Acute Spinal Cord Compression Research Articles

Comprehensive Insights into Metastasis-Associated Spinal Cord Compression: Pathophysiology, Diagnosis, Treatment, and Prognosis: A State-of-the-Art Systematic Review.

Background: Spinal cord compression is a formidable complication of advanced cancer, and clinicians of copious specialities often have to encounter significant complex challenges in terms of diagnosis, management, and prognosis. Metastatic lesions from cancer are a common cause of spinal cord compression, affecting a substantial portion of oncology patients, and only in the US has the percentage risen to 10%. Acute metastasis-correlated spinal cord compression poses a considerable clinical challenge, necessitating timely diagnosis and intervention to prevent neurological deficits. Clinical presentation is often non-specific, emphasizing the importance of thorough evaluation and appropriate differential diagnosis. Diagnostic workup involves various imaging modalities and laboratory studies to confirm the diagnosis and assess the extent of compression. Treatment strategies focus on pain management and preserving spinal cord function without significantly increasing patient life expectancy, while multidisciplinary approaches are often required for optimal outcomes. Prognosis depends on several factors, highlighting the importance of early intervention. We provide an up-to-date overview of acute spinal cord compression in metastases, accentuating the importance of comprehensive management strategies. Objectives: This paper extensively explores the pathophysiology, clinical presentation, diagnostic strategies, treatment modalities, and prognosis associated with spinal cord metastases. Materials and Methods: A systematic literature review was conducted in accordance with the PRISMA guidelines. Conclusions: We aim to help healthcare professionals make informed clinical decisions when treating patients with spinal cord metastases by synthesizing current evidence and clinical insights.

A rare case of spontaneous spinal epidural hematoma with spontaneous resolution

Spontaneous spinal epidural hematoma (SSEH) is an uncommon cause of acute spinal cord compression. It is a neurological emergency that requires urgent imaging and appropriate treatment to prevent permanent neurological sequelae. Here, we present the case of a 30-year-old male with no known comorbidities who presented to the emergency department with a history of sudden onset of upper backache and chest discomfort followed by bilateral lower limb weakness. On examination, the blood pressure was 220/120 mmHg, and neurological examination showed decreased tone and power of 2/5 in bilateral lower limbs. In view of the initial chest discomfort, a cardiac evaluation was done, which was normal, followed by magnetic resonance imaging of the whole spine, which showed a lesion in the anterior epidural space suggestive of hematoma, causing spinal cord compression. A final diagnosis was C6-T2 dorsal SSEH secondary to a hypertensive emergency.

Spontaneous Spinal Subdural Hematoma: A Case Report

Spinal epidural hematomas (SEH) are a rare form of hematoma affecting the nervous axis. Spontaneous epidural hematomas are defined as the presence of blood in the epidural space without any known cause. They may be associated with coagulopathies or arteriovenous malformations. HSSE can lead to disabling neurological deficits. Imaging and rapid intervention should be initiated as soon as a patient presents with symptoms suggestive of HGSS. We report the case of a 36-year-old patient who presented with SEH in a setting of acute spinal cord compression.

Epidural lipomatosis with foci of hemorrhage and acute compression of the spinal cord in a child with CLOVES syndrome: illustrative case.

Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, spinal/skeletal anomalies, and/or scoliosis (CLOVES) syndrome is the most recently described combined vascular anomaly characterized by congenital excessive growth of adipose tissue, vascular malformations, epidermal nevi, and skeletal deformities. This condition exhibits a significant variability in clinical manifestations and a tendency for rapid progression and affects extensive anatomical regions. Information regarding the association of epidural lipomatosis with low-flow venous lymphatic malformations is rare, with few reports in the literature. The authors present a case of a 6-year-old girl who was admitted to the emergency department complaining of rapidly progressing weakness in her lower extremities and partial loss of sensation in the inguinal area. Radiologically, an extradural mass was identified at the T2-6 level, causing acute spinal cord compression. Urgent decompression and partial resection of the mass were performed. Despite satisfactory intraoperative hemo- and lymphostasis, postoperative lymphorrhea/seroma leakage was encountered as a delayed complication and was managed conservatively. CLOVES syndrome is characterized by the combination of various clinical symptoms, not all of which are included in the abbreviation, as well as a progressively deteriorating course, the emergence of new symptoms, and complications throughout the patient's life. This necessitates ongoing monitoring of such patients.

Systematic Review and Meta-Analysis on Optimal Timing of Surgery for Acute Symptomatic Metastatic Spinal Cord Compression.

Introduction: Symptomatic acute metastatic spinal epidural cord compression (MSCC) is an emergency that requires multimodal attention. However, there is no clear consensus on the appropriate timing for surgery. Therefore, to address this issue, we conducted a systematic review and meta-analysis of the literature to evaluate the outcomes of different surgery timings. Methods: We searched multiple databases for studies involving adult patients suffering from symptomatic MSCC who underwent decompression with or without fixation. We analyzed the data by stratifying them based on timing as emergent (≤24 h vs. >24 h) and urgent (≤48 h vs. >48 h). The analysis also considered adverse postoperative medical and surgical events. The rates of improved outcomes and adverse events were pooled through a random-effects meta-analysis. Results: We analyzed seven studies involving 538 patients and discovered that 83.0% (95% CI 59.0-98.2%) of those who underwent urgent decompression showed an improvement of ≥1 point in strength scores. Adverse events were reported in 21% (95% CI 1.8-51.4%) of cases. Patients who underwent emergent surgery had a 41.3% (95% CI 20.4-63.3%) improvement rate but a complication rate of 25.5% (95% CI 15.9-36.3%). Patients who underwent surgery after 48 h showed 36.8% (95% CI 12.2-65.4%) and 28.6% (95% CI 19.5-38.8%) complication rates, respectively. Conclusion: Our study highlights that a 48 h window may be the safest and most beneficial for patients presenting with acute MSCC and a life expectancy of over three months.

Two pediatric observations of spinal extradural arteriovenous fistulas presenting with epidural hemorrhages and cord compression.

We report two cases of acute spinal cord compression in children with low-flow spinal epidural arteriovenous fistulas (SEAVFs) and discuss the clinical presentation and management of these vascular anomalies. While most low-flow SEAVFs without radiculomedullary drainage are benign lesions typically diagnosed incidentally, we suggest that asymptomatic lesions may warrant aggressive management in specific circumstances, including lesions diagnosed at an early age or in patients under anticoagulation therapy. Our observations also emphasize that patients with a "spontaneous" epidural hemorrhage should undergo dedicated preoperative or postoperative vascular imaging to identify a possible underlying vascular anomaly.

Acute spinal cord compression under systemic therapy - radiotherapy or surgery?

Vertebral bodies are one of the most common metastasis sites found in advanced prostate cancer and have a significant impact on patients' quality of life. Spinal metastases frequently cause severe back pain and in some occasions can lead to secondary complications, with serious neurological deficits and loss of function. The main treatment goals include adequate pain management, controlling tumour growth and restoring spinal stability. Publications on the role of surgery - both conventional and stereotactic radiotherapy, and either as an individual modality or in combination - have been inconclusive. The NOMS score has proven to be useful in making treatment decisions. Existing data show better outcomes in patients with surgical therapy, both when performed in isolation and also combined with radiotherapy, in which some of the cohorts studied including patients with primary cancer other than prostate cancer. Comparative studies that specifically investigate the superiority of specific therapy modalities for metastatic prostate carcinoma are scarce. Similarly, there are limited data on microsurgical interventions for spinal metastases. Radiotherapy alone is crucial in the setting of palliation, especially for pain relief, and its effectiveness has been shown in many studies. The patient's life expectancy plays a crucial role in deciding the most appropriate treatment approach. Given the complexity of the patient population, a multimodal therapy approach is necessary. Current trends in therapy favour greater use of surgical interventions, particularly in the early detection of spinal metastases.

Surgical Intervention for Primary B-cell Lymphoma of the Spine: A Systematic Review and Meta-analysis of Clinical Presentation, Treatment, Postoperative Outcomes, and Histologic Markers.

Systematic review and meta-analysis. To perform a systematic review of the clinical symptoms, radiographic findings, and outcomes after spinal decompression in B-cell lymphoma. B-cell lymphoma is a potential cause of spinal cord compression that presents ambiguously with nonspecific symptoms and variable imaging findings. Surgical decompression is a mainstay for both diagnosis and management, especially in patients with acute neurological deficits; however, the efficacy of surgical intervention compared with nonoperative management is still unclear. The databases of Medline, PubMed, and the Cochrane Database of Systemic Reviews were queried for all articles reporting spinal B-cell lymphoma. Data on presenting symptoms, treatments, survival outcomes, and histologic markers were extracted. Using the R software "survival" package, we generated bivariate and multivariate Cox survival regression models and Kaplan-Meier curves. In total, 65 studies were included with 72 patients diagnosed with spinal B-cell lymphoma. The mean age was 56.22 (interquartile range: 45.00-70.25) with 68% of patients being males and 4.2% of patients being immunocompromised. Back pain was the most common symptom (74%), whereas B symptoms and cauda equina symptoms were present in 6% and 29%, respectively. The average duration of symptoms before presentation was 3.81 months (interquartile range: 0.45-3.25). The most common location was the thoracic spine (53%), with most lesions being hyperintense (28%) on T2 magnetic resonance imaging. Surgical resection was performed in 83% of patients. Symptoms improved in 91% of patients after surgery and in 80% of patients treated nonoperatively. For all 72 patients, the overall survival at 1 and 5 years was 85% (95% CI: 0.749-0.953; n = 72) and 66% (95% CI: 0.512-0.847; n = 72), respectively. Although surgery is usually offered in patients with acute spinal cord compression from B-cell lymphoma, chemotherapy and radiation alone offer a hopeful alternative to achieve symptomatic relief, particularly in patients who are unable to undergo surgery.

196. Rapid MRI protocol for acute spinal cord trauma and cord compression

196. Rapid MRI protocol for acute spinal cord trauma and cord compression

Acute Myeloid Leukemia with Acute Spinal Cord Compression as the First Feature

Abstract Malignant myeloid sarcoma (chloroma) is a rare extramedullary solid tumor that consists of immature myeloid precursor cells, constantly associated with acute myeloid leukemia (AML). Here, we report the case of a 35-year-old male who developed an acute paraplegia secondary to paraspinal chloroma associated with AML. A careful review of the patient’s history, blood smear, and bone marrow findings will decrease the chance of missing the diagnosis.

Progressive lower extremity weakness as the initial presentation of isolated large thoracic plasmacytoma

Plasmacytoma is a tumor of monoclonal plasma cells of bone or soft tissue that can occur anywhere in the body without evidence of systemic multiple myeloma. It may present as solitary or multiple masses and is classified as osseous if arising from bone or extraosseous if arising from soft tissue. Osseous plasmacytoma is the most common form of plasmacytoma with predominance in active hematopoietic bones, including vertebrae, femur, pelvis, and ribs. The diagnosis is made with a tissue biopsy. Different imaging modalities allow for tumor localization, and magnetic resonance imaging (MRI) is the gold standard to detect spinal cord compression. Corticosteroids provide analgesia, reduce vasogenic edema, and have anti-myeloma activity which may result in better neurological outcomes in cases of acute spinal cord compression. Corticosteroids should be started promptly once cord compression is suspected. We report a case of progressive lower extremity weakness as the initial presentation of a thoracic plasmacytoma. The patient was started on a high-dose corticosteroid after acute cord compression was suspected. Magnetic resonance imaging confirmed cord compression. T1-T2 corpectomy with C5-T5 posterior spinal fusion for decompression and stabilization was done. He was successfully discharged to an inpatient rehabilitation facility with plans for definitive radiotherapy. Worsening back pain and lower extremity weakness in elderly patients should raise concerns for acute cord compression. Early intervention to relieve compression is crucial to preserve neurological functions.
 
 Keywords: plasmacytoma, weakness, steroids, multiple myeloma

Systemic sclerosis-associated compressive cervical calcinosis: intersection of degenerative spine instability, lesional spinal cord compression, and traumatic spinal cord injury. Illustrative case.

BACKGROUNDTumoral calcinosis, mass-like calcium deposition into the soft tissues, is an uncommon manifestation of the systemic sclerosis subtype of scleroderma. When this process affects the spinal epidural space, it can cause canal narrowing and place the spinal cord at significant risk of injury.OBSERVATIONSHere a 62-year-old female with systemic sclerosis and no previous evidence of spinal cord compromise who developed acute spinal cord injury and quadriparesis after a mechanical fall is described. She was found to have a large dorsal epidural calcified mass compressing her cervical spinal cord. She underwent medical management for acute spinal cord compression as well as surgical management for acute spinal cord injury and degenerative spine disease. Her case illustrates a rare etiology of simultaneous degenerative spine instability and lesional spinal cord compression with acute spinal cord injury.LESSONSTumor calcinosis leading to acute spinal cord injury in the setting of systemic sclerosis is an uncommon but critical entity to recognize in patients with scleroderma and may require the physician to use a combination of medical and surgical management strategies from each of these categories of spine pathology.

Acute Metastatic Spinal Cord Compression: Urgent Surgery versus Radiotherapy and Treatment Result Prediction versus Actual Results.

Background Context: The role of radiotherapy versus surgery in treating acute metastatic spinal cord compression (AMSCC) has changed over the years. Purpose: Our study evaluates neurological and functional outcomes following urgent surgery and radiotherapy (USFR) versus urgent radiotherapy alone in treating AMSCC. Study Design/Setting: A retrospective cohort of 54 patients with AMSCC with variable neurological deficits. Overall, 32 patients were treated with USFR, and 22 received urgent radiotherapy alone. Outcome Measures: Neurological status regarding the Asia and Frankel scores, continence and ambulation, and Kranofsky’s functional score and patient life span comprised the outcome measures. Methods: This was a retrospective EMR study. Results: USFR and radiotherapy cohorts were similar in age, gender, tumor origin, and the number of spinal metastases. The most common cause of AMSCC was carcinoma of the breast (24.1%), followed by carcinoma of the lung (16.7%) and multiple myeloma (13%). Neurological status at AMSCC presentation was similar between cohorts regarding Asia and Frankel scores, continence and ambulation, and Kranofsky’s functional score. Following USFR, 59.3% of the patients had a motor strength improvement, 31.3% regained sphincter function, and 34.4% regained ambulation, while 90% of the patients treated by radiotherapy did not show any improvement. One patient under radiotherapy lost sphincter function. The treatment received did not affect the patient’s survival. A subanalysis of patients with a short life expectancy, by Tomita and Tokuhashi scores, showed missed prediction in 29.4% of cases. Conclusion: The study supports the beneficial effect of UFSR compared to urgent radiotherapy alone in treating AMSCC in all subgroups. Early surgery improved function, motor strength, sphincter control, and ambulation without affecting life span. Prognostic scores failed to predict life span in almost one-third of the patients, requiring further investigation.

Surgery in Acute Metastatic Spinal Cord Compression: Timing and Functional Outcome.

Simple SummarySpinal metastases affect an exceptionally high number of cancer patients and thereby represent a common challenge for healthcare providers. Patients may suffer from debilitating symptoms, including excruciating back pain, immobility and even neurological dysfunction. An exceptionally acute clinical presentation is caused by the compression of the spinal cord through growth of a spinal metastasis within the spinal canal, which may leave the patient with acute spinal cord injury in need of rapid surgical treatment. In clinical practice and science, no true timeframe has yet been defined within which these patients need to undergo surgery, although it is generally understood that their recovery and functional rehabilitation correlate with the time to surgery after symptom onset. In our study, we analyzed a surgically treated cohort of patients with acute spinal cord injury by metastatic compression to investigate the correlation of the timing of surgery with neurological recovery. We were able to identify a subgroup of patients with significantly improved recovery, in whom surgery was initiated within 16 h after admission. Complication rates were not significantly more frequent in this subgroup compared to patients operated on after 16 h. Based on these findings, we conclude that striving for surgery as early as feasible is a warranted strategy in patients with acute neurological deterioration due to metastatic spinal cord compression.Background: Patients with metastatic spinal cord compression (MSCC) may experience long-term functional impairment. It has been established that surgical decompression improves neurological outcomes, but the effect of early surgery remains uncertain. Our objective was to evaluate the impact of early versus late surgery for acute MSCC due to spinal metastases (SM). Methods: We retrospectively reviewed a consecutive cohort of all patients undergoing surgery for SMs at our institution. We determined the prevalence of acute MSCC; the time between acute neurological deterioration as well as between admission and surgery (standard procedure: decompression and instrumentation); and neurological impairment graded by the ASIA scale upon presentation and discharge. Results: We screened 693 patients with surgery for spinal metastasis; 140 patients (21.7%) had acute MSCC, defined as neurological impairment corresponding to ASIA grade D or lower, acquired within 72 h before admission. Non-MSCC patients had surgery for SM-related cauda equina syndrome, radiculopathy and/or spinal instability. Most common locations of the SM in acute MSCC were the thoracic (77.9%) and cervical (10.7%) spine. Per standard of care, acute MSCC patients underwent surgery including decompression and instrumentation, and the median time from admission to surgery was 16 h (interquartile range 10–22 h). Within the group of patients with acute MSCC, those who underwent early surgery (i.e., before the median 16 h) had a significantly higher rate of ASIA improvement by at least one grade at discharge (26.5%) compared to those who had late surgery after 16 h (10.1%; p = 0.024). Except for a significantly higher sepsis rate in the late surgery group, complication rates did not differ between the late and early surgery subgroups. Conclusions: We report data on the largest cohort of patients with MSCC to date. Early surgery is pivotal in acute MSCC, substantially increasing the chance for neurological improvement without increasing complication rates. We found no significant impact when surgery was performed later than 24 h after admission. These findings will provide the framework for a much-needed prospective study. Until then, the treatment strategy should entail the earliest possible surgical intervention.

Thoracic spondylodiscitis secondary to Klebsiella oxytoca urosepsis—a case report

Spondylodiscitis is an insidious and infectious pathology of the spinal column attributable to pathogenic micro-organisms and occurs in a variety of contexts. These micro-organisms can be inoculated surgically or can metastasise from distant sites of infection. Klebsiella species are important community-acquired and nosocomial pathogens but are uncommonly implicated in spinal infection. Klebsiella oxytoca is more obscure than its generic relative Klebsiella pneumoniae and has only five times previously been reported in spondylodiscitis. It possesses the ability to acquire inducible and recombinant antibiotic resistance, especially in the hospital setting. We describe the case of an elderly man with complex urology and this rare sequela due to incomplete treatment of a K. oxytoca urinary infection. He developed sepsis that recurred after incomplete antibiosis and seeded to his thoracic spine causing overt spondylodiscitis. The infection fulminated and his spinal lesion deteriorated into acute spinal cord compression with neurological compromise, requiring surgical decompression, fixation and long-term antibiotics. This is a sixth documented instance of a rare spinal bacterial infection. We describe the relevant microbiology and pathology, neurosurgical considerations, and general practice points for clinicians. Our report is a novel illustration of the potentially catastrophic consequences of inadequately treated urosepsis and is a stark reminder of the importance of antimicrobial stewardship.

A rare case of cord compression secondary to extramedullary haematopoiesis from a radiological perspective.

Objective: Extramedullary haematopoiesis is commonly encountered occurrence which can rarely cause acute spinal cord compression secondary to intraspinal extension. We present case of a young gentleman who presented with acute paralysis due to this condition.

Pneumorrhachis complicating acute pain management using a thoracic epidural catheter

The use of thoracic epidural catheters to infuse local anaesthetics and opioids is a common practice in acute pain management to attenuate the pain associated with thoracic and abdominal surgical procedures. The placement and maintenance of epidural analgesia is known to be associated with a variety of potential complications. A rare complication is the development of air of within the spinal canal (pneumorrhachis). Although pneumorrhachis is typically asymptomatic and resolves spontaneously, it rarely can be associated with neurological dysfunction. Here we describea case of pneumorrhachis that led to symptomatic acute spinal cord compression in a 27 year old man who had a thoracic epidural placed to help with pain management following laparotomy for the management of Crohn’sdisease. Postoperatively, the patient developed unilateral weakness in his upper and lower extremities and sensory dysfunction in the upper extremity. Urgent neuroimaging demonstrated epidural air causing mass effect on the cervical spinal cord. His symptoms resolved completely following conservative management. This rare presentation of pneumorrhachis highlights the need for close vigilance regarding neurological function in patients with epidural catheters for acute pain management. This presentation also promotes mitigation of factors that may be associated withthe administration of air into the epidural space, such as changing epidural infusion solution bags and malfunction of epidural infusion pumps.

Paraparesis as a Rare Complication of Dengue Fever Causing Spontaneous Spinal Subarachnoid Haemorrhage

A smaller number of confirmed dengue cases worldwide present with neurological symptoms such as headache, seizure, neck stiffness, drowsiness, altered sensorium, behavioural disorders, delirium, cranial nerves palsies, and rarely, spinal cord involvement. This report is about a 54-year-old female patient with dengue, who presented with acute spinal cord compression due to spontaneous spinal Subarachnoid Haemorrhage (SAH). She complained of sudden onset of febrile illness associated with headache, myalgia, retro-orbital pain, and low backache for three days, followed by sudden onset paraplegia three days after the onset of the illness. A haemogram was obtained, which showed a platelet count of 60,000/µL. She had antibodies against dengue NS1 and dengue Immunoglobulin M (IgM), but not against dengue IgG. A Magnetic Resonance Imaging (MRI) spine contrast imaging revealed a spinal SAH from the level of T12 to L1, as well as significant cord compression. An MRI of the brain revealed a SAH in the bilateral parieto-occipital region. She underwent an emergency laminectomy and complete haematoma evacuation. Postsurgical period was uneventful with complete recovery of sensation and weakness. In patients from endemic areas of dengue infection who present with fever and spinal cord involvement a high degree of suspicion of this disease should arise and it should always be investigated further for dengue-related neurological complications.

Non-traumatic spontaneous spinal intradural extramedullary hemorrhage (SIEH) associated with rivaroxaban

Non-traumatic Spontaneous Intradural-Extramedullary Hematoma (SIEH) is a rare condition. Rivaroxaban is a Novel Oral Anticoagulant (NOAC), and there are few reports of rivaroxaban-associated SIEH. We report a 72-year-old male who had been taking rivaroxaban for his atrial fibrillation. He presented with sudden-onset paraplegia with a T7 sensory level and absent anal contraction. Magnetic resonance images of the spine revealed a long-segment T4-T8 ventral intradural extramedullary hematoma and T9-T10 dorsal intradural extramedullary hematoma both causing cord compression, associated with spinal cord oedema spanning from T8-T10 levels. To address the acute spinal cord compression, T4 to T10 laminectomy and evacuation of SIEH was performed for urgent spinal cord decompression. Sixteen months post-operation, he was able to ambulate independently albeit with residual bilateral lower limb weakness and numbness. Keywords: SIEH; spinal hematoma; laminectomy; hematoma evacuation; rivaroxaban; NOAC.

Acute spinal cord compression due to spinal subdural hematoma after spinal anaesthesia in-patient under anticoagulant drug

BackgroundSubdural spinal cord hematomas are very rare condition. They most often occur in patients with primary or secondary blood haemostasis disorders and following lumbar punctures. Early diagnosis and management preserve functional prognosis.Case descriptionWe report the case of a female 69-year-old patient on oral anticoagulant, Acenocoumarol 4 mg (SINTROM) for previous aortic prosthesis. The patient had undergone surgery for appendicitis under spinal anaesthesia 2 days before her admission in neurosurgery department. She was admitted in emergency for 1/5 central flaccid paraplegia with sensitive umbilical level. A spinal MRI performed showed a collection intradural in intermediate signal in T1 and hyposignal in T2 with echo gradient of 8 mm thickness extended from D8 to L2 compressing the marrow with anomalies of intramedullary signal extended from D8 to the conus medullaris. We retained indication to operate the patient early in emergency because of acute spinal cord compression. We performed T12-L2 laminectomy, durotomy and evacuated hematoma. Postoperative marked by an immediate recovery of sensitivity and an onset of motor recovery from 1/5 to 2/5 and 4/5 follow up at on year with physiotherapy.ConclusionSpinal cord compression due to subdural spinal hematomas not often described especially in patients with haemostasis blood disorders due to anticoagulants drugs. In addition, we should pay attention with lumbar puncture in these patients. Emergency surgery allows a good prognosis about recovery of neurological disorders.