NeurologyTier 1Disease (DEADMAN)

Spinal cord compression

Description

Cord ends at L1-L2 (conus medullaris) -> below that is cauda equina (roots, LMN only)
Time to treatment is the whole prognosis - once paraplegic, recovery is rare

Tract rules that generate every syndrome

Tract	Carries	Crosses
Corticospinal (lateral)	Motor	Medulla - so cord lesion = ipsilateral weakness
Dorsal columns	Vibration, proprioception, fine touch	Medulla - ipsilateral loss
Spinothalamic	Pain, temperature	At the segment, within 1-2 levels - contralateral loss, starting a few levels below

Spinothalamic lamination: sacral fibres most lateral
- Extrinsic compression hits sacral first (ascending sensory level)
- Intrinsic/central lesion spares them (sacral sparing = intrinsic until proven otherwise)

Cord syndromes

Syndrome	Motor	Sensory
Complete transverse	Bilat UMN below; LMN at level	All modalities below a level
Brown-Sequard (hemisection)	Ipsilateral UMN below, LMN at level	Ipsi dorsal column loss, contra pain/temp (a few segments below). Light touch preserved
Anterior cord	Bilat spastic paraparesis, extensor plantars	Bilat pain/temp loss, dorsal columns spared
Central cord	Arms > legs ("man in a barrel")	Cape/suspended dissociated pain+temp loss, sacral sparing
Posterior cord	Preserved	Vibration/proprioception loss -> sensory ataxia, Romberg+
Conus medullaris	Symmetric, mild, legs largely spared	Saddle, early bladder/bowel, absent anal reflex

Epidemiology

Malignant cord compression in 5-10% of all cancer patients; ~20% of these it is the first cancer presentation
Primaries: breast, lung, prostate ~60%; then myeloma, renal, lymphoma, unknown primary
Level: thoracic 60-70%, lumbosacral ~20%, cervical ~10%
Multiple non-contiguous levels in up to 1/3 - image the whole spine**
Non-malignant: degenerative cervical myelopathy is the commonest cause of cord dysfunction in adults >55

Aetiopathogenesis

Extrinsic (compressive) - the ones to exclude first

Malignant - vertebral body metastasis with posterior extension (commonest), or direct paraspinal/epidural tumour, lymphoma, myeloma
Degenerative - cervical spondylotic myelopathy, disc prolapse, OPLL
Infection - epidural abscess (IVDU, diabetes, bacteraemia; back pain + fever + inc CRP), Pott's disease (TB)
Trauma / fracture - including osteoporotic burst fracture
Haematoma - anticoagulants, post-procedural, AVM
Atlantoaxial subluxation - RA, Down syndrome

Intrinsic (non-compressive myelopathy)

Demyelinating - MS (short, <2 vertebral segments, dorsolateral), NMOSD/MOGAD (longitudinally extensive, >=3 segments)
Metabolic - B12 (SACD), copper deficiency (mimics B12; think bariatric surgery, zinc excess), nitrous oxide abuse
Vascular - anterior spinal artery infarct, dural AV fistula
Infective - HIV vacuolar myelopathy, HTLV-1 (tropical spastic paraparesis), neurosyphilis, VZV, schistosomiasis
Inflammatory - sarcoidosis, SLE, Sjogren's, Behcet's
Neoplastic intramedullary - ependymoma, astrocytoma
Syringomyelia - usually with Chiari I; post-traumatic; post-arachnoiditis
Radiation myelopathy, paraneoplastic (anti-amphiphysin, CRMP5)
Hereditary spastic paraplegia - pure motor, no sensory level, positive family history

Diagnosis

Red flags for compression

New/progressive back pain that is nocturnal, band-like, worse on cough/strain or lying flat
Known malignancy; unexplained weight loss; age >50 first episode
Progressive leg weakness, gait disturbance, sensory level
Bladder/bowel dysfunction = late; do not wait for it

Establishing the level

Sensory level is the single most useful sign - but the true lesion may be up to several segments higher
LMN signs at the level, UMN signs below - the segmental LMN band localises it

Level	Signs
>C4	UMN 4 limbs + diaphragm (C3-5) -> respiratory failure
C5	LMN rhomboids/deltoid/biceps/brachioradialis; absent biceps jerk, inverted supinator jerk; UMN below
C7	Absent triceps jerk
T7-T8	Loss of upper abdominal reflexes
T10-T11	Loss of lower abdominal reflexes; Beevor sign (umbilicus rides up on head lift)
L1	Loss of cremasteric reflex, UMN legs
L2-L3	LMN hip flexion + knee extension, absent knee jerk, anterior thigh pain
L4	LMN quads + weak inversion; medial leg sensory loss
L5	Weak dorsiflexion/eversion + hip abduction + knee flexion; all reflexes intact
S1	Weak plantarflexion, absent ankle jerk; sensory behind lateral malleolus
Conus / low sacral	Legs strong, saddle anaesthesia, absent anal reflex, retention

Absent ankle jerks + extensor plantars - the classic mixed picture
- Usually dual pathology (UMN lesion + peripheral neuropathy, e.g. cord compression in a diabetic)
- Also: SACD (B12), copper deficiency, Friedreich ataxia, MND, taboparesis (tertiary syphilis), hereditary spastic paraparesis, conus lesion

Investigation

MRI whole spine with and without contrast is the first-line test - do not delay for anything
- Within 24 h of suspicion (immediately if neurological signs); CT myelogram only if MRI contraindicated
- Plain films and bone scan do not exclude compression
If no compressive lesion, work up non-compressive myelopathy:
- Bloods: FBE, ESR/CRP, B12 + MMA/homocysteine, copper + caeruloplasmin, HIV, HTLV-1, syphilis serology, ANA/ENA, ACE, TFT
- CSF - cells, protein, oligoclonal bands, cytology, PCR, AFB
- Serum AQP4 (NMOSD) and MOG antibodies - cell-based assay
- Brain MRI + visual evoked potentials if demyelination suspected
- Spinal angiography / CT myelography if dural AV fistula suspected
Malignancy work-up if primary unknown: CT CAP, SPEP/serum free light chains, PSA, mammogram, tissue biopsy

Patterns worth recognising

Syringomyelia - cavity usually C5-6
- Cape-distribution dissociated pain/temp loss, preserved light touch and proprioception
- Wasting + areflexia in the arms; UMN signs in the legs
- Scoliosis, Charcot shoulder, painless burns; lumbar syrinx -> leg wasting, sacral sensory loss, sphincter failure
SACD - dorsal column loss + UMN legs but absent ankle jerks, extensor plantars
Anterior spinal artery - abrupt, pain/temp lost, proprioception preserved; watershed at T4-T6
Spastic paraparesis with cerebellar signs, cranial nerve involvement or optic neuritis -> demyelination, not compression

Management

A. Malignant cord compression - a same-day emergency

1. Dexamethasone immediately on suspicion, before imaging returns

16 mg daily (IV or oral), continued while awaiting definitive treatment, then wean over 5-7 days once surgery/RT has started
Withhold only if lymphoma is a real possibility and tissue has not been obtained - steroid lyses the diagnosis
PPI, glucose monitoring

2. MRI whole spine

3. Discuss with neurosurgery AND radiation oncology on the same day - decision is joint

Surgical decompression + stabilisation, then postoperative RT if: good performance status, life expectancy >3 months, spinal instability (SINS), single level, radioresistant tumour (renal, melanoma, sarcoma), unknown histology needing tissue, or progression during/after previous RT
- Patchell: surgery + RT vs RT alone -> ambulation 84% vs 57%
Radiotherapy alone for radiosensitive tumours (myeloma, lymphoma, germ cell, small cell), multi-level disease, poor performance status, or established complete paraplegia >24-48 h
- 8 Gy single fraction to 20 Gy/5#; SBRT where oligometastatic and good prognosis
Systemic therapy may be primary treatment in chemo/hormone-sensitive disease (lymphoma, germ cell, prostate)

4. Bed rest flat only if the spine is unstable - routine flat bed rest is no longer recommended

5. VTE prophylaxis, bladder scan +/- catheter, bowel regimen, pressure care, early rehab referral

6. Bone-modifying agent (zoledronic acid or denosumab) once compression treated

B. Epidural abscess

Blood cultures then empirical IV antibiotics covering S. aureus (incl. MRSA) - do not wait
Urgent surgical decompression + drainage unless purely medical management is agreed with a neurosurgeon
Prolonged IV therapy 6+ weeks; look for endocarditis and other seeding

C. Degenerative cervical myelopathy

Surgical decompression for moderate/severe or progressive myelopathy - surgery halts progression; it does not reliably reverse deficit
Mild non-progressive: monitor with serial mJOA

D. Non-compressive myelopathy

Transverse myelitis: IV methylprednisolone 1 g daily x3-5 days; plasma exchange if steroid-refractory (start within days)
- Then treat the cause: MS DMT, NMOSD (rituximab, eculizumab, satralizumab, inebilizumab), MOGAD
B12 deficiency: hydroxocobalamin IM, treat before the neurology is fixed - deficit >6-12 months may not recover
- Never give folate alone - precipitates/worsens SACD
Copper: oral copper replacement; stop zinc
Spasticity: baclofen, tizanidine, botulinum toxin; bladder: anticholinergic/intermittent catheterisation

Associations

Malignancy - breast, lung, prostate, myeloma, renal, lymphoma
Rheumatoid arthritis and Down syndrome - atlantoaxial instability
Osteoporosis - vertebral collapse
IVDU, diabetes, bacteraemia, spinal instrumentation - epidural abscess
Achondroplasia, OPLL, congenital canal stenosis - reduced reserve, symptomatic earlier
Chiari I malformation - syringomyelia
Anticoagulation, neuraxial procedures - epidural haematoma
Pernicious anaemia, ileal resection, metformin, nitrous oxide abuse - B12/SACD

Natural history & complications

Prognosis in malignant compression

Neurological status at the time of treatment is the strongest predictor of outcome
- Ambulant at presentation -> ~80-90% still ambulant
- Non-ambulant but with some power -> ~50% regain walking
- Complete paraplegia >24-48 h -> <10% recover
Median survival after MSCC ~3-6 months overall; much longer in myeloma, lymphoma, breast, prostate
Sphincter dysfunction at presentation = poor recovery

Complications

Permanent paraplegia/tetraplegia, neurogenic bladder and bowel
Autonomic dysreflexia in lesions at or above T6 - noxious stimulus (blocked catheter, constipation) -> severe hypertension, headache, flushing above / pallor below the level
- Sit up, remove the stimulus, then antihypertensive - a hypertensive emergency
Respiratory failure (lesions >C5), aspiration
Pressure injury, VTE, contracture, heterotopic ossification
Neuropathic pain, spasticity
Post-radiation myelopathy - latent months to years

6 more sections, plus exam facts

Premium unlocks every note across every specialty, and the full exam fact library behind it.

Get premium access