Acute Spinal Cord Compression


  • Neurological/oncological emergency
  • Often underrecognised due to non-specific symptoms
  • Can result in paraplegia


  • Can be caused either by a space occupying lesion compressing the spinal cord or injury causing transection of the cord
    • Trauma is the most common cause- high impact C-spine damage
    • Tumours- extradural are usually mets; intradural are normally primaries
    • Infection- abscess (TB/staph most common)
    • Haemorrhage (trauma/bleeding disorders/anticoagulant treatment/ AVMs)
    • Oedema from venous obstruction or ischaemia from arterial obstruction (spinal stroke)
  • Aetiology can be classed by site:
    • Vertebral (80%)
      • e.g. trauma; metastatic (bony) disease (most commonly from breast, prostate or bronchial)
    • Meninges (15%)
      • e.g. tumours (meningioma; neurofibroma; ependymoma; lymphoma; metastatic disease; leukaemia); epidural abscess
    • Spinal cord (intramedullary; 5%)
      • Spinal cord tumours e.g. gliomas; ependymoma or metastases


  • Onset is usually gradual (weeks) but can be acute e.g. in traumatic, metastatic or vascular causes
    • Pain (early)
      • Localised over the spine (this is a common early symptom, particularly in patients with metastatic disease- i.e. DO NOT ignore this in these patients) and/or in a radicular distribution (may be aggravated by coughing, sneezing, straining)
    • Sensory (early)
      • Paraesthesia and numbness which often begins in the lower limbs and spreads up, often to a specific level on the trunk
        • Can be loss of proprioception, light touch or pin-prick sensation
      • Can also cause a reduction in proprioception depending on extent of compression (often later than light sensation; particularly in anterior compression syndromes where the dorsal columns are the last to be affected)
    • Motor (late but common)
      • Weakness or stiffness of the limbs (lower > upper)
        • Weakness may be hard to determine if the patient is not walking prior to symptom onset
        • Can be bilateral or unilateral
    • Sphincters (late)
      • Urgency or hesitancy of micturition, progressing to urinary retention
      • Bowel constipation
  • Typically, there are a mixture of upper and lower motor neuron signs
    • Below the level of compression there are usually upper motor neuron signs i.e. brisk reflexes and spasticity
    • At the level of compression there are usually lower motor neuron signs (due to compression of the nerve roots as well as spinal cord) i.e. hyporeflexia and weakness
    • Above the level of compression, signs can be normal

Signs of injury at different spinal levels

  • Cervical (above C5)
    • Upper motor neuron signs in all limbs and diaphragmatic weakness (phrenic nerve affected)
  • Cervical (at or below C5)
    • Lower motor neuron signs and segmental sensory loss in the arms; upper motor neuron signs in the legs
    • Respiratory (intercostal) weakness
  • Thoracic
    • Spastic paraplegia with a sensory level at the trunk
    • Weakness of the legs, sacral loss of sensation and extensor (upward) plantar reflexes

Specific syndromes associated with cord compression (often traumatic/hyperacute causes)

  • Cord transection i.e. complete lesion (all motor and sensory modalities affected)
    • Complete loss of motor control and sensation from the anywhere below the level affected
    • Initially a flaccid arreflexic paralysis (spinal shock) with hypotension, bradycardia and hypothermia (classic triad)
      • UMN signs later on
    • Unlikely to recover

  • Brown-Sequard Syndrome (Cord hemisection- very rare but produces some classical signs to note; NB can be due to compressive lesions so may present slowly)
    • Disruption of the ipsilateral motor pathways; ipsilateral dorsal column tracts (fine touch/proprioception/reflexes) and contralateral spinothalamic tract


*- side of lesion; 1- hypotonic paralysis; 2- spastic paralysis and loss of vibration, proprioception and fine touch; 3- loss of pain/temperature sensation
  • Central cord syndrome
    • usually caused by a hyperflexion/hyperextension injury to an already stenotic neck
    • Predominantly distal upper limb weakness; cape-like spinothalamic sensory loss (lower limb power and dorsal column sensation preserved)
NB that weakness is the distal upper limb


  • Arrange an URGENT MRI (as soon as possible)


  • Depends on cause
  • Trauma-
    • ABCDE; Immobilise; investigate (X-ray/MRI)
    • Methylprednisolone (Must be given within 8 hours)- Bolus and 24hr infusion
    • Decompress and stabilise
  • Tumours
    • Depends on tumour/patient
    • Dexamethasone as soon as possible
      • 16mg IV stat then 4mg PO QDS + PPI cover
      • Reduces vasogenic oedema
    • Radiotherapy or Surgery if clinically suitable
      • Surgery if single level involvement without widespread disease; or radio-resistant disease/previous radiotherapy to the site OR if unknown primary
      • Chemotherapy can only really be considered in rarer highly sensitive tumours
  • Infection
    • Surgical drainage
    • Antimicrobial treatment- (High dose IV Ceftriaxone and Metronidazole +/- Flucloxacillin if staph aureus involvement)
  • Bleeding
    • Reverse any anticoagulant and surgically decompress

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