Spinal cord compression
From WardWiki - Foundation Doctor Helper
Spinal cord compression is a serious neurological emergency that requires immediate investigation and management. It must not be missed and nothing is gained by delaying treatment beyond removing any reversible contraindications to surgery and this largely involves full resuscitation and reversal of anticoagulation where possible.
Apart from the general ABCDE approach, a full peripheral neurological examination (including formal inspection of the site of pain) and clinical history (including red flags) must be taken. A current and pre-morbid assessment of faecal and urinary continence is mandatory as is their pre-morbid mobility. Corticosteroids may be of help for inflammatory causes as in cauda equina syndrome. It is best to speak with a senior immediately after a cord lesion is suspected rather than procrastinate over such a decision. IV access must be established for the MRI as contrast may be used. Note that cord compression from metastases is often from the inflammatory oedema around the tumour.
Traumatic cord compressions need immediate tranfer for surgical decompression; malignant cord compression is treated with IV Dexamthsone 8mg, usually referred to orthopaedics, and is much more common.
There are several causes of this syndrome with disc herniation, tumour and trauma all common but arranging the confirmatory imaging of critical neural compression is the key to foundation doctor involvement in this medical emergency. Delays in the recognition, investigation, and referral for specialist care and surgery, as for patients with cauda equina syndrome (CES), are a major cause of serious and potentially avoidable neurological morbidity. The clinical assessment of patients with suspected CES is difficult. The definitions below seem clear but there is a need for sound clinical judgment. The majority of patients with suspected cauda equina syndrome will not have critical neural compression and in practice, it is only possible to exclude treatable spinal cord compression by appropriate imaging. In all but the specialist neurosurgical centres, this condition is best assessed by orthopaedic surgeons. No delay must be made, a written referral is inexcusable: the orthopaedic SHO must be called at once and his voice heard to refer this case. If there is such a delay discuss this with radiologist oncall to arrange an immediate MRI scan. If no orthopaedic opinion can be gained, contact the SpR and then the consultant but do not bypass anyone in the chain of command.
Take a full history but note the following as they are highly relevant:
- Any oncological history including previous treatments and known stage of disease
- History of saddle anaesthesia, altered sense of micturition or defaecation, or reduced lower limb sensorium.
- Degree of continence, mobility and level of independence in the past weeks.
A full external examination including neurological examination must be performed but the following points are highly relevant:
- Inspection and palpation of the spine. Note any tenderness or signs of recent epidural / spinal needle !
- Sensation of lower limbs and perineum. Test fine touch, pain and balance.
- Power and reflexes of the lower limbs including gait analysis if possible.
- Digital rectal examination for tone and sensation - this is all too often missed.
Same day investigations
FBC, U&E, CRP, Calcium are important baseline bloods, urinary retention can cause acute kidney injury Myeloma screen should be done only if MRI shows cord compression. It consists firstly of serum electrophoresis and then bone marrow biopsy. Skeletal surveys and fancy urine tests are very poor screens for myeloma and are often normal even with a proliferative gammaglobinopathy, of which myeloma is just one type.
Back xrays are likewise not indicated and may delay more confirmatory imaging. The MRI of whole spine must be considered as a same day investigation.
This should be immediate and involves an urgent MRI of the whole spine to look for white matter compression +/- cord oedema. Evidence shows sensory level rarely does not equate to lesion level and in any case sensory disturbance is a late sign of compression. Plain xrays are useless for cord compression and should only be used for focal back pain for more than six weeks without neurology.
This should be done immediately when out of hours MRI is not available; daytime availability is irrelevant here as decompression needs to be as soon as possible. This should be made after initial imaging with MRI when available. Follow the neurosurgical team referral checklist to focus all key facts to make an efficient referral.
- Vicky Doughty, Pre-treatment Superindent and MSCC Project Manager, Raigmore Hospital - The Design and Implementation of a Fast Track Malignant Spinal Cord Compression (MSCC) Service in Highland - http://www.nhshealthquality.org/nhsqis/2643.html
- Guidelines for referral, management and rehabilitation of adults with suspected or actual malignant spinal cord compression in the West of Scotland