Spinal cord Compression

Spinal cord compression is an oncological emergency caused by compression of the spinal cord or cauda equina, most commonly from metastatic malignancy. It threatens mobility, neurological function, independence, and survival. In some patients, spinal cord compression may be the first presentation of an otherwise undiagnosed and potentially curable malignancy. Early recognition, prompt imaging, immediate corticosteroid therapy, and urgent multidisciplinary management are essential to prevent irreversible neurological damage.

Epidemiology

Metastatic spinal cord compression occurs in approximately 5–10% of patients with cancer. It most commonly arises from vertebral metastases involving cancers of the breast, prostate, lung, kidney, thyroid, and multiple myeloma. The thoracic spine is the most frequently affected region, followed by the lumbar and cervical spine.

Risk factors

Risk factors include:

• Metastatic cancer involving the spine

• Breast cancer

• Prostate cancer

• Lung cancer

• Renal cell carcinoma

• Thyroid carcinoma

• Multiple myeloma

• Lymphoma

• Vertebral pathological fractures

• Known vertebral metastases

Pathophysiology

Spinal cord compression most commonly occurs when metastatic tumor within a vertebral body enlarges and extends into the epidural space, compressing the spinal cord. Compression may also result from collapse of a vertebral body weakened by metastatic infiltration, leading to pathological fracture and spinal instability. Persistent compression causes ischemia, demyelination, neuronal injury, and irreversible neurological deficits if not relieved promptly.

Clinical presentation

Patients usually present with progressive back pain followed by neurological deficits. The severity depends on the level and duration of spinal cord compression.

Symptoms

• Progressive back pain

• Localized spinal tenderness

• Radicular pain

• Limb weakness

• Difficulty walking

• Numbness or tingling of the limbs

• Sensory loss

• Bladder dysfunction

• Bowel dysfunction

• Urinary retention

• Reduced mobility

Clinical signs

• Spinal tenderness

• Motor weakness

• Sensory deficits below the level of compression

• Hyperreflexia

• Increased muscle tone

• Positive Babinski sign

• Gait disturbance

• Reduced anal sphincter tone

• Saddle anaesthesia in cauda equina involvement

Differential diagnosis

• Vertebral pathological fracture without cord compression

• Intervertebral disc prolapse

• Epidural abscess

• Epidural hematoma

• Transverse myelitis

• Degenerative spinal stenosis

• Acute ischemic myelopathy

• Primary spinal cord tumors

Diagnostic criteria

The diagnosis of spinal cord compression is based on compatible clinical features together with urgent spinal imaging demonstrating compression of the spinal cord or cauda equina.

Diagnosis is established by:

• Clinical features suggestive of spinal cord compression.

• MRI of the whole spine demonstrating spinal cord or cauda equina compression.

• CT scan of the spine where MRI is unavailable or contraindicated.

• Identification of the underlying malignancy where appropriate.

Investigations

• Urgent MRI of the whole spine (preferred investigation)

• CT scan of the whole spine if MRI is unavailable or contraindicated

• Full blood picture (FBP)

• Serum electrolytes

• Renal function tests

• Histopathological confirmation of the underlying malignancy where required

Management

Spinal cord compression is a medical emergency requiring immediate treatment.

Initial management includes:

• Assess airway, breathing, and circulation.

• Perform an urgent neurological assessment.

• Immobilize the patient to minimize further spinal injury.

• Arrange urgent MRI of the whole spine.

• Initiate corticosteroid therapy immediately when spinal cord compression is suspected.

• Insert a bladder catheter when urinary retention or bladder dysfunction is present.

• Seek urgent neurosurgical and radiation oncology consultation once the diagnosis is confirmed.

Non-pharmacological treatment

Initial supportive management

• Immobilize the patient.

• Arrange urgent MRI of the whole spine.

• Bladder catheterization where appropriate.

• Provide pressure area care and thromboprophylaxis according to institutional protocols.

• Early physiotherapy and rehabilitation following definitive treatment.

Surgical management

• Urgent neurosurgical assessment is required once spinal cord compression is confirmed.

• Surgical decompression should be considered as the initial treatment in suitable patients, depending on:

  • Spinal stability

  • Patient performance status

  • Type and extent of malignancy

  • Expected prognosis

Radiotherapy

Radiotherapy is recommended for patients who are not suitable candidates for upfront surgical decompression.

Recommended palliative radiotherapy schedules include:

• 8 Gy in a single fraction

OR

• 20 Gy in 5 fractions

OR

• 30 Gy in 10 fractions

Pharmacological treatment

Corticosteroid therapy

Corticosteroids should be started immediately when spinal cord compression is suspected.

• Dexamethasone – 16 mg – IV – immediately as a loading dose.

Then:

• Dexamethasone – 16 mg – IV or PO – daily in divided doses – duration according to specialist recommendation and clinical response.

Management according to underlying cause

Metastatic spinal cord compression

• Immediate corticosteroid therapy.

• Urgent MRI.

• Surgical decompression where appropriate.

• Radiotherapy for patients unsuitable for surgery or following surgery when indicated.

• Definitive treatment of the underlying malignancy.

Pathological vertebral fracture

• Immobilization.

• Surgical stabilization where indicated.

• Radiotherapy following specialist assessment.

Radiosensitive tumors

• Early radiotherapy following confirmation of diagnosis.

• Systemic therapy according to tumor type.

Referral

All patients with suspected spinal cord compression require immediate referral.

Urgently refer to:

• Neurosurgeon

• Radiation oncologist

• Medical oncologist where appropriate

Immediate referral is indicated for patients with:

• New neurological deficits

• Progressive limb weakness

• Difficulty walking

• Bladder or bowel dysfunction

• Suspected cauda equina syndrome

• MRI or CT evidence of spinal cord compression

Complications

• Permanent paralysis

• Loss of ambulation

• Chronic neuropathic pain

• Urinary retention

• Urinary incontinence

• Faecal incontinence

• Pressure ulcers

• Venous thromboembolism

• Recurrent spinal cord compression

• Reduced quality of life

Prognosis

The prognosis depends on the underlying malignancy, severity of neurological impairment, ambulatory status before treatment, and time to initiation of therapy. Patients who remain ambulatory before treatment are more likely to retain mobility. Early diagnosis and prompt surgical decompression and/or radiotherapy significantly improve neurological outcomes and quality of life.

Prevention

Early identification of spinal metastases and prompt evaluation of new back pain in patients with known malignancy are essential to prevent spinal cord compression. Patients with vertebral metastases should be monitored closely for neurological symptoms, and any suspicion of spinal cord compression should prompt immediate imaging and specialist referral.