FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Cord & peripheral

Spinal cord compression

Cord compression (metastatic, disc, abscess, haematoma)

Overview

Compression of the spinal cord — an emergency because delay causes permanent paralysis. Metastatic malignant spinal cord compression (MSCC) is the classic cause. Presents with progressive limb weakness, a SENSORY LEVEL and sphincter disturbance; needs urgent MRI of the WHOLE spine and high-dose steroids.

Recognise

  • Progressive (UMN) leg weakness, a SENSORY LEVEL, bladder/bowel disturbance (late)
  • Back pain (often worse on coughing/lying), known malignancy (breast, lung, prostate, myeloma, renal)
  • UMN signs below the lesion (spasticity, brisk reflexes, upgoing plantars)

Red flags

  • New back pain in a cancer patient, progressive weakness, sensory level, sphincter involvement → MSCC emergency

Differentials & how to tell them apart

Cauda equina syndromeLMN signs — saddle anaesthesia, urinary retention with overflow, reduced anal tone, areflexia below L1/L2 (a cord-level emergency too)
Transverse myelitisinflammatory, MS/post-infectious, MRI cord signal change
Guillain-Barréareflexic ascending weakness, NO sensory level
Peripheral neuropathydistal, glove-and-stocking, no level

Investigations

URGENT whole-spine MRI (within 24h) — the diagnostic test; identify the cause (metastasis, disc, abscess, haematoma).

Management

Immediate high-dose dexamethasone + urgent whole-spine MRI → surgery/radiotherapy

  1. 1Suspected cord compression → immediate high-dose dexamethasone and urgent whole-spine MRI (within 24h); flat bed rest until stability assessed.Gate: Image the WHOLE spine (multiple-level metastases are common) and act fast — the neurological deficit at treatment predicts the final outcome
  2. 2Definitive: surgical decompression/stabilisation or radiotherapy (malignant); treat the underlying cancer; rehab.
High-dose dexamethasone — immediately to reduce oedema while arranging definitive treatment
Definitive: surgery or radiotherapy — decompression/stabilisation or radiotherapy for malignant compression

Key points

New back pain + progressive weakness + sensory level + sphincter signs in a cancer patient = MSCC → steroids + whole-spine MRI now. Cauda equina is the LMN, lumbosacral counterpart.

Monitor & prognosis

Neurological level/function, bladder, response to treatment.

Outcome depends on the deficit and speed of treatment — function at treatment is the key predictor.

Source: NICE NG (metastatic spinal cord compression)