What is the best approach for a neurologic assessment and treatment of a patient with spinal cord compression in the lumbosacral area?

Neurologic Assessment and Treatment of Lumbosacral Spinal Cord Compression

Use the ASIA Impairment Scale (AIS) as your primary neurologic assessment tool, document sacral sensation, ankle spasticity, and sphincter function, then obtain emergent MRI of the entire spine to guide treatment decisions. 1

Initial Neurologic Assessment

Validated Assessment Tools

• The ASIA Impairment Scale has the highest internal reliability and validity for thoracolumbar spinal cord injuries and should be your primary assessment tool 1
• Document baseline lower limb motor and sensory function before any intervention, as this facilitates rapid assessment of post-procedural changes 1
• The Frankel Scale demonstrates 94-100% inter-rater reliability and can be used as an alternative, though it is less sensitive to subtle changes in motor, sensory, bladder, or walking function 1

Critical Clinical Findings to Document

• Sacral sensation - presence predicts better neurologic recovery 1
• Ankle spasticity - highly accurate in predicting neurogenic bladder dysfunction 1
• Urethral and rectal sphincter function - essential for prognosis 1
• Abductor hallucis motor function - helps predict neurological outcomes 1
• Point tenderness at the spinous process - localizes the acute painful level in compression fractures 1

Prognostic Indicators

• Lumbar and conus injuries demonstrate the greatest neurologic recovery compared to thoracic injuries, attributed to higher concentration of lower motor neurons and "root escape" capability 1
• The anatomic level of injury based on neurological examination is a better predictor of recovery than MRI fracture location alone 1
• Entry AIS grade at presentation significantly impacts outcome measures 1

Imaging Protocol

First-Line Imaging

Obtain emergent MRI without and with IV contrast of the entire spine - this is the gold standard with 96% sensitivity and 94% specificity for spinal cord compression 2, 3, 4

• MRI directly visualizes the spinal cord, nerve roots, disc material, hematomas, and bone fragments causing compression 2
• MRI assesses severity of cord injury including intramedullary hemorrhage, length of edema, and evidence of cord transection 2
• MRI evaluates ligamentous instability not apparent on CT 2
• Always image the entire spine, as 20% of spine injuries have a second noncontiguous spinal injury 2

When MRI is Contraindicated or Unavailable

• Use CT myelography as second-line imaging to assess spinal canal narrowing and cord compression 2
• CT alone has 94-100% sensitivity for thoracolumbar fractures but cannot adequately visualize the spinal cord itself 2
• Plain radiographs are inadequate with only 67-82% sensitivity for lumbar fractures and cannot evaluate the epidural space or cord compression 2

Immediate Medical Management

Corticosteroid Administration

If neurologic deficits are present, administer dexamethasone 10 mg IV loading dose immediately, followed by 4 mg every 6 hours 3, 4

• Do not delay steroid administration while waiting for imaging if neurologic deficits are present 4
• If pain is the predominant symptom without significant deficits, lower doses can be given or steroids withheld pending immediate imaging 4
• Quick taper is recommended once definitive treatment is established 3

Hemodynamic Support

• Maintain systolic blood pressure >110 mmHg - mortality increases markedly below this threshold 5
• Never use permissive hypotension in patients with ongoing neurological impairment 5
• Monitor for signs of increased intracranial pressure if associated head injury: pupillary abnormalities, hypertension, bradycardia 5

Pain Management

• Address pain adequately with opioids if necessary 4
• Document if significant side effects of analgesia occur (confusion, sedation, severe constipation) as this may influence treatment decisions 1

Surgical Consultation and Indications

Immediate Neurosurgical Consultation Required For:

• Any mass effect or midline shift on imaging 5
• Spinal instability or significant kyphosis 4
• Compression secondary to bony fragments or retropulsion 1, 4
• Progressive neurologic deterioration despite medical management 5
• Patients with limited systemic disease burden and better predicted survival 4

Relative Contraindications to Vertebral Augmentation

• Significant spinal canal stenosis or compressive myelopathy from retropulsed fracture fragments or epidural tumoral extension 1
• Radiculopathy exceeding local vertebral pain 1

Treatment Algorithm Based on Imaging Findings

If Compression from Degenerative Disease or Disc Herniation

• Surgery is most effective for relief of cord compression 3
• Consider radiation therapy for radiosensitive tumors if surgery not feasible 3, 4

If Compression from Malignancy

• Multidisciplinary consultation with medical oncology, radiation oncology, and neurosurgery is imperative 3
• Surgery indicated for spinal instability, limited systemic disease, or radioresistant tumors 3, 4
• Radiation therapy is most commonly used after surgical decompression or in non-surgical candidates 3
• Stereotactic radiosurgery increasingly effective for radioresistant tumors 3

If Epidural Hematoma

• Particularly suspect in patients on anticoagulation or after minor trauma 2
• Surgical decompression typically required 2

If Epidural Abscess

• Look for fever and elevated inflammatory markers 2
• Requires emergent surgical decompression and antibiotics 2

Monitoring and Follow-up

• Perform neurological checks every 2-4 hours for deterioration 5
• Vital signs and lower limb neurological function should be assessed at regular intervals post-procedure 1
• Supervised ambulation should occur after appropriate observation period 1
• Most patients require a period of bed rest and observation tailored to clinical circumstances 1

Critical Pitfalls to Avoid

• Do not delay treatment while waiting for imaging - administer steroids immediately if neurologic deficits present 4
• Do not perform vertebral augmentation if there is clear disparity between physical examination findings and imaging or a clear alternative source of back pain 1
• Do not use plain radiographs alone - they are inadequate for evaluating spinal cord compression 2
• Do not image only the symptomatic level - always image the entire spine to detect noncontiguous injuries 2
• Do not use corticosteroids in traumatic brain injury - they have failed to demonstrate benefit 5