← Diagnosis and Management Guides
Spinal Cord Compression
Key considerations: Metastatic spinal cord compression, Epidural abscess, Cauda equina syndrome
Cannot miss
- Metastatic spinal cord compression
- Epidural abscess
- Cauda equina syndrome
Likely diagnoses
- Metastatic cord compression
- Epidural abscess
- Central disc herniation
- Vertebral fracture with retropulsion
Red flags
- Progressive weakness
- Bowel/bladder dysfunction
- Saddle anesthesia
- Sensory level
- Cancer history with new back pain
- Fever with back pain and neuro deficit
Workup
- history: Back pain, weakness, bowel/bladder function, cancer history, fever, IVDU; exam: Motor exam, sensory level, rectal tone, post-void residual, Babinski, clonus; labs: CBC, ESR/CRP, blood cultures (if abscess suspected); imaging: EMERGENT MRI of entire spine (contrast if abscess/tumor suspected); If MRI unavailable: CT myelogram; bedside: Post-void residual, neurologic assessment
Management
- immediate: IV dexamethasone 10mg bolus (cord compression from tumor); Emergent MRI — do NOT delay; Neurosurgery consult for surgical decompression; general: Metastatic: dexamethasone + radiation ± surgery; Epidural abscess: surgical drainage + IV antibiotics 6-8 weeks; Surgery within 24-48 hours improves neurologic outcomes
Disposition
- admit: All spinal cord compression — emergent neurosurgical evaluation; discharge: Never acutely; consults: Neurosurgery, radiation oncology, ID (if abscess)
Clinical pearls
- Back pain + neuro deficit + cancer history = cord compression until proven otherwise
- Epidural abscess: classic triad of fever, back pain, and neuro deficit — but only present in ~10-15%
- Once complete paralysis >48hr, recovery is very unlikely — early diagnosis is critical
Source and review
- AANS Spinal Cord Compression Guidelines 2020. Last reviewed: 2024-11-01