Spinal cord compression

Spinal cord compression is characterised by a combination of a progressive history of neurological deficit and a sensory level on examination.

This is a lesion that causes lower motor neurone signs at the level of the lesion and upper motor neurone lesions below that level.

It is a neurological emergency because:

• the final events are ischaemic, so they are fast and irreversible
• the patient may be left in a wheelchair, incontinent of urine

Pain characteristics suggesting spinal metastases (1):

• severe unremitting back pain
• progressive back pain
• mechanical pain (aggravated by standing, sitting or moving)
• back pain aggravated by straining (for example, coughing, sneezing or bowel movements)
• night-time back pain disturbing sleep
• localised tenderness
• claudication (muscle pain or cramping in the legs when walking or exercising)

Symptoms and signs suggesting cord compression (1):

• bladder or bowel dysfunction
• gait disturbance or difficulty walking
• limb weakness
• neurological signs of spinal cord or cauda equina compression
• numbness, paraesthesia or sensory loss
• radicular pain

Note that the commonest cause of acute cord compression is metastatic disease.

• metastases to the spinal column are diagnosed in around 16% of all people with cancer and may cause pain, vertebral collapse and spinal cord or root compression (1)
  • more than 4,000 people present annually in England and Wales with spinal metastases
    
    
• metastatic spinal cord compression (MSCC) develops in 40% of patients with pre-existing non-spinal bone metastasis (2)
  
  
• treatments for patients with MSCC differ based on their life expectancies (3,4)
  • to improve the quality of life, patients with a life expectancy of more than 3–6 months may undergo surgery (5,6)
  • decompressive surgery, which is considered to be the “gold standard” in tumours which are not specifically radiosensitive (7)
  • evidence shows that survival of MSCC patients can be improved with palliative decompression before motor deficits occur. After motor deficit onset, survival can still be improved with surgery within 7 days. Overall survival was better in patients aged <=55 years (8)

Reference:

1. NICE (September 2023). Spinal metastases and metastatic spinal cord compression
2. Schmidt MH, Klimo P Jr, Vrionis FD. Metastatic Spinal Cord Compression. J Natl Compr Canc Netw. 2005. September;3(5):711–9
3. Mattana JL et al. Study on the applicability of the modified Tokuhashi score in patients with surgically treated vertebral metastasis. Rev Bras Ortop. 2015. November;46(4):424–30
4. Murakami H et al. Perioperative complications and prognosis for elderly patients with spinal metastases treated by surgical strategy. Orthopedics. 2010. March;33(3):165–8.
5. Lee CH et al. Direct decompressive surgery followed by radiotherapy versus radiotherapy alone for metastatic epidural spinal cord compression: a meta-analysis. Spine (Phila Pa 1976). 2014. April;39(9):E587–92
6. 6.Nemelc RM, Stadhouder A, van Royen BJ, Jiya TU. The outcome and survival of palliative surgery in thoraco-lumbar spinal metastases: contemporary retrospective cohort study. Eur Spine J. 2014. November;23(11):2272–8.
7. 7. Klimo P, Kestle JRW, Schmidt MH. (2005) A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol. 2005;7:64–75.
8. 8. Lo W-Y. Metastatic spinal cord compression (MSCC) treated with palliative decompression: Surgical timing and survival rate. PLoS 2017; 12(12): e0190342.