Spinal cord compression
Spinal cord compression is mechanical narrowing of the spinal canal by tumor, hematoma, abscess, disc herniation, or trauma that produces myelopathy; it is a neurologic emergency requiring urgent MRI of the affected level and immediate treatment of the cause, since surgical decompression rarely restores function once paraplegia develops.
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What this article covers
- Overview
Definition: spinal cord compression (compressive myelopathy) is mechanical narrowing of the spinal canal or neural foramen by tumor, hematoma, abscess, herniated disc, bone fragment, or degenerative stenosis that impairs cord function.
- Epidemiology
Degenerative cervical spondylotic myelopathy is the most common cause of chronic, nontraumatic compression in older adults, from age-related disc and facet degeneration narrowing the cervical canal.
- Risk factors
Degenerative spinal disease: osteoarthritic cervical and lumbar changes are the dominant risk factor for chronic compressive myelopathy in older adults.
- Pathophysiology
Mechanical cord injury: direct compression distorts axons and compresses the microvasculature supplying the cord, producing mechanical and secondary ischemic injury to the segment.
- Clinical features
Diagnostic clinical pattern: neck or back pain, often the earliest symptom, followed by progressive weakness, sensory change, and bladder or bowel dysfunction defines the compressive myelopathy…
- Differential diagnosis
Malignant spinal cord compression: the same syndrome from vertebral metastasis; distinguished by a known or new cancer diagnosis and a vertebral body lesion on imaging, managed with immediate…
- Diagnosis
First, establish the diagnosis with emergent MRI: MRI at the suspected level confirms compressive myelopathy and often reveals the cause; image emergently whenever abscess, hematoma, or malignancy is suspected.
- Management
First, treat the unstable or rapidly progressing patient emergently: obtain emergent MRI, involve neurosurgery immediately, and begin cause-directed therapy without delay for any new or worsening deficit.
- Complications
Permanent paraplegia or quadriplegia: the most feared outcome if decompression is delayed until severe deficits are established.
- Prognosis
Time to treatment is the dominant prognostic factor: function at treatment onset predicts function recovered; full function is rarely regained once severe weakness or paraplegia has developed.
- Prevention
No universal primary prevention: the causes are heterogeneous, so prevention is cause-specific rather than a single measure.
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- Malignant spinal cord compression
Malignant spinal cord compression (metastatic epidural spinal cord compression) is an oncologic emergency from vertebral metastasis that requires whole-spine MRI within 24 hours, immediate high-dose dexamethasone, and urgent radiotherapy or surgical decompression to prevent irreversible paralysis.
- Cauda equina syndrome
Cauda equina syndrome is compression of the lumbosacral nerve roots below the spinal cord causing saddle anesthesia, bladder or bowel dysfunction, bilateral leg weakness with areflexia, and low tone, most often from a large central lumbar disk herniation. It is a surgical emergency diagnosed by emergent MRI of the lumbar spine and treated with urgent decompression.
- Radiculopathy
Radiculopathy is dysfunction of a spinal nerve root, most often from disk herniation or degenerative spinal disease, producing radicular pain, dermatomal sensory loss, myotomal weakness, and reduced reflexes in a nerve-root distribution. Diagnosis is clinical; most cases resolve with conservative therapy within 6 to 12 weeks, and imaging is reserved for red flags or persistent symptoms.
- Epidural hematoma
Epidural hematoma is an arterial bleed, classically from the middle meningeal artery after a temporal bone fracture, that collects between the skull and dura in a biconvex shape that does not cross suture lines; a lucid interval followed by rapid decline is classic, and a GCS below 9, anisocoria, or hematoma over 30 mL requires urgent surgical evacuation.
- Acute subdural hematoma
Acute subdural hematoma is venous bleeding between the dura and arachnoid membrane from ruptured bridging veins, producing a crescent-shaped collection that crosses suture lines on CT. Older adults and patients with alcohol use disorder or on anticoagulation are most susceptible; a hematoma over 10 mm, a GCS under 9, or pupillary asymmetry mandate immediate surgical evacuation.
- Syringomyelia
Syringomyelia is a fluid-filled cavity (syrinx) within the spinal cord, most often arising from Chiari I malformation, trauma, or a spinal cord tumor. It produces a classic cape-like loss of pain and temperature sensation as the syrinx damages the crossing spinothalamic fibers, diagnosed by MRI and treated surgically when progressive.
- Transverse myelitis
Transverse myelitis is inflammation across one or more contiguous spinal cord segments causing subacute weakness, a sensory level, and bladder or bowel dysfunction; diagnosis requires spinal MRI showing cord enhancement or CSF inflammation with exclusion of compressive and infectious causes, and idiopathic disease is treated with high-dose intravenous methylprednisolone.
- Spinal epidural abscess
Spinal epidural abscess is a suppurative infection of the spinal epidural space, most often hematogenous Staphylococcus aureus, presenting with fever, focal spinal pain, and, if missed, progressive weakness. The diagnosis is established by emergent MRI with contrast. Treatment is empiric intravenous vancomycin plus ceftriaxone or cefepime, with emergent surgical decompression whenever a neurologic deficit is present.