Early diagnosis is imperative
RECOGNITION AND ASSESSMENT
- In patients with mild weakness and urinary hesitancy, especially if history of cancer, have high index of suspicion
Symptoms and signs
- Acute (usually symmetrical) weakness of arms or legs or both
- weakness of the arms only is rare but apparently normal strength in the legs does not rule out spinal cord compression
- Sensory level
- may be absent or at least difficult to pick up in high cervical spine compression
- Hyperreflexia and extensor plantar responses
- because of spinal shock these may not be present at outset
- Bowel/bladder dysfunction
- Erectile dysfunction in males
- Local spinal pain and/or tenderness +/- radicular pain
- In patient with diagnosed cancer, certain symptoms strongly suggest spinal metastases:
- cervical or thoracic pain
- progressive or unremitting severe lumbar pain
- nocturnal spinal pain preventing sleep
Examination
- Full neurological examination with clear documentation on ASIA chart
- Upper and lower limb strength and reflexes
- Sensory examination of upper and lower limbs and perineum
Investigations
- Refer such patients IMMEDIATELY to a spinal specialist
- do not delay referral until a scan has been done
- If spinal cord compression suspected, request immediate MRI scan of whole spine
- if MRI scan required out-of-hours. See Accessing imaging: inpatients and emergencies guideline
- FBC, U&E, LFT, ESR, CRP
- If infection suspected, blood cultures. See Collection of blood culture specimens guideline
- Chest X-ray
- If malignant cause of cord compression suspected from MRI scan:
- CT head/chest/abdomen/pelvis
Differential diagnosis
- First exclude spinal cord compression
- Transverse myelitis
- Cord ischaemia
- Guillain-Barré syndrome
- Intrinsic spinal cord lesion such as intramedullary tumour
- Intracranial lesion
IMMEDIATE TREATMENT
- If malignancy suspected or proven, refer immediately to musculoskeletal cancer team
- Optimise spinal cord perfusion by treating hypovolaemic or neurogenic shock
- ideally keeping MAP ≥75–80 mmHg
- Both because of potential for spinal instability, and to optimise cord perfusion, ensure patient is nursed flat
- with turns side-to-side for pressure area care
- Catheterise the bladder. See Urethral catheterisation guideline
- If symptoms and signs suggest high cervical spinal cord compression, be aware of potential for respiratory failure
Dexamethasone
- Once MRI scan performed and infective cause excluded, and after discussion with on-call spinal surgery team, give dexamethasonesodium phosphate 6.6 mg (Hameln brand) IV immediately
- then 8 mg oral twice daily at breakfast and lunchtime
- with concomitant administration of a PPI (e.g. omeprazole or lansoprazole)
- if oral route inappropriate, continue dexamethasone 6.6 mg IV twice daily at breakfast and lunchtime
- Review need for dexamethasone at 48 hr
- If patient requires surgery +/- radiotherapy, review dose
SUBSEQUENT MANAGEMENT
- If surgery not indicated, and patient has cancer, refer immediately to oncology team
- share treatment decisions with oncology, but this need not delay urgent surgery
- Further management will be decided by spinal team or oncology team, as patients may receive radiotherapy after or as an alternative to surgery
© 2022 The Bedside Clinical Guidelines Partnership.
Created by University Hospital North Midlands and Keele University School of Computing and Mathematics.
Research and development team: James Mitchell, Ed de Quincey, Charles Pantin, Naveed Mustfa