What are the symptoms and treatment options for spinal cord compression?

Symptoms and Treatment of Spinal Cord Compression

Clinical Presentation

The cardinal symptom of spinal cord compression is back pain, present in 90% of patients at presentation, though back pain alone is not predictive of malignant spinal cord compression (MSCC). 1

Key Symptoms to Recognize

• Motor weakness and gait deterioration occur in approximately 67% of patients before diagnosis, with up to 50% of patients unable to walk at presentation 1, 2
• Sensory changes including numbness, paresthesias, and sensory level deficits 1
• Autonomic dysfunction manifesting as bladder retention (48% of patients), bowel dysfunction, and sphincter disturbances 1, 2
• Radicular pain extending from the spine along nerve root distributions 1

Critical Timing Issue

Approximately 70% of patients experience progressive neurologic deterioration between symptom onset and treatment initiation, making this a true medical emergency. 1 Two-thirds of diagnostic delays are attributed to patients failing to recognize symptoms as urgent 3, and delays at the general practitioner level compound the problem 1.

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Diagnostic Approach

MRI of the entire spine is the preferred imaging modality and should be performed emergently for any patient with neurologic symptoms and a history of cancer. 1, 3, 4

Imaging Performance

• MRI sensitivity: 0.44-0.93; specificity: 0.90-0.98 1, 3
• Myelography with CT is an alternative with sensitivity 0.71-0.97 and specificity 0.88-1.00 1, 3
• Plain radiography cannot visualize discs or accurately evaluate spinal stenosis and should not be used 1

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Treatment Algorithm

Immediate Management: Corticosteroids

High-dose dexamethasone should be initiated immediately upon clinical suspicion, even before radiographic confirmation. 3

• Standard regimen: 96 mg IV daily, tapered over 14 days 3
• Evidence: High-dose dexamethasone before radiotherapy significantly improves ambulation rates (81% vs 63% at 3 months, P=0.046) compared to no corticosteroids 1, 3
• Caveat: This carries significant toxicity risk, and more studies are needed to establish optimal dosing 1

Definitive Treatment Selection

Surgery followed by radiotherapy is indicated for patients meeting ALL of the following criteria: 3

• Single level of compression
• Neurologic deficits present for <48 hours
• Predicted survival ≥3 months
• Age <65 years

Absolute surgical indications regardless of other factors: 3

• Bony retropulsion or bone fragments causing cord compression
• Frank spinal instability
• Unknown primary requiring tissue diagnosis 1

Surgery plus radiotherapy maintains ambulation longer than radiotherapy alone (P=0.006) in selected patients. 3

Radiotherapy Alone

For patients not meeting surgical criteria, radiotherapy is the primary treatment. 1, 3

• Standard regimen: 30 Gy in 10 fractions 3
• Alternative regimens: 37.5 Gy in 15 fractions, 40 Gy in 20 fractions, or 28 Gy in 7 fractions—no regimen demonstrates superiority 1, 3
• Important: Pain relief may be delayed up to 2 weeks following treatment 3

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Prognostic Factors That Determine Outcomes

Pretreatment ambulatory status is the single strongest predictor of post-treatment function and survival. 1, 3

Expected Outcomes by Pretreatment Status

• Ambulatory patients: 96-100% remain ambulatory after treatment 3
• Paraparetic (non-ambulatory) patients: Only 18-30% regain walking ability 3, 2
• Paraplegic patients: Only 2-6% regain ambulatory function 3

Patients with slower motor deficit development (>14 days) have significantly better functional outcomes than those with rapid progression (<14 days, P<0.01). 1, 3

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High-Risk Populations Requiring Vigilance

Lung cancer (24%), prostate cancer (20%), and breast cancer (21%) account for 65% of MSCC episodes. 1 Other high-risk malignancies include myeloma (7.9% lifetime risk) and renal cell carcinoma 1, 5.

For asymptomatic patients with extensive bone metastases (>20 lesions), the risk of MSCC reaches 32% before hormone therapy and 44% after 24 months of treatment. 1

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Critical Pitfalls to Avoid

• Do not wait for complete neurologic deficit before imaging—back pain with any sensory changes or mild weakness warrants emergent MRI 1, 4
• Do not assume back pain alone excludes MSCC—while not predictive, 90% of MSCC patients have pain 1
• Do not delay corticosteroids pending imaging—start dexamethasone on clinical suspicion 3
• Do not image only the symptomatic level—image the entire spine as 15% of patients have multiple compression sites 1