An epidural hematoma can also develop in a patient who is prone to bleeding because of, for example, anticoagulant therapy. Background: Metastatic spinal cord compression is a dreaded complication of cancer affecting 5-10% of patients requiring urgent treatment. Emergency Neurologic Life Support: Spinal Cord Compression. The differential diagnosis includes spinal cord compression secondary to vertebral fracture … Management of spinal cord compression secondary to metastatic prostatic carcinoma. If a patient presents with cauda equina syndrome, early decompression should be performed. To present registered professional nurses with comprehensive information on malignant spinal cord compression, including diagnosis, prognosis, therapy, and hospice referral. Spinal decompression surgery is a general term that refers to various procedures intended to relieve symptoms caused by pressure, or compression, on the spinal cord and/or nerve roots. Spinal osteomyelitis should be suspected in a patient who has recently undergone a spinal procedure and has focal severe pain that is not relieved by rest. Below the level of L2 vertebra, compression is of the cauda equina (i.e. If the lateral projection is inadequate, a swimmer's projection, oblique projections or a CT scan is indicated. Find out about treatments for pressure on the spinal cord (spinal cord compression). Numaguchi Y, Wipf JE, Commonly Missed Diagnoses in the Childhood Eye Examination, Assessment and Treatment of Depression Following Myocardial Infarction. The physician should be aware that, if present, a positive (abnormal) Babinski's sign is helpful, but a negative or absent sign does not exclude severe disease. Acad Emerg Med 1998;5:1041–3, Spinal Nerve Root Levels and Corresponding, Criteria for Ordering Plain-Film Radiographs of the Cervical Spine, Criteria for Ordering CT Scanning of the Cervical Spine. MRI studies may identify spinal metastasis in patients with normal radiographs and bone scans (Figure 2). Paraplegia. Clin Sports Med. The spinal cord is enveloped by three layers of meninges. This injury is characterized by ipsilateral loss of motor function and proprioception, with contralateral loss of pain and temperature sensation.7. Ernestus RI, Alexiadou-Rudolf C, 7. Mull M, Symptoms are beli… Facts about spinal cord compression. Paleologos TS, The annulus fibrosus is made of lamelliform connective tissue bands. Koch D, Am Fam Physician. Posner, J. Mayfrank L, Nussbaum ES, 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. : U.S. Dept. Get Permissions, Access the latest issue of American Family Physician. Acta Neurochir [Wien]. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. Numaguchi Y, Patel N, Spinal cord compression is a complex and challenging condition that greatly affects the quality of life. Y1 - 2017/9/1. It can also develop if a tumour puts pressure on the spinal cord. Rockville, Md. Spinal cord syndromes. Low back pain: an algorithmic approach to diagnosis and management. Want to use this article elsewhere? Spinal cord compression is a medical emergency that requires immediate treatment to avoid permanent damage. Surrounding these elements are multiple ligaments and muscles. Early diagnosis and treatment are the most important factors influencing on prognosis. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Suggested approach to the initial assessment of the patient with acute low back pain. 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). Discitis and osteomyelitis of the cervical spine in a 52-year-old man with fever and neck pain. Spinal epidural abscess: a report of 40 cases and review. Petri R, 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. 13. Tuberculous infection may result in vertebral collapse and a sharply angulated deformity (Pott's disease).2. Gouliamos AD, Neurol Clin. However, MRI can demonstrate accompanying soft tissue changes such as epidural hematomas and traumatic disc protrusions9,17 (Figure 4). Imaging studies are extremely important in the evaluation of spinal cord emergencies. This is known as metastatic spinal cord compression. Gimbel R. van Velthoven V. Spinal cord compression develops when the spinal cord is compressed by bone fragments from a vertebral fracture, a tumor, abscess, ruptured intervertebral disc or other lesion. Contact your doctor straight away if you have any symptoms of spinal cord compression. Physicians caring for patients with cancer must maintain a high index of suspicion for this problem. Acad Emerg Med 1998;5:1041–3. 1999;17:43–63. Babinski's sign and hyperreflexia are widely understood to be cardinal signs of the upper motor neuron syndrome that typically occurs in spinal cord compression. 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: The authors indicate that they do not have any conflicts of interest. Emerg Med Clin North Am. The most important information in the assessment of a possible spinal cord emergency comes from the history and the clinical evaluation. Engstrom JW. Dugas AF, Lucas JM, Edlow JA. Klug N. Chatzidakis EE, Metastatic spinal cord compression as an oncology emergency: getting our act together. Acad Emerg Med 1998. Mermel LA, J Emerg Nurs. 1994;32(2):70-80. 2 It is possible for the cord to be compressed in both the front and back. Prompt diagnosis and treatment are critically important. / Journals 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. The differential diagnosis includes spinal cord compression secondary to vertebral fracture or space-occupying lesion, spinal infection or abscess, vascular or hematologic damage, severe disc herniation and spinal stenosis. Treatment of acute SCC may include corticosteroids, surgery, or radiotherapy. Gaufberg SV. Low back pain: an algorithmic approach to diagnosis and management. Wagner R, Surgery is indicated if the diagnosis is in doubt, a tissue diagnosis is required, the spine is unstable or neurologic deterioration is severe, rapid and progressive. 2-4 The physician must first ... in spinal cord compression. An important differential diagnosis in spinal emergencies. Geriatrics. 12. Philip L, Acute myelopathy in patients with cancer may also be caused by irradiation, paraneoplastic necrotizing myelitis, ruptured intervertebral disc and meningeal carcinomatosis with spinal cord involvement. 1996;23:345–64. Neurol Clin. The causes of spinal cord compression include the following: Certain degenerative diseases, such as arthritis, can lead to spinal cord compression. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Klug N. A ruptured disk may lead to spinal cord compression. Spinal cord compression happens when pressure on the spinal cord stops the nerves working normally. 4. Why are spinal decompression surgeries done? Depending on the cause of the compression, symptoms may develop suddenly or gradually, and they may require anything from supportive care to emergency surgery. The anterior column of the spine includes the anterior longitudinal ligament, anterior portion of the vertebral body and anterior portion of the intervertebral disc. “Red Flags” Suggesting a Serious Underlying Pathology Possibly Requiring Imaging, Adapted from Bigos SJ, et al. Spinal cord compression is caused by a condition that puts pressure on your spinal cord. Lanfermann H, Surgery for metastasis to the brain. Your spine is divided into three areas. Acute nontraumatic spinal epidural hematomas. Spinal cord compression is an emergency.  |  Urol Clin North Am. Bigos SJ, et al. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. The trauma may cause both a head injury and a spinal cord injury. The diagnosis is established by thorough neurologic examination, plain x-rays, myelography, CT and MRI scanning. Paleologos TS, of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. Van der Reis W. 2009 May;27(2):195-208. doi: 10.1016/j.emc.2009.02.001. Nocturnal spinal pain preventing sleep. Unless a red flag is noted on the clinical examination, plain-film radiographs are not recommended for the routine evaluation of patients with acute neck or low back pain within the first month of symptoms3  (Table 1).5, Computed tomographic (CT) scanning, magnetic resonance imaging (MRI), myelography and combined CT and myelography can clearly define anatomy. Spinal cord compression can occur anywhere from your neck (cervical spine) down to your lower back (lumbar spine). Clipboard, Search History, and several other advanced features are temporarily unavailable. Please enable it to take advantage of the complete set of features! Swenson R. The … Rosen P. Emergency medicine: concepts and clinical practice. Neurological signs of spinal cord or cauda equina compression. 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. Spinal epidural abscess: correlation between MRI findings and outcome. 1998;17:111–20. Neurosurgical involvement, or transfer to a tertiary care center with neurosurgical and neuroimaging capabilities, is prudent. d'Arcy HS, Physicians who work in primary care settings and emergency departments frequently evaluate patients with neck and back pain. Author information: (1)Department of Neurology, University of Miami, Miami, FL, USA. Papadopoulos SS, A smaller disc herniation is noted at C5-C6. kophelan@med.miami.edu. Athletic spinal cord and spine injuries. Spinal cord compression is a complex and challenging condition that greatly affects the quality of life. Spinal cord emergencies: false reassurance from reflexes. An MRI study that reveals a narrow spinal canal can confirm the diagnosis of spinal stenosis. Treatment for spinal cord compression should start as soon as possible, usually within 24 hours of diagnosis. Laboratory tests are particularly useful when infection or malignancy is considered to be a possible cause of the spinal pathology. Wilberger JE. Gaufberg SV. 64/No. Keep him or … Haldeman S. Osteophytic overgrowth ventrally and, in some cases, buckling of the ligamentum flavum dorsally can cause direct compression of the spinal cord resulting in myelopathy (clinically evident spinal cord dysfunction). Spinal cord compression can occur anywhere from your neck down to your lower spine and cause symptoms, such as numbness, pain, and weakness. Chatzidakis EE, Magnetic resonance imaging in spinal emergency. Acute low back problems in adults. Don't miss a single issue. If you suspect spinal cord compression, get … of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994; AHCPR publication no. 1999;44:785–92. Spinal cord emergencies: false reassurance from reflexes. 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. Southampton This is a corrected version of the article that appeared in print. Surgery is also indicated if decompression by radiation therapy is not expected to become effective in time to save a patient from severely disabling neurologic deficits.7. SCC should be among the first potential causes considered given the significant permanent loss of neurologic function commonly associated with SCC. Acad Emerg Med. Quint DJ, Spinal cord compression is a surgical emergency and if unrecognised or untreated, can result in irreversible neurological damage and disability. Copyright © 2020 American Academy of Family Physicians. Nanassis K, Acute nontraumatic spinal epidural hematomas. Can often be helped with medicines, physical therapy, or other treatments percent of patients neck! The American Academy of Family physicians localized tenderness or a suspicious mechanism of injury protected! Frequently in adults than in children afpserv @ aafp.org for copyright questions permission! The L1-L2 level for processes such as bleeding, neoplasm and infection to reach an advanced before. Tests for the imaging of cervical spinal cord or cauda equina cause both a head injury and a urinalysis disc... 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