Oncologic emergency. Back pain โ radiculopathy โ weakness โ sensory level โ bowel/bladder dysfunction. MRI STAT. Dexamethasone 10mg IV immediately. Neurosurgery + radiation oncology within hours. Time to treatment determines outcome.
๐ Overview
Etiology
Cause
Details
Metastatic disease
#1 cause. Lung, breast, prostate, RCC, myeloma. Usually epidural (vertebral body mets โ posterior extension)
Primary spine tumors
Meningioma, schwannoma, ependymoma
Epidural abscess
Fever + back pain + risk factors (IVDU, recent spinal procedure). S. aureus #1.
Epidural hematoma
Post-procedure or anticoagulation
Disc herniation
Most common cause of non-malignant cord compression
ANY cancer patient with new back pain must have spinal cord compression excluded. Once motor deficits appear, the window for meaningful recovery is hours. Ambulatory status at diagnosis is the #1 predictor of outcome.
๐จ Management
Emergent Management
Dexamethasone 10 mg IV STAT then 4 mg IV q6h -reduces vasogenic edema around cord
MRI entire spine with contrast -STAT. Multiple levels in 30% of cases.
Neurosurgery consult -surgical decompression if: single level, good functional status, life expectancy > 3 months, radioresistant tumor
Radiation oncology consult -definitive treatment for most metastatic SCC. Start within 24h.
Patchell trial (2005): Surgery followed by radiation was superior to radiation alone for ambulatory recovery (84% vs 57%) in patients with single-level metastatic SCC and reasonable prognosis.
๐งช Workup
MRI entire spine with gadolinium -gold standard. Must image ENTIRE spine (multiple lesions in 30%)
CT myelogram -if MRI contraindicated (pacemaker)
Plain films -vertebral body collapse, but misses early compression
Post-void residual -bladder dysfunction is late sign
๐ Medications
Drug
Dose
Purpose
Dexamethasone (Decadron)
10 mg IV bolus โ 4 mg IV q6h
Reduce cord edema. Start immediately on clinical suspicion.
Oxycodone (OxyContin)
5โ15 mg PO q4โ6h
Pain control. Often severe.
Gabapentin (Neurontin)
300โ900 mg TID
Neuropathic pain adjunct
Omeprazole (Prilosec)
20โ40 mg daily
GI prophylaxis with high-dose steroids
๐ On Rounds
Pimp Questions
What is the clinical progression of spinal cord compression?
Back pain (earliest, present in 95%) โ radiculopathy (dermatomal pain) โ motor weakness (UMN pattern: spasticity, hyperreflexia below level) โ sensory level โ bowel/bladder dysfunction (latest -if present, prognosis for recovery is poor). Ambulatory status at presentation is the #1 predictor of outcome. Once paraplegia develops, only 10% regain ambulation.
Why must you image the ENTIRE spine in suspected SCC?
30% of patients with metastatic SCC have disease at multiple spinal levels. Imaging only the symptomatic level may miss additional lesions that could cause future compression or be targeted with radiation. Additionally, a symptomatic thoracic lesion may have additional cervical involvement that changes surgical planning. Always order MRI of the entire spine with gadolinium contrast.
What is cauda equina syndrome and how does it differ from cord compression?
Cauda equina syndrome affects the nerve roots below the conus medullaris (L1-L2), producing LMN signs: flaccid weakness, areflexia, saddle anesthesia, and early bowel/bladder dysfunction (urinary retention โ overflow incontinence). Cord compression above this level produces UMN signs: spastic weakness, hyperreflexia, Babinski sign. Both are surgical emergencies, but the clinical picture differs.
Clinical Examples
๐ Case 1, Metastatic Spinal Cord Compression
Patient: 67M with known metastatic prostate cancer. Progressive mid-back pain ร 3 weeks, now unable to walk since yesterday. Bilateral LE weakness (3/5), hyperreflexia, upgoing toes. Urinary retention (600 mL on bladder scan).
Key findings: UMN signs (hyperreflexia, Babinski) + sensory level at T8 + bladder dysfunction = thoracic spinal cord compression. Metastatic prostate cancer is the #1 cause of malignant cord compression.
Management:
Dexamethasone 10 mg IV STAT โ 4 mg IV q6h (reduces vasogenic edema around the cord)
Emergent MRI entire spine with contrast (30% have multiple levels of compression)
Neurosurgery consult for decompressive surgery if single level, good prognosis, and not radiosensitive Patchell, 2005
Radiation oncology consult, XRT alone if radiosensitive tumor (lymphoma, myeloma, SCLC) or poor surgical candidate
Foley catheter for urinary retention; bowel regimen
Teaching point: Ambulatory status at diagnosis is the #1 predictor of outcome. Patients who can still walk at presentation have ~80% chance of maintaining ambulation. Once paralyzed > 48h, recovery is rare. Speed matters, dexamethasone and MRI are both emergent.
๐ Case 2, Cauda Equina Syndrome from Disc Herniation
Patient: 42F with acute low back pain after heavy lifting, now with bilateral leg weakness, saddle numbness, and inability to urinate ร 12 hours. Exam: flaccid bilateral LE weakness, absent ankle reflexes, decreased perianal sensation, lax anal tone.
Key findings: LMN signs (flaccid weakness, areflexia) + saddle anesthesia + urinary retention = cauda equina syndrome. Disc herniation at L4-L5 or L5-S1 is the most common cause in young adults.
Management:
Emergent MRI lumbar spine, do not delay for any reason
Neurosurgery consult for emergent decompressive laminectomy (within 24-48h of symptom onset for best outcomes)
Foley catheter for urinary retention
Pain management: avoid opioids if possible pre-surgery; ketorolac 15 mg IV
Post-op: bladder function recovery may take weeks-months; monitor post-void residuals
Teaching point: Cauda equina syndrome is a surgical emergency with a narrow treatment window. Decompression within 48 hours of urinary retention onset gives the best chance of bladder recovery. After 48h, permanent deficits are common.
๐ Case 3, Epidural Abscess Mimicking Cord Compression
Patient: 55M IVDU with 5 days of progressive back pain, fever (39.2ยฐC), and now bilateral LE weakness. WBC 22K, ESR 110, blood cultures positive for MSSA. MRI: epidural abscess T10-T12 with cord compression.
Key findings: Spinal epidural abscess, classic triad: back pain + fever + neurologic deficits. IVDU is the #1 risk factor. S. aureus is the #1 organism. Hematogenous spread from bacteremia.
Vancomycin 25-30 mg/kg IV load + cefepime 2g IV q8h (empiric until culture-directed, cover MRSA + GNRs)
Narrow to nafcillin/oxacillin once MSSA confirmed (6-8 weeks IV antibiotics)
Serial MRI to monitor abscess resolution
Echo to rule out endocarditis (IVDU + S. aureus bacteremia = 30% concomitant endocarditis)
Teaching point: The classic triad of epidural abscess (back pain + fever + neuro deficits) is only present in 10-15% at initial presentation. Back pain + fever in IVDU โ MRI the spine. Once motor deficits develop, surgery must happen within hours to prevent permanent paralysis.