Emergency Management of Spinal Cord Mass Effect
Immediate corticosteroid administration (dexamethasone 16 mg/day minimum) must be initiated the moment spinal cord compression is diagnosed clinically or radiologically, followed by urgent MRI within 12 hours if cord compression is suspected, and definitive treatment (surgery or radiation) within 24 hours. 1, 2
Immediate Actions (First Hour)
Corticosteroid Administration
- Administer dexamethasone immediately upon clinical or radiological diagnosis of spinal cord compression, before any definitive treatment 1, 2
- Minimum dose: 4 mg every 6 hours (16 mg/day total) 1, 2
- Doses may range from 10-100 mg depending on severity of neurological deficit 2
- Gradual taper over 2 weeks after definitive treatment 2
Spinal Immobilization
- Immobilize the spine immediately in any patient with suspected spinal cord injury to prevent onset or worsening of neurological deficit 3
- Use manual in-line stabilization combined with removal of anterior cervical collar during any airway procedures 3
Urgent Imaging Protocol
MRI Timing Based on Clinical Presentation
- Suspected epidural spinal cord compression with motor weakness, sensory level, or sphincter dysfunction: MRI within 12 hours 4, 2
- Progressive radicular deficit present <7 days: MRI within 24 hours 2
- Progressive radicular deficit present >7 days: MRI within 48 hours 2
- Unilateral radicular pain only: MRI within 1 week 2
- Back pain only: MRI within 2 weeks 2
MRI Technical Requirements
- Full spine MRI with contrast (T1 and T2 sequences) is the gold standard 1, 2
- MRI is superior to CT, plain radiographs, and bone scintigraphy for demonstrating spinal cord compression 4, 2
- A normal plain radiograph does NOT exclude spinal cord compression 4
Definitive Treatment Selection (Within 24 Hours)
Surgical Decompression Indications
- Emergency surgical decompression within 24 hours improves long-term neurological recovery in traumatic spinal cord injury 3
- Absolute surgical indications include: 2
- Spinal instability
- Recurrence or progression after radiation therapy
- Neurological deterioration during radiation and corticosteroids
- Life expectancy ≥3 months required 2
Surgical Contraindications
- Hematological malignancies (lymphoma, multiple myeloma) 2
- Paraplegia >24 hours duration 2
- Life expectancy <3 months 2
Radiation Therapy (First-Line for Metastatic Disease)
- Radiation therapy is preferred when adequate dose can be delivered and surgery is contraindicated 1, 2
- Provides pain relief in 50-58% and complete pain resolution in 30-35% of patients 1, 2
- Hypofractionated regimens are the standard approach 2
- Stereotactic body radiation therapy (SBRT) achieves >80% local control 2
Multidisciplinary Coordination
Urgent Consultation Requirements
- Urgent ad hoc multidisciplinary consultation (within hours) including neurosurgery, radiation oncology, and medical oncology is mandatory for progressive neurological deficits 1, 2
- Treatment must be initiated within 24 hours after diagnosis of metastatic epidural spinal cord compression 2
- Designate a single responsible physician to coordinate all care 1
Critical Pitfalls to Avoid
Diagnostic Errors
- Do not rely on plain radiographs to exclude spinal cord compression—they are inadequate 4
- Do not delay MRI for patients with progressive neurological symptoms 4, 2
- Recent trauma history does not exclude tumor as the underlying cause 4
Treatment Delays
- Do not wait for MRI results to start dexamethasone if clinical suspicion is high 1, 2
- Do not delay definitive treatment beyond 24 hours once diagnosis is confirmed 2
- Early surgery (<24 hours) reduces pulmonary complications and improves neurological outcomes 3
Airway Management Considerations
If Intubation Required (Cervical Involvement)
- Use rapid sequence induction with videolaryngoscopy as first-line in emergency settings 3
- Apply manual in-line stabilization during intubation 3
- Remove anterior portion of cervical collar to improve glottic exposure 3
- Use gum elastic bougie to increase first-pass success 3