Spinal cord compression occurs when something presses on the spinal cord, impacting the spaces meant for blood vessels, cerebrospinal fluid, and the cord itself. This pressure disrupts the normal function of the spinal cord.

This compression can originate from issues outside the spinal cord or from problems within the cord itself. External causes might include injuries or tumors pressing on the cord, while internal causes could involve issues within the spinal cord tissue. Essentially, anything that compromises the spinal cord’s function, whether from surrounding structures or its own blood supply, can lead to compression.

The resulting symptoms stem from damage to the spinal cord itself or the nerve roots that branch off from it. These symptoms can include muscle weakness, changes in sensation or complete loss of feeling, problems with bladder or bowel control, and difficulties with sexual function.

Causes of spinal cord compression

Trauma (including car accidents, falls and sports injuries): Physical injuries can directly damage the spine and spinal cord.
* This often involves breaks in the bones of the spine (vertebral fractures), particularly in the neck. It can also involve the small joints in the spine (facet joint dislocation).
* In severe cases, the spinal cord can be completely severed.
* Sometimes only one side of the spinal cord is damaged, known as Brown-Séquard’s syndrome, typically caused by a penetrating injury.
Tumours, both benign or malignant: Abnormal growths can press on the spinal cord.
* This includes tumors originating in the bone, tumors that have spread from other parts of the body (metastatic), cancers of the blood cells (lymphomas, multiple myeloma), and tumors of the nerve sheaths (neurofibromata).
* Rapid spinal cord issues in cancer patients can also arise from radiation treatment, an immune system reaction affecting the spinal cord, a ruptured spinal disc, or cancer spreading to the membranes surrounding the spinal cord.
A prolapsed intervertebral disc: The soft cushion between the spinal bones can bulge or rupture, pressing on the cord.
* The lower back (L4-L5 and L5-S1) are the most frequent locations for this. Large disc herniations can cause a serious condition affecting the nerves at the base of the spinal cord (cauda equina syndrome).
* Disc herniation can also occur in the neck.
An epidural or subdural haematoma: A collection of blood forming outside or beneath the membrane covering the spinal cord.
* This may occur after an injury, a recent procedure on the spine, and/or in individuals taking blood-thinning medications.
Inflammatory disease, especially rheumatoid arthritis: Conditions causing inflammation can affect the spine.
* In rheumatoid arthritis, the ligaments supporting the top of the spinal column (odontoid peg) can weaken significantly. If this ligament breaks, the first vertebra (atlas) can slide forward on the second vertebra (axis), compressing the upper part of the spinal cord.
Infections: Infections can affect the spinal structures.
* Spinal infections can develop quickly or slowly over time.
* Rapid infections are usually caused by bacteria, while slower infections are often due to tuberculosis or fungal organisms.
* Infections of the vertebrae, the discs between them, or the spread of infection through the bloodstream can lead to a pocket of pus near the spinal cord (epidural abscess).
Cervical spondylitic myelopathy: Age-related changes can narrow the spinal canal in the neck.
* As people age, bony spurs (osteophytes), bulging discs, and thickening of ligaments in the spinal canal can occur.
* In advanced cases, this narrowing can put pressure on the spinal cord.
Spinal manipulation: Though rare, forceful manipulation can sometimes damage the spinal cord.
* Very rarely, chiropractic or osteopathic manipulation of the neck can lead to spinal cord damage.

Clinical Presentation

1. Neurological symptoms: Signs of nerve dysfunction such as changes in walking, clumsiness or weakness in the hands, or problems with sexual function, bladder control, or bowel control.

2. Neurological signs: Observable indicators of nerve damage.

   • Lhermitte’s sign: A sensation like an electric shock travelling down the spine and into the limbs when the neck is bent forward.

   • Upper motor neurone signs in the lower limbs: Indicators of damage to the nerves controlling movement, such as an abnormal reflex of the foot (Babinski’s sign), exaggerated reflexes, rhythmic muscle contractions (clonus), and increased muscle stiffness (spasticity).

   • Lower motor neurone signs in the upper limbs: Signs of damage to nerves directly controlling muscles, such as muscle wasting (atrophy) and reduced reflexes.

   • Sensory changes are variable: Altered sensation, with a greater loss of the ability to feel vibrations and the position of joints in the hands compared to the feet.

3. Motor, sensory and autonomic dysfunction can occur: Problems with movement, sensation, and involuntary bodily functions. Disruption of autonomic function can lead to dangerously low blood pressure (neurogenic shock), paralysis of the intestines (paralytic ileus), inhalation of foreign material into the lungs (aspiration), inability to urinate (urinary retention), persistent and painful erection (priapism), and difficulty regulating body temperature. The specific symptoms depend on how much of the cord is compressed and how quickly the compression develops.

4. Motor symptoms can include ready fatigue and disturbance of gait: Experiencing tiredness easily and having difficulty walking normally.

5. Cervical spine lesions can produce quadriplegia: Damage in the neck region can cause paralysis of all four limbs. Injury above the level of C3, C4, C5: Damage at or above these points, where the nerve controlling the diaphragm originates, can paralyze the diaphragm, requiring mechanical ventilation to breathe.

6. Thoracic spine lesions produce paraplegia: Damage in the middle part of the back can cause paralysis of the lower body.

7. Lumbar spine lesions can affect L4, L5 and sacral nerve roots: Damage in the lower back can impact nerve roots controlling the legs and pelvic organs.

8. Sensory symptoms can include sensory loss and paraesthesia: Decreased feeling and abnormal sensations like tingling or numbness. The ability to feel light touch, sense body position, and joint movement is reduced.

9. There can be root pain in the legs: Pain radiating down the legs due to pressure on nerve roots.

10. Tendon reflexes are typically: Involuntary muscle contractions in response to tapping on tendons.

    • Increased below the level of injury and/or compression: Reflexes are stronger than normal below the site of compression.

    • Absent at the level of injury and/or compression: Reflexes are missing at the site of the compression.

    • Normal above the level of injury and/or compression: Reflexes are unaffected above the compression.

11. Sphincter disturbances – late features of cervical and thoracic cord and/or compression: Problems with bladder and bowel control tend to appear later in compressions of the neck and upper back.

12. There may be loss of autonomic activity with lack of sweating below the level, loss of thermoregulation and drop in peripheral resistance causing hypotension: A loss of involuntary functions can lead to an inability to sweat below the compression, difficulty regulating body temperature, and a widening of blood vessels causing low blood pressure.

Investigations

Haemoglobin and haematocrit levels should be measured initially and monitored serially to monitor blood loss: Checking red blood cell levels to detect and track any blood loss.
Renal function and electrolytes: dehydration: Assessing kidney function and the balance of important minerals in the blood, which can be affected by dehydration.
MRI scan of the whole spine: A detailed imaging technique to visualize the spinal cord and surrounding structures to identify the compression.
Further investigations will depend on the underlying cause for cord compression: Additional tests will be necessary to determine the specific reason for the compression.

Management

1. Nurse the patient flat with the spine in neutral alignment (eg, using logrolling or turning beds) until spinal stability and neurological stability are ensured: Keep the patient lying flat and prevent twisting or bending of the spine to avoid further injury until the spine is confirmed to be stable and the patient’s nerve function is stable.

2. Give a course of dexamethasone unless contra-indicated until a definitive treatment plan is made: Administer a steroid medication to reduce swelling around the spinal cord, unless there are reasons not to, while a long-term treatment plan is developed.

3. Manage postural hypotension with positioning and devices to improve venous return; avoid over hydration: Address low blood pressure upon standing by using position changes and aids to help blood flow back to the heart, while being careful not to give too much fluid.

4. Insert a catheter to manage bladder dysfunction: Place a tube into the bladder to drain urine if the patient is unable to urinate on their own.

5. Use breathing exercises, assisted coughing, and suctioning to clear airway secretions: Help the patient clear their lungs by encouraging deep breaths and coughs, and using suction to remove mucus if necessary.

6. Offer and provide psychological and spiritual support as needed (including after discharge): Provide emotional and spiritual support to the patient and their family during and after their hospital stay.

7. Analgesia, palliative radiotherapy, spinal orthoses, vertebroplasty or kyphoplasty, or spinal stabilization surgery may be required for pain control: Various methods can be used to manage pain, including pain medications, radiation to shrink tumors, braces to support the spine, procedures to stabilize fractured vertebrae, or surgery to stabilize the spine.

8. Bisphosphonates should be offered to all patients with vertebral involvement from myeloma and breast cancer and to patients with prostate cancer in whom conventional analgesia is inadequate: Medications to strengthen bones should be given to patients with spinal involvement from certain cancers or when standard pain relief isn’t enough for prostate cancer.

9. Specialized pain control procedures may be needed for intractable pain (eg, epidural analgesia): More advanced methods of pain relief, such as injecting pain medication directly into the space around the spinal cord, may be necessary for severe pain.

10. If definitive treatment of the cord compression is appropriate, it should be started before patients lose the ability to walk or before other neurological deterioration occurs, and ideally within 24 hours: Long-term treatment to address the compression should begin promptly, ideally within a day, before significant nerve damage occurs.

11. Definitive treatment may be using surgery (eg, laminectomy, posterior decompression ± internal fixation) or using radiotherapy: The main treatments to relieve compression are surgical procedures to remove the source of pressure or radiation therapy to shrink tumors.

12. Discharge should be fully planned and community-based rehabilitation and support should be available when the patient returns home. This includes support and any necessary training of carers and families: Careful planning for the patient’s return home is essential, including access to rehabilitation services and support and education for caregivers.

Cancer Screening.

1. The following symptoms suggest possible spinal metastases in those with cancer: These signs may indicate that cancer has spread to the spine.

   • Pain in the thoracic or cervical spine: Pain in the middle or upper back.

   • Severe unremitting or progressive lumbar spinal pain: Intense, continuous, or worsening pain in the lower back.

   • Spinal pain aggravated by straining (eg, coughing, sneezing, passing stool): Back pain that gets worse with physical exertion.

   • Nocturnal spinal pain preventing sleep: Back pain that is worse at night and interferes with sleep.

   • Localised spinal tenderness: Pain when a specific area of the spine is touched.

2. The following symptoms suggest metastatic spinal cord compression in patients with cancer and pain suggestive of spinal metastases: These signs suggest the spinal cord is being compressed by cancer.

   • Radicular pain: Pain that shoots down the arms or legs.

   • Limb weakness: Loss of strength in the arms or legs.

   • Difficulty in walking: Problems with mobility.

   • Sensory loss, or bladder or bowel dysfunction: Changes in sensation or problems with bladder or bowel control.

   • Neurological signs of spinal cord or cauda equina compression: Physical examination findings indicating pressure on the spinal cord or the nerve roots at the base of the spine.

3. MRI of the whole spine (not plain X-rays) should be carried out so that definitive treatment can be planned: Detailed imaging is necessary to plan the best course of treatment. This should be:

   • Within one week if clinical features suggest spinal metastases: Done relatively quickly if cancer spreading to the spine is suspected.

   • Within 24 hours if clinical features suggest spinal cord compression: Done urgently if there are signs of the spinal cord being compressed.

   • Sooner (including out of hours) if emergency treatment is needed: Performed immediately if the situation is critical.

Complications

Complications will depend on the site of compression and the severity of associated neurological dysfunction: The specific problems that arise depend on where the compression is located and how badly the nerves are affected.
Complications may include:
Pressure sores: Skin damage caused by prolonged pressure, preventable with frequent repositioning.
Hypothermia: Dangerously low body temperature.
Potential lung complications include aspiration, pneumonia, acute respiratory distress syndrome, atelectasis, ventilation-perfusion mismatch and decreased coughing with retention of secretions: Various problems affecting the lungs, including inhaling foreign material, infection, a severe lung condition, lung collapse, and problems with oxygen and carbon dioxide exchange due to reduced coughing and mucus buildup.
Depression associated with restriction of activities of daily living: Sadness and low mood resulting from limitations in everyday activities.

Prognosis
The spinal cord has very limited powers of regeneration: The spinal cord has a poor ability to repair itself after damage.
Prognosis for neurological deficit depends on the magnitude of the spinal cord damage present at the onset: The extent of nerve damage at the time of diagnosis is a key factor in predicting recovery.
As well as neurological dysfunction, the prognosis is also determined by the prevention and effective treatment of infections – eg, pneumonia, and urinary tract infections: Preventing and treating infections is crucial for improving outcomes.
The prognosis will also depend on the underlying cause of cord compression: The specific reason for the compression also influences the long-term outlook.

General Paralysis of The Insane (GPI)
General paralysis of the insane (GPI), also called General paresis, paralytic dementia, or syphilitic paresis, is a serious mental disorder. It is categorized as an organic mental disorder caused by untreated late-stage syphilis. The chronic inflammation of the brain and its linings (meningoencephalitis) and the shrinking of brain tissue (cerebral atrophy) associated with this late stage of syphilis lead to GPI.

The degenerative changes in GPI primarily affect the frontal and temporal lobes of the brain. Approximately 7% of individuals infected with syphilis develop this condition. It is more prevalent in developing countries where access to timely treatment is limited and more common in men.

Signs and symptoms

Symptoms of the disease first appear from 10 to 30 years after the initial syphilis infection.

Early Signs and Symptoms: Initial, often subtle symptoms.
Neurasthenia difficulties, such as: Symptoms related to a feeling of nervous exhaustion.
fatigue: Persistent tiredness.
headaches: Pain in the head.
insomnia: Difficulty sleeping.
dizziness: Feeling lightheaded or unsteady.

Signs and Symptoms as the disease progresses:

More noticeable mental and personality changes.
mental deterioration and personality changes occur: Decline in mental abilities and shifts in behavior.
Typical symptoms include loss of social inhibitions: Acting inappropriately or without regard for social norms.
gradual impairment of judgment: Making poor decisions.
concentration and short-term memory impairment: Difficulty focusing and remembering recent events.
euphoria: An exaggerated feeling of happiness or well-being.
Mania: A state of abnormally elevated mood, energy, and activity levels.
Depression: A persistent feeling of sadness and loss of interest.
apathy: Lack of interest, enthusiasm, or concern.
Subtle shivering: Small, involuntary muscle tremors.
minor defects in speech: Slight difficulties with articulation.
Delusions: False beliefs that are firmly held despite evidence to the contrary. They can be grandiose (beliefs of great importance or ability), melancholic (beliefs of guilt or worthlessness), or paranoid (beliefs of being persecuted). These delusions include ideas of great wealth, immortality, having many sexual partners, immense power, nihilism (belief in nothing), self-blame, or unusual physical complaints.

Late Signs and Symptoms: Severe physical and mental decline.

Dysarthria: Difficulty speaking clearly due to problems with the muscles used for speech.
intention tremors: Shaking that worsens with purposeful movement.
Hyperreflexia: Overly active reflexes.
myoclonic jerks: Sudden, involuntary muscle twitches.
confusion: Disorientation and difficulty thinking clearly.
seizures: Uncontrolled electrical activity in the brain.
severe muscular deterioration: Significant muscle wasting and weakness.
Eventually, the paretic dies bedridden, cachectic and completely disoriented, frequently in a state of status epilepticus: The individual becomes confined to bed, severely malnourished and wasted, completely disoriented, and often experiences prolonged or repeated seizures without regaining consciousness.

Diagnosis

Definitive diagnosis is based on the analysis of cerebrospinal fluid and tests for syphilis: Examining the fluid surrounding the brain and spinal cord and conducting blood tests for syphilis are crucial for diagnosis.

Physical Examination: A medical assessment of the patient.

Treatment
Using penicillin or other antibiotics to treat the infection: Antibiotics are used to eliminate the underlying syphilis infection.
Treatment will likely continue until the infection has completely cleared: The course of antibiotics will continue until the infection is eradicated. Treating the infection will reduce new nerve damage: Stopping the infection can prevent further damage to the nervous system. But it will not cure damage that has already occurred: Existing neurological damage from GPI is usually permanent.