What are the different diseases that can cause spinal cord compression in a patient with a history of cancer, trauma, or degenerative spinal conditions, and what are their clinical manifestations?

Diseases Causing Spinal Cord Compression and Their Clinical Manifestations

Spinal cord compression arises from distinct disease categories—degenerative, neoplastic, infectious, inflammatory, vascular, and traumatic—each presenting with characteristic patterns that guide urgent diagnosis and treatment.

Degenerative Diseases

Spondylotic Myelopathy

• Most common cause of chronic spinal cord compression, predominantly affecting the cervical spine 1
• Contributing factors include:
  • Disc herniations 1
  • Spinal degenerative changes and osteophyte formation 1
  • Epidural lipomatosis 1
  • Malalignment and subluxation 1
  • Congenitally short pedicles that accentuate compression 1

Clinical manifestations:

• Progressive weakness and gait disturbance 1
• Sensory deficits in hands and feet 1
• Loss of fine motor coordination 1
• Bladder dysfunction in advanced cases 1

Neoplastic Diseases

Metastatic Epidural Spinal Cord Compression (MESCC)

• Affects approximately 2.5-5% of all cancer patients, with incidence varying by primary tumor (7.9% in myeloma, lower in other malignancies) 1, 2
• Results from extradural and intradural extramedullary tumors encroaching on the spinal canal 1
• Can present acutely or progressively 1

Clinical manifestations:

• Back pain in 88-90% of patients—the earliest and most common symptom 1, 2
• Up to 50% are non-ambulatory at presentation 1
• Sensory loss and radicular pain 1, 2
• Bladder and bowel dysfunction 1, 2
• Motor weakness progressing to paralysis if untreated 1, 2

Risk factors for pathological fracture and MESCC:

• Tumor size >25% of vertebral body occupancy 3
• Vertebral endplate and 3-column involvement 3
• Posterior element and costovertebral joint involvement 3
• Fast-growing primary tumors 3
• Multiple vertebral metastases 3

Primary Spinal Cord Tumors

• Include intramedullary neoplasms (astrocytomas, ependymomas) 1
• Present with progressive myelopathy 1

Clinical manifestations:

• Insidious onset of weakness 1
• Dissociated sensory loss 1
• Pain less prominent than in metastatic disease 1

Infectious Diseases

Epidural Abscess

• Causes acute extrinsic compression of the spinal cord 1
• Can occur postoperatively or spontaneously 1

Clinical manifestations:

• Severe back pain with fever 1
• Rapidly progressive neurologic deficits 1
• Elevated inflammatory markers 1

Chronic Infections

• Tuberculosis (Pott's disease): vertebral body destruction with kyphotic deformity 1
• Schistosomiasis: granulomatous inflammation 1
• HIV vacuolar myelopathy: progressive weakness and ataxia 1
• Tertiary syphilis: tabes dorsalis with posterior column involvement 1
• HTLV-1 myelitis: progressive spastic paraparesis 1

Inflammatory and Demyelinating Diseases

Multiple Sclerosis (MS)

• Spinal cord involvement in 80-90% of MS patients, most commonly cervical cord 1
• Primary progressive MS shows more spinal involvement than relapsing-remitting 1

Clinical manifestations:

• Incomplete transverse myelitis 1
• Lhermitte's sign (electric shock sensation with neck flexion) 1
• Asymmetric motor and sensory deficits 1
• Bladder urgency and frequency 1

Neuromyelitis Optica (NMO)

• Longitudinally extensive transverse myelitis (≥3 vertebral segments) 1

Clinical manifestations:

• Severe bilateral motor weakness 1
• Sensory level 1
• Bladder and bowel dysfunction 1

Acute Disseminated Encephalomyelitis (ADEM)

• Post-infectious or post-vaccination inflammatory demyelination 1

Vascular Diseases

Spinal Cord Ischemia

• Results from atheromatous disease or complication of aortic surgery 1
• Acute onset myelopathy 1

Clinical manifestations:

• Sudden onset of flaccid paralysis 1
• Dissociated sensory loss (preserved posterior columns) 1
• Bladder and bowel dysfunction 1

Spinal Dural Arteriovenous Malformations/Fistulas

• Cause progressive myelopathy through venous hypertension 1

Clinical manifestations:

• Progressive lower extremity weakness 1
• Sensory disturbances 1
• Symptoms worsen with exercise or Valsalva 1

Postoperative Complications

Early Complications

• Seromas, pseudomeningoceles, hematomas, epidural abscesses 1

Late Complications

• Adjacent level degenerative disease with stenosis 1
• Recurrent disc herniation 1

Clinical manifestations:

• New or recurrent radicular pain 1
• Progressive myelopathy 1

Metabolic and Toxic Myelopathies

Vitamin B12 (Cobalamin) Deficiency

• Subacute combined degeneration affecting posterior and lateral columns 1

Clinical manifestations:

• Progressive sensory ataxia 1
• Weakness 1
• Paresthesias in hands and feet 1

Copper Deficiency

• Mimics B12 deficiency 1

Nitrous Oxide Toxicity

• Inactivates B12, causing similar syndrome 1

Rare Causes

Hirayama Disease (Cervical Flexion Myelopathy)

• Juvenile-onset asymmetric weakness from dynamic cord compression during neck flexion 1

Dorsal Arachnoid Webs

• Focal cord compression from fibrous bands 1

Ventral Cord Herniation

• Cord protrudes through dural defect 1

Critical Diagnostic Approach

MRI of the entire spine is the gold standard for evaluating spinal cord compression, offering superior soft-tissue resolution and multiplanar capability 1, 4. In patients unable to undergo MRI (implantable devices, claustrophobia), enhanced CT should be used 1. Urgent spinal MRI is mandatory when neurologic symptoms develop 1.

Common Pitfalls

• Delaying imaging in cancer patients with new back pain—88% of MESCC patients present with pain before neurologic deficits 1, 2
• Assuming all myelopathy is intrinsic—extrinsic compression must be systematically excluded first 5
• Imaging only the symptomatic level—consider imaging the entire spine as multilevel involvement is common 1
• Waiting for complete paralysis before intervention—ambulatory status at treatment initiation is the strongest predictor of outcome 1, 4, 6