Types of Compressive Spinal Emergencies
Compressive spinal emergencies include extrinsic compression from degenerative disease, epidural abscesses, hematomas, primary or metastatic tumors, vertebral fractures with retropulsion, and postoperative complications requiring urgent intervention to prevent permanent neurological damage. 1
Noninflammatory Causes of Spinal Cord Compression
Degenerative Disease (Spondylotic Myelopathy): Most common cause of extrinsic compression in the acute setting, particularly in the cervical spine. Contributing factors include spinal degenerative changes, disc herniations, and malalignment, which may be accentuated by congenitally short pedicles 1
Epidural Hematoma: Can occur after minor trauma or spontaneously, especially in patients on anticoagulation. May present with local or radicular pain and progressive neurological deficits 1
Vertebral Fractures with Retropulsion: Osteoporotic or pathologic fractures can lead to myelopathy even with minor trauma or no obvious history of trauma 1
Traumatic Spinal Injuries: Include fractures, subluxation, and dislocation causing cord compression. These are classified according to the AO Spine Thoracolumbar Injury Classification System based on injury morphology and neurological status 1
Postoperative Complications: Extrinsic compression can develop throughout the postoperative course due to seromas, pseudomeningoceles, hematomas, and/or epidural abscesses 1
Neoplastic Compression: Primary or metastatic tumors of the extradural and intradural extramedullary spaces encroaching upon the spinal canal, causing acute or progressive myelopathy 1
Epidural Abscess: Infectious process in the epidural space causing cord compression, often accompanied by fever and elevated inflammatory markers 1, 2
Vascular Causes of Spinal Cord Compression
Spinal Cord Ischemia: Though infrequent, can result from atheromatous disease, aortic surgery complications, systemic hypotension, thoracoabdominal aneurysms or dissection, sickle cell disease, and spinal arteriovenous malformations (AVMs) 1
Hematomyelia: Very rarely, patients may develop intramedullary hemorrhage from an AVM or spinal artery aneurysm rupture 1
Fibrocartilaginous Embolic Disease: Can cause acute ischemic myelopathy 1
Inflammatory Causes of Spinal Cord Compression
Demyelinating Diseases: Multiple sclerosis (MS), neuromyelitis optica (NMO), and acute disseminated encephalomyelitis (ADEM) 1
Systemic Inflammatory Conditions: Systemic lupus erythematosus, Sjogren syndrome, mixed connective tissue disorder, Behcet disease, and sarcoidosis 1
Infectious Myelitis: Various pathogens can cause inflammatory compression of the spinal cord 1, 3
Clinical Presentation and Diagnosis
Neurological Deficits: Patients typically present with motor and sensory dysfunction referable to one or a few contiguous spinal levels, often with bowel and bladder dysfunction 4
Imaging: MRI is the gold standard for evaluation of spinal cord compression, offering superior soft-tissue resolution and multiplanar capability 1
CT Imaging: Useful in trauma settings to detect fractures, subluxation, and dislocation requiring immediate stabilization 1
Management Considerations
Timing: Interventions for spinal cord compression are time-sensitive; delays in treatment can lead to irreversible neurological damage 4
Surgical Decompression: Emergency decompressive surgery is necessary for many extramedullary compressive causes 3
Medical Management: High-dose corticosteroids within 8 hours of traumatic spinal cord injury may be beneficial 5
Multidisciplinary Approach: Management of pathologic fractures often requires coordination between interventional radiology, surgery, and radiation oncology 1
Early recognition and appropriate imaging are critical in diagnosing compressive spinal emergencies. The prognosis depends largely on the preoperative neurological status and the time to intervention, highlighting the importance of prompt diagnosis and treatment 3, 4.