Haemorrhagic spinal cord compression

Extradural and subdural haematomas are common and well known conditions in cranial neurosurgery, but are uncommon in the spine.65 Subdural haematomas in particular are rare, with few cases being reported. Epidural haematomas, although uncommon, are a recognised cause of cord compression and about a third are associated with patients receiving anticoagulant therapy. Lumbar puncture may lead to the formation of a spinal epidural haematoma, but a substantial proportion have no apparent reason although in the literature they are coincidentally associated with or even causally related to what might be described as minor trauma of everyday living.66,67 It seems more likely that these are coincidental rather than causal factors. There is little evidence that arteriovenous abnormalities in the vertebra or other forms of angiomatous malformation are causally related to more than a very small number of spinal epidural haematomas.68,69

The clinical presentation of spinal haematomas is similar to several other forms of structural spinal cord compression. They produce a combination of spinal pain and root pain, followed by a progressive myelopathy, whose features will depend on the level of compression. Occasionally the process develops over several days and there are documented cases in whom the myelopathy has developed over several weeks.70 Most present relatively rapidly, within one or two days, and the diagnosis is confirmed by MRI or CT myelography.71 The appearances are those of an extradural compressive lesion, although with MRI it is possible to distinguish haematoma from pus or extradural tumour in some cases. Treatment is by laminectomy across the level of compression.72

Management of acute spinal cord compression: the role of the non-specialist

• The importance of the non-specialist in prompt recognition and specialist referral of cases of spinal cord compression has been emphasised. It is better to err on the side of "false alarm" than to make a late diagnosis and referral when function is no longer salvageable.

• The history should include the site and duration of spine and root pain, sensory or motor loss, and sphincter disturbance, any history of trauma, malignancy, or rheumatoid disease, relevant medications such as anticoagulants and coincident symptoms of systemic illness such as fever, night sweats, or weight loss. Spinal pain in patients under about 25 years of age or with a history of malignancy and thoracic or radicular pain in any patient should raise suspicion of an organic lesion and should not be attributed to non-specific or degenerative conditions. "Hysterical paralysis" is a diagnosis of exclusion and should not be made by junior staff without consultation with senior colleagues or spinal specialists.

• Examination should note whether the patient is ambulatory and whether the power in the lower limbs is MRC grade 3 or better. Motor power in the proximal arm muscles and the hands should be noted separately. The distribution of sensory loss should be recorded. The presence of a sensory level helps to target imaging studies. Careful examination may reveal that reflexes are depressed at the level of compression and exaggerated below, although this pattern may take some days to develop. A detailed neurological examination is not necessary and can be left to the specialist unit, but early clinical information can be useful in monitoring change.

• Investigation is dependent on the urgency for transfer and the resources available to the referring clinician. Plain radiographs of the symptomatic level of the spine are invaluable in trauma, neoplastic cord compression, rheumatoid arthritis, and vertebral osteomyelitis. Cervical flexion/extension films may be appropriate but only after discussion with a specialist or senior clinician. If CT or MRI scanning facilities are available at the referring hospital, obtaining these studies prior to transfer may expedite the patient's management. Other imaging studies may include a chest radiograph, bone scan, and abdominal ultrasound to suggest an origin and define the extent of neoplastic disease. Further investigations that may aid pathological diagnosis are serum prostate specific antigen, urine Bence Jones protein, ESR, and CRP. Depending on the severity and duration of cord compression, it is not always practical to obtain all or even any of these investigations prior to transfer to the specialist unit and each case should be assessed and discussed individually.

• In preparation for transfer, an unstable spine should be immobilised using traction, a cervical collar, and/or a spinal backboard as appropriate. Trauma patients should be stabilised according to principles of trauma management: establish an airway, respiration, and haemodynamic stability, manage life threatening head and torso injuries, and reduce and splint long bone fractures. A medical escort should accompany patients who remain at risk of recurrent circulatory or respiratory instability after initial resuscitation. All radiographic studies and not just a report should accompany the patient if they have not been sent to the specialist unit prior to transfer.

• Early recognition of acute cord compression by the non-specialist along with a thorough history, physical examination, and investigations with appropriate arrangements for transfer to a specialist unit provide the patient with the greatest chance of functional recovery following spinal cord compression.

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