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, Freitas RR, Mello GJ, Neto MA, Freitas Filho Gd, Ferreira CB, 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, Kawahara N, Demura S, Kato S, Yoshioka K, Sasagawa T, 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, Kwon JW, Lee J, Hyun SJ, Kim KJ, Jahng TA, 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.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. 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. Lo W-Y. Metastatic spinal cord compression (MSCC) treated with palliative decompression: Surgical timing and survival rate. PLoS 2017; 12(12): e0190342.