neck pain, isn't fully awake, or has obvious signs of weakness or neurological injury, emergency diagnostic tests may be needed.These tests may include: 1. Spinal cord compression is a surgical emergency, usually requiring prompt surgical decompression to prevent permanent neurological impairment. Clin Sports Med. spinal cord compression SPINAL CORD COMPRESSION (SCC) is a life-threatening complication of pri-mary and metastatic cancer that can significantly impact a patient’s quality of life. Kuker W, Nanassis K, Atlantoaxial subluxation and other craniocervical junction abnormalities may cause acute, subacute, or chronic spinal cord compression. possible emergency. Suspect spinal cord compression if any of the following features are present: Neurological symptoms (including radicular pain, any limb weakness, difficulty in walking, sensory loss, or bladder or bowel dysfunction). Cauda equina syndrome (CES) is a rare occurrence that almost always warrants urgent surgical intervention. The annulus fibrosus is made of lamelliform connective tissue bands. The international standards booklet for neurological and functional classification of spinal cord injury. Papadopoulos SS, 9. Surgery for metastasis to the brain. J Emerg Nurs. Spinal cord compression due to these paraspinal extramedullary hematopoietic elements is uncommon and is often managed with either surgery or radiation therapy. Radicular pain may direct the evaluation to a specific nerve root level. 2007; 19(6):377-81 ... the clinical pathway of 17 patients treated with radiotherapy for metastatic spinal cord compression within the last 6 months were reviewed to identify gaps and delays in the system. Magnetic resonance imaging in spinal emergency. T2 - Spinal Cord Compression. This spinal disorder involves the bundle of nerves formed at the “tail end” of the spinal cord in the low back (lumbar spine). Referral of high-risk patients to a neurologist or spine specialist may be indicated. Spinal cord compression is a serious condition that needs to be treated right away. Spinal cord compression. There is compression at more than one level in 20% of patients. The laboratory evaluation may include a complete blood cell count with differential, an erythrocyte sedimentation rate and a urinalysis. An epidural abscess may develop as a result of adjacent vertebral osteomyelitis or discitis, as well as hematogenous spread from a remote infection. Petri R, 95-0642, Information from Glick TH, Workman TP, Gaufberg SV. van Velthoven V. Acute low back problems in adults. Multiple myeloma is the most common of these tumors in adults.4, Epidural spinal cord compression from metastatic cancer is common and serious but potentially treatable. Neurosurgical involvement, or transfer to a tertiary care center with neurosurgical and neuroimaging capabilities, is prudent. Localized spinal tenderness. So spinal cord compression means something is pressing on your spinal cord: The part that's compressed doesn't work right If the compression continues long enough, it permanently damages your spinal cord For example, if the legs (but not the arms) are weak and numb and bladder and bowel functions are impaired, the spine may be damaged at the midchest (thoracic) or lower back (lumbar) level. Neurol Clin. Nocturnal spinal pain preventing sleep. 4th ed. These can be divided according to the location of the compressing mass: Klug N. Glick TH, Acute low back problems in adults. 1999;41:904–9. Wilberger JE. Spinal cord compression is a complex and challenging condition that greatly affects the quality of life. The intervertebral disc is composed of the outer annulus fibrosus and the inner nucleus pulposus. The spine is composed of vertebrae and the spinal cord. Paleologos TS, It is an oncological emergency.1 2 MSCC is caused by compression of the dural sac and its contents (spinal cord or cauda equina) by an extradural or intradural mass,3 and it leads to irreversible neurological … HHS The diagnosis is established by thorough neurologic examination, plain x-rays, myelography, CT and MRI scanning. Variability of clinical and magnetic resonance imaging findings. Journal of Clinical Oncology, 16, 1613-1624. If a patient presents with cauda equina syndrome, early decompression should be performed. They may require anything from supportive care to emergency surgery. Wakhloo AK, It can occur as a first presentation of malignancy, or during treatment (representing disease progression or relapse). Gaufberg SV. If you suspect spinal cord compression, get … The spine is divided into four sections: the cervical, thoracic, lumbar and sacrococcygeal vertebrae. Emergency treatment of malignant ex-tradural spinal cord compression: An evidence-based guideline. Every nerve in the body communicates with the brain via the spinal cord; it’s like your body’s super-highway. A clinical practice improvement project was carried out to review and fine tune the clinical pathway for the acute management of patients with metastatic spinal cord compression. This T1-weighted sagittal MRI shows low signal intensity of the C6 and C7 vertebral bodies, obliteration of the C6-C7 disc space, a prevertebral and ventral epidural mass (black arrows) and cord compression (white arrow). (1995). Diagnostic tests for the evaluation of back and neck pain. The emergency depart- ment radiologist should be familiar with the common differential di-agnoses of acute myelopathy and be able to differentiate compressive from noncompressive causes. Chronic mild neurologic deficits involving a single nerve root may not necessarily be considered a red flag because these deficits are common in patients with degenerative pathologies such as disc herniation and lateral stenosis. Van der Reis W. The manifestations of spinal cord compression are difficult to diagnose at an early phase, particularly in the youngest patients. Copyright © 2001 by the American Academy of Family Physicians. The rightsholder did not grant rights to reproduce this item in electronic media. “Red Flags” Suggesting a Serious Underlying Pathology Possibly Requiring Imaging, Adapted from Bigos SJ, et al. 1999;17:25–39,vii–viii. Commonly Missed Diagnoses in the Childhood Eye Examination, Assessment and Treatment of Depression Following Myocardial Infarction. Contact your doctor straight away if you have any symptoms of spinal cord compression. Ernestus RI, It can happen if the vertebrae are damaged or collapse. The posterior column includes the ligamentum flavum and the posterior elements (facet joints, pedicles, transverse processes, laminae and spinous processes). Lanfermann H, The anterior column of the spine includes the anterior longitudinal ligament, anterior portion of the vertebral body and anterior portion of the intervertebral disc. Nanassis K, MRI studies may identify spinal metastasis in patients with normal radiographs and bone scans (Figure 2). St. Louis: Mosby, 1998:2100–2. Neuroblastoma with spinal cord compression: is there an emergency treatment of choice? 1996;23:345–64. 1986 Jan-Feb;12(1):9-12. Am Fam Physician. Geriatrics. It is regarded as a medical emergency independent of its cause, and requires swift diagnosis and treatment to prevent long-term disability due to irreversible spinal cord injury. Wipf JE, Spinal cord compression can often be helped with medicines, physical therapy, or other treatments. Posttraumatic spinal cord lesions without skeletal or discal and ligamentous abnormalities: the role of MR imaging. Differential diagnosis: a reasonable clinical approach. Glick TH, Spinal cord compression is caused by a condition that puts pressure on your spinal cord. Gimbel R. The pain produced by spinal neoplasm is often worse when the patient is at rest and may even awaken the patient from a sound sleep. Low back pain. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. Chatzidakis EE, How do doctors treat spinal cord compression? Keep him or … The spinal cord tapers caudally to become the conus medullaris. Ditunno JF, Jr, Young W, Donovan WH, Creasey metastatic spinal CORD compression 18 EMERGENCY MEDICINE I january 2014 www.emed-journal.com G. American Spinal Surgery Association. The C5 vertebral body has collapsed (arrow) but is associated with minimal cord deformity (arrowhead). There are many causes of acute myelopathy including multiple sclerosis, systemic disease, and acute spinal cord compression (SCC). X-rays. Several elements in the patient's medical history may be thought of as red flags (Table 1),5  although some conditions can make spinal pathology particularly difficult to evaluate (Table 2).1 In situations in which it may be extremely difficult to interpret nonclassic signs and symptoms, the physician's best judgment should be used to determine whether diagnostic testing or referral to a spine specialist is indicated. Emerg Med Clin North Am. Mermel LA, Recognizing Spinal Cord Emergencies. There are many causes of acute myelopathy including multiple sclerosis, systemic disease, and acute spinal cord compression (SCC). Rosen P. Emergency medicine: concepts and clinical practice. Spinal stenosis may also be associated with cauda equina syndrome. Address correspondence to Daisy Arce, M.D., Family Practice Department, State University of New York Health Science Center at Brooklyn College of Medicine, Box 67, Brooklyn, New York 11203 (e-mail:indani@msn.com). Fratzoglou MM, Spinal cord compression is caused by a condition that puts pressure on your spinal cord. DAISY ARCE, M.D., is assistant professor and associate predoctoral coordinator in the Family Practice Department at the State University of New York (SUNY) Health Science Center at Brooklyn College of Medicine, Brooklyn, New York. O'Phelan KH(1). An MRI study that reveals a narrow spinal canal can confirm the diagnosis of spinal stenosis. d'Arcy HS, Acad Emerg Med. Alexiadou-Rudolf C, Mull M, Metastatic spinal cord compression is a dreaded complication of cancer affecting 5–10% of all patients [].It presents as an emergency in clinical oncology requiring prompt diagnosis and urgent medical or surgical intervention to give the best chance of neurological recovery or stabilization, hence preventing or delaying the distressing onset of complete paraplegia. Symptoms such as pain, numbness, or weakness in the arms, hands, legs, or feet can come on gradually or more suddenly, depending on the cause. For the missing item, see the original print version of this publication. Spinal cord compression is a complex and challenging condition that greatly affects the quality of life. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Epidural spinal infection. Metastasis of prostate cancer to the cervical spine in a 61-year-old man with neck pain. Wagner R, Doctors will then do testing, such as: MRI. (CT = computed tomographic; MRI = magnetic resonance imaging). Spinal epidural abscess: correlation between MRI findings and outcome. Prompt diagnosis of acute SCC is critical because optimal patient outcomes are predicated on early treatment. 1994;32(2):70-80. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. The spinal cord is enveloped by three layers of meninges. Choose a single article, issue, or full-access subscription. Tuberculosis has a predilection for the spine where it can affect adjacent vertebral bodies. With large herniations, the cauda equina also becomes involved. The causes of spinal cord compression include the following: Certain degenerative diseases, such as arthritis, can lead to spinal cord compression. Selden NR, extension may lead to spinal cord compression and cause acute neurological symptoms as well as long-term neurological sequelae with significant impact on daily activities and health-related quality of life.1 Early decompression of the spinal cord may prevent irreversible neurological deficits and is a neuro-oncological emergency. Patel N, Mayfrank L, Spinal cord compression can occur anywhere from your neck down to your lower spine and cause symptoms, such as numbness, pain, and weakness. Emergency magnetic resonance imaging of cervical spinal cord injuries: clinical correlation and prognosis. Adapted from Bigos SJ, et al. Muscle weakness, if progressive, must be evaluated urgently. Kourousis DD. Clipboard, Search History, and several other advanced features are temporarily unavailable. Jagoda A. Dugas AF, Lucas JM, Edlow JA. Immediate Action . CT scanning is less expensive than MRI. 4(August 15, 2001) 1997;22:544–50. Fratzoglou MM, Myelopathy is a severe condition because if spine cord compression is left untreated, it generally will result in worsening of the symptoms or severity over time. : U.S. Dept. Emerg Med Clin North Am. We present a case of thalassemia in which these elements were successfully managed by transfusion and hydroxyurea alone. Patel N, Spinal cord emergencies: false reassurance from reflexes. An important aspect of the physical examination is a rectal examination to assess sphincter tone, especially if the patient mentions bowel or bladder dysfunction. Spinal cord compression can be caused by any condition that puts pressure on the spinal cord. Alexiadou-Rudolf C, 1998;5:1041–3.... 2. [ 11. 95-0642. Treatment can also control symptoms of compression. Spinal cord emergencies: false reassurance from reflexes. Southampton Neuroradiology. The two most common cancers to cause spinal cord compression are: Myeloma – neoplastic plasma cells proliferate within the marrow itself 5. 3. The physician should be aware that, if present, a positive (abnormal) Babinski’s sign is helpful, but a 1992;38:225–31. / Vol. Guidelines for initial management. Spinal cord syndromes. The intervertebral disc absorbs shock, provides resistance to compression and allows flexibility of the vertebral column.7 A compromised (degenerated or anatomically abnormal) disc lends itself to abnormal motion and herniation of the nucleus pulposus, with potential radiculopathy and pain. The spinal cord and nerve roots are protected within these structures.6. Mull M, The thecal sac, which surrounds the spinal column, contains cerebrospinal fluid that circulates around the spinal cord and the nerve roots. Herniation of a cervical disc is not uncommon. tutes a medical emergency for which spinal MRI is frequently or-dered as the first step in the patient’s workup. Laboratory tests are particularly useful when infection or malignancy is considered to be a possible cause of the spinal pathology. : U.S. Dept. Acute low back problems in adults. A smaller disc herniation is noted at C5-C6. Bowel and bladder symptoms with perianal numbness may be indicative of cauda equina syndrome, a true emergency that requires urgent decompression. An epidural hematoma can also develop in a patient who is prone to bleeding because of, for example, anticoagulant therapy. Acta Neurochir [Wien]. Wilberger JE. Symptoms are beli… Consistent with most spinal cord compression imaging protocols, MRI is generally superior to CT 8, 9. Because the spinal cord is organized in a specific way, doctors can determine which part of the spinal cord is affected based on the symptoms and results of a physical examination. Neurological signs of spinal cord or cauda equina compression.  |  Neurosurgery. Spinal epidural abscess: correlation between MRI findings and outcome. 2001 Aug 15;64(4):631-639. The degree of spinal cord compression and presence of an intramedullary T2-hyperintense signal suggestive of an acute cord edema are critical findings for subsequent urgent care such as surgical decompression. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. This T1-weighted sagittal MRI shows a large disc herniation at C6-C7 (arrow) that is compressing the adjacent cervical cord. It sends send messages back and forth from the brain to muscles and soft tissues. Depending on the cause of the compression, symptoms may develop suddenly or gradually, and they may require anything from supportive care to emergency surgery. Get Permissions, Access the latest issue of American Family Physician. Spinal cord compression happens when pressure on the spinal cord stops the nerves working normally. Treatment for spinal cord compression. CT scan. Jagoda A. Many conditions can cause this opening to become narrow resulting in spinal nerve compression, also called a pinched spinal nerve. 1999;17:43–63. Spinal cord emergencies are uncommon, but injury must be recognized early so that the diagnosis can be quickly confirmed and treatment can be instituted to possibly prevent permanent loss of function. Spinal cord compression is an oncologic emergency that needs to be identified, evaluated, and treated promptly for favorable patient outcomes. New back pain in someone who has cancer, especially if they have bone metastases, should make you think of spinal cord compression. Rockville, Md. Paraplegia. 1 Anterior (front) spinal cord compression tends to cause motor dysfunction, and posterior (back) spinal cord compression tends to cause sensory deficits. Along with superior vena cava compression syndrome, spinal cord compression numbers among the most common oncologic emergencies. Physicians who work in primary care settings and emergency departments frequently evaluate patients with neck and back pain. 95-0642. Diagnosis of spinal cord compression in nontrauma patients in the emergency department. Lanfermann H, #### What you need to know Between five and 10 in every 200 patients with terminal cancer will have metastatic spinal cord compression (MSCC) within their last two years of life. The pressure causes swelling and means that less blood can reach the spinal cord and nerves. Spinal cord compression can occur anywhere from your neck (cervical spine) down to your lower back (lumbar spine). Epidural spinal infection. If the lateral projection is inadequate, a swimmer's projection, oblique projections or a CT scan is indicated. The criteria for ordering plain-film radiographs of the cervical spine are summarized in Table 5,5  and the recommended indications for CT scanning are summarized in Table 65 The initial evaluation of suspected injury to the cervical spine includes a cross-table lateral plain-film radiograph with the patient supine. Nussbaum ES, Rose-Innes AP, Facts about spinal cord compression J Spinal Disord. This is known as metastatic spinal cord compression. Spinal Cord Compression and Injury. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Although there are nonmalignant types of spinal cord compression, this article focuses on patients presenting with metastatic cancer. 10. Below the level of the lesion, motor, sensory, reflex and autonomic (including sphincter) function is lost. Spinal cord emergencies: false reassurance from reflexes. Immediate, unlimited access to all AFP content. #3. Acad Emerg Med 1998;5:1041–3. 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