What are the management guidelines for compressive myelopathy, including diagnosis, symptoms, and treatment options?

Compressive Myelopathy: Types, Symptoms, Diagnosis, and Management Guidelines

Patients with compressive myelopathy should receive immediate high-dose dexamethasone therapy, with surgical decompression for those with bone fragment compression, and radiotherapy for those with neurologic impairment. 1

Types of Compressive Myelopathy

Compressive myelopathy refers to compression of the spinal cord from various sources, including:

• Extradural causes (84% of cases) 2:

  • Trauma (fractures, dislocations)
  • Degenerative changes (cervical spondylosis, disc herniation)
  • Neoplasms (primary and metastatic tumors)
  • Infections (epidural abscess, tuberculosis)
  • Multiple myeloma with vertebral collapse

• Intradural-extramedullary causes (16% of cases) 2:

  • Meningiomas
  • Schwannomas
  • Neurofibromas

Clinical Presentation and Symptoms

The symptoms of compressive myelopathy depend on the level and severity of compression:

• Early symptoms:

  • Local or radicular pain (may be the first symptom) 1
  • Sensory disturbances (numbness, paresthesias)
  • Subtle gait changes

• Progressive symptoms:

  • Motor weakness (decreased hand dexterity in cervical myelopathy) 3
  • Gait instability and balance problems 3
  • Sensory deficits below the level of compression
  • Sphincter dysfunction (urinary and bowel problems) 1

• Severe cases:

  • Paralysis
  • Complete loss of sensory function
  • Total loss of bowel/bladder control

Diagnostic Approach

Clinical Evaluation

• Thorough neurological examination focusing on motor strength, sensory deficits, reflexes, and gait
• Assessment of sphincter function
• Evaluation for signs of spinal cord compression

Imaging Studies

• MRI is the preferred imaging modality for evaluating compressive myelopathy 1, 4, 2

  • Provides excellent visualization of the spinal cord and surrounding structures
  • Can identify the cause, location, and extent of compression
  • Helps differentiate between compressive and non-compressive myelopathy

• CT myelography may be used when MRI is contraindicated 3

• Plain radiographs may show bony abnormalities but are insufficient for diagnosis

Additional Testing

• Electrophysiological studies may help confirm the diagnosis and assess severity

Management Guidelines

Emergency Management

1. High-dose dexamethasone therapy should be immediately initiated in patients with spinal cord compression 1

   • Helps reduce edema and inflammation around the spinal cord
   • May improve neurological symptoms and pain

2. Surgical decompression is indicated when:

   • Compression is due to bone fragments 1
   • Vertebral collapse is present 1
   • Spinal instability exists 1
   • Neurological deterioration occurs during conservative treatment 5

3. Radiotherapy should be administered to:

   • Patients with neurologic impairment (deficits and/or symptoms) 1
   • Cases with neoplastic compression 1
   • Post-operatively once healing has occurred in surgical candidates 1

Management Based on Severity

Mild Myelopathy

• Options include:
  • Surgical intervention OR
  • Supervised trial of structured rehabilitation 5
  • If non-operative management is initially chosen, surgery is recommended if neurological deterioration occurs 5

Moderate to Severe Myelopathy

• Surgical intervention is strongly recommended 5
  • Early intervention is crucial to prevent irreversible neurological damage
  • The type of surgical approach depends on the location and cause of compression

Non-myelopathic Patients with Evidence of Cord Compression

• Without radiculopathy: Prophylactic surgery is not recommended 5
• With radiculopathy: Higher risk of developing myelopathy; offer either surgical intervention or close follow-up 5

Specific Management for Multiple Myeloma-Related Compression

• Bisphosphonates for patients with bone disease 1

  • Options include oral clodronate, IV pamidronate, or IV zoledronic acid
  • Monitor renal function during treatment

• Kyphoplasty may be beneficial for vertebral augmentation in cases of vertebral collapse 1

Prognosis and Outcomes

• Recovery of neurologic function depends primarily on pretreatment status 1, 4

  • Only 30% of non-ambulatory patients regain ability to walk 1, 4
  • Only 2-6% of paraplegic patients recover ambulatory function 1, 4

• Early diagnosis and treatment are critical for better outcomes

  • Patients with slower development of motor deficits (>14 days) have better functional outcomes 1

Prevention and Screening

• Patients at high risk for spinal cord compression (e.g., multiple myeloma patients) should be aggressively screened and educated about symptoms 1

• Patients with extensive bone metastases (>20 lesions) have a higher risk of developing spinal cord compression and should be monitored closely 1

Key Pitfalls to Avoid

1. Delayed diagnosis - Recognize that early symptoms may be subtle and easily missed
2. Inadequate imaging - Always obtain MRI when compressive myelopathy is suspected
3. Delayed treatment - Immediate intervention with steroids and appropriate surgical/radiation therapy is essential
4. Inadequate follow-up - Patients with risk factors need close monitoring for progression

By following these guidelines, clinicians can optimize outcomes for patients with compressive myelopathy through early diagnosis and appropriate management.