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Spinal cord compression

 

Spinal cord tumors

Spinal canal tumors divided into primary and secondary (metastases). These tumors can be located above (extradural or epidural) and underneath the spinal cord dura (intradural). Intrathecal (intradural) tumor may be located outside and inside of spinal cord parenchyma (intramedullary, extramedullary).

Extradural tumor pushes the spinal cord anterior and aside.

Extradural tumor pushes the spinal cord anterior and aside.

 

Spinal cord extradural tumors

In neurologist and neurosurgeon clinical practice are more common extradural spinal tumors. Extradural spinal tumors - a tumor metastasis from near the spine located organs. Especially common are metastasis of prostate, breast and lung, as well as lymphomas and plasmocytic dyscrasias. The development of metastatic spinal cord epidural compression is described in almost all of human cancers types. The first symptom of epidural (extradural) spinal cord compression is usually the patient's complaint to the local back pain. Back pain can be enhanced in the supine position and forcing the patient to wake up at night. Back pain often associated with radiating radicular pain, which intensified by coughing, sneezing or straining. Often back pain and local pain on palpation precede in weeks other symptoms of spinal cord epidural (extradural) compression.

Extradural tumor pushes the spinal cord posteriorly.

Extradural tumor pushes the spinal cord posteriorly.

 

Neurological symptoms in a patient with epidural (extradural) spinal cord compression usually develops within a few days or weeks. The first manifestation of the syndrome of spinal cord compression is a progressive weakness in the limbs. Weakness in the limbs could carry all the symptoms of a transverse myelopathy with paraparesis and of sensitivity disorders as a result.

In conventional spine X-ray radiography can be detected vertebral body destruction or compression fracture at the corresponding spinal cord lesions syndrome level. Bone scintigraphy is more informative. Compression is most indicative on the spinal cord examination on CT, MRI, and myelography (with contrast). The site of the spinal cord horizontal symmetric expansion and compression by extramedullary pathological formation, noticeable along the boundaries of subarachnoid space liquor flow blockade (CSF block). In case of cerebrospinal fluid block are identified of neighboring vertebrae morphological changes.

Medical management of spinal cord compression by extramedullary tumor can be conservative and operative. In neurosurgical hospital in case of extramedullary spinal cord compression tumor can be performed operation laminectomy. Laminectomy operation goal is to expand the bone window at the site of spinal cord tumor masses. When conservative treatment methods in patients with extramedullary spinal cord compression is used high doses of corticosteroids with fractional radiotherapy combination. The outcome of this treatment method will depend on the type of tumor and its sensitivity to radiotherapy. After the corticosteroids injections in two days the severity of the legs muscle weakness (paraparesis) in patients often decreases. In some early partial spinal cord transverse lesion syndromes, neurosurgical treatment may be advisable. In any case requires individual analysis of treatment strategies, based on the tumors radiosensitivity, other localizing metastases and patient's general condition. Regardless of the chosen therapeutic tactics (surgery or radiotherapy), it should be applied to the patient as quickly as it possible. For suspected spinal cord compression for patients can be prescribed corticosteroids.

 

Spinal cord intradural extramedullary tumors

Spinal cord intradural extramedullary tumors in growth rate inferior to extradural tumors. Intradural extramedullary tumors are much less often compress the spinal cord. Among the intradural extramedullary spinal tumors meningiomas and neurofibromas are more common. Such spinal tumors, or like hemangiopericytoma other membranes tumors in clinical practice are rare.

In the beginning of the spinal cord lesions by intradural extramedullary tumors in patients have radicular sensation disorders syndrome and asymmetrical neurological disorders. At spinal cord computed tomography (CT) and myelography detected typical pattern of the spinal cord displacement (dislocation) in outside direction from tumors, located in the spinal cord subarachnoid space.

Spinal cord pushed aside by intradural extramedullary tumor.

Spinal cord pushed aside by intradural extramedullary tumor.

A slight increase in the cerebrospinal fluid (CSF, liquor) protein content detected in patients with all types of oncological compressive myelopathy. In the case of forming the liquor flow blockage in the spinal cords subarachnoid space, the protein concentration in cerebrospinal fluid (CSF, liquor) increases to 1000-10000 mg/l. This is due to the delay of liquorodynamics from caudal sac into the cranial cavity subarachnoid space, where it have has reverse physiological absorption (resorption of cerebrospinal fluid, CSF).

In normal adult human liquor practically no cellular elements. Their number in the cerebrospinal fluid (CSF, liquor) with intradural extramedullary spinal tumors will be small or fully absent. Note that the cytological examination of cerebrospinal fluid (CSF, liquor) cannot detect tumor cells. The glucose content in the patient's cerebrospinal fluid may also be in the normal range, if the tumor is not accompanied by widespread spinal membranes carcinomatous meningitis.

Intradural intramedullary tumor is located in the center of the spinal cord.

Intradural intramedullary tumor is located in the center of the spinal cord.

 

Spinal cord epidural abscess

Treatment of spinal epidural abscess in patients is not difficult. It is important to diagnose the epidural abscess at the beginning of the disease and differentiate it from the spinal cords neoplastic lesion. Following diseases is predispose to emergence of the spinal cords epidural abscess:

  • furunculosis of the occipital region of the scalp,
  • bacteremia (sepsis),
  • minor back injury.

Spinal cords epidural abscess may develop as a complication after surgery on the spine structures (herniated discs, vertebroplasty, etc.) or after lumbar puncture. The cause of epidural abscess formation, which increasing in size and then compresses the spinal cord, is vertebrogenic osteomyelitis. Focus of the spine osteomyelitis may be small and not detectable on plain X-ray spondilography. For accurate diagnosis of the vertebral spine osteomyelitis must carrying out multislice computed tomography (MSCT).

In a patient with spinal epidural abscess in a several days or weeks is noted:

  • unknown nature of increase temperature,
  • minor back pain,
  • local tenderness to palpation,
  • radicular pain (appears later).

Increasing in size, epidural abscess will be compresses the spinal cord. This extramedullary growing spinal cord compression causes a neurological syndrome its hemisection lesion, sometimes with its complete transsection. If neurological symptoms will be increased than its need urgent decompression by laminectomy surgery and drainage of abscess cavity in case spinal cords epidural abscess compression. Postoperatively, the patient with spinal epidural abscess need antibiotics therapy, based on antibiotic susceptibility testing (AST). As in any infectious process, abscess cavity incomplete drainage often leads to development of chronic granulomatous and fibrotic process. Antibiotics in this case, does not eliminate the patient's spinal cords compression. Spinal cords compression by tuberculosis abscess are rare in developed countries.

 

Spinal cord epidural hemorrhage and hematoma (hematomyelia, hemorrhachis, hematorrhachis)

In case of spinal cords subarachnoid and epidural space bleeding (hematomyelia, hemorrhachis, hematorrhachis) in patient can develop the clinical picture of acute transverse myelopathy (for a few minutes or hours). Spinal bleeding (hematomyelia, hemorrhachis, hematorrhachis) is accompanied by severe back pain. The source of spinal bleeding (hematomyelia, hemorrhachis, hematorrhachis) can be:

  • spinal cords arteriovenous malformation (AVM, angioma, hemangioma),
  • hemorrhage into the tumor,
  • cerebral venous sinuses thrombosis anticoagulation therapy with warfarin,
  • spontaneous spinal bleeding (occurs in patients most often).

Spinal cords epidural hemorrhage may develop because of:

In the spinal bleeding (hematomyelia, hemorrhachis, hematorrhachis) patients complaints of back and radicular pain, that is often precedes to appearance of weakness (for a few minutes or hours). Pain and weakness can be significantly expressed, forcing patients to take antalgic posture during movement. Epidural hematoma at the level of the spinal cords lumbar segments accompanied by a loss of knee and ankle reflexes, whereas in retroperitoneal hematomas usually will be lost knee reflexes only.

MRI of thoracic level spinal extradural hematoma, that occurred after hemangioma removal surgery.

MRI of thoracic level spinal extradural hematoma, that occurred after hemangioma removal surgery.

 

In spinal hemorrhage diagnosis on myelography determined volumetric process. Spine computed tomography (CT) sometimes do not detect of this hematoma, because of blood clot cannot be distinguished from the adjacent vertebral bones.

Spinal hematomas can be formed because of spontaneous bleeding. Blood clots can be conditioned by the same factors as the epidural or subdural hemorrhage and giving severe pain, located into the subarachnoid space. Cerebrospinal fluid (CSF, liquor) with epidural hemorrhage, usually, pure or contains a small number of red blood cells. Cerebrospinal fluid in subarachnoid hemorrhage initially bloody and later acquires expressed yellow-brown color (xanthosis) due to the presence of blood pigments in it. In addition, in the liquor can be detected pleocytosis and reduced glucose concentration. This creates a false picture similar to bacterial meningitis.

Intraspinal (intramedullary) hematoma can be caused by spontaneous rupture of the inner vascular malformations such as telangiectasia in gray matter. Most often, it is the result of an injury. If bleeding began in the central area, it usually extends upward and downward along the spinal cords several segments, and denoted as hematomyelia, hemorrhachis or hematorrhachis. Clinically developed acute syndrome, which can really resemble chronic syndrome, typical for syringomyelia.

Spinal epidural bleeding is rare. Usually it is not caused by trauma, but vascular malformations rupture (often small vessel hemangioma (AVM, angioma)) into the epidural space or near the spine bones. When radiography revealed vertical trabeculae in the vertebral cancellous bone, typical of angioma. Blood is not always going in the angioma. Hematoma usually develops over the dorsal part of the spine cord middle thoracic level. It can cause acute radicular pain at the bleeding level. Then develop a syndrome of transverse myelopathy with paresthesias, alternating with loss of sensitivity. Motor paresis starts in the toes and feet and rises to the spinal cord compression level. In such cases is indicated immediate neurosurgeon consultation.

 

Intervertebral disc acute herniation (extrusion)

Intervertebral discs herniation (extrusion) on the lumbar and cervical spine - is a common pathology in modern humans. Extrusion of intervertebral discs are less common cause of spinal cord compression. Typically, disc herniation, that can cause spinal cord compression and myelopathy, develop on thoracic after a spinal injury.

The destruction of the cervical intervertebral discs (extrusion, herniation) with concomitant intervertebral joints osteoarthritis and of the posterior longitudinal and yellow ligament hypertrophy (cervical spondylosis) causes chronic myelopathy at spinal cords cervical level in elderly patients.

On cervical spine MRI C5-C6 herniated disc compresses the spinal cord at the cervical level and causes compressive myelopathy.

On cervical spine MRI C5-C6 herniated disc compresses the spinal cord at the cervical level and causes compressive myelopathy.

 

Other atypical spinal cord compression lesion

In patients with various diseases prolonged treatment by adrenocortical hormones (glucocorticoids), or with primary Cushing's syndrome, is a tendency to an increased proliferation of epidural adipose tissue. Such epidural adipose tissue volume increase can compress thoracic spinal cord in a patient. In some blood diseases spinal cord compression caused by extramedullary hemorrhage foci.

Rare diseases, causing spinal cord compression in patients, include:

  • erosion exposed aortic aneurysm,
  • hydatid and other parasitic cysts,
  • tuberculous gumma,
  • lymphomatous-granulomatous processes,
  • mucopolysaccharidoses.

Intervertebral joints inflammatory diseases are manifested in two clinical forms:

On cervical spine MRI revealed atlanto-axial articulation arthropathy and 2 odontoid process erosive changes, that causing compressive cervical cord myelopathy in patient with rheumatoid arthritis of the cervical spine.

On cervical spine MRI revealed atlanto-axial articulation arthropathy and 2 odontoid process erosive changes, that causing compressive cervical cord myelopathy in patient with rheumatoid arthritis of the cervical spine.

 

Complications from affected joints in rheumatoid arthritis, causing effects on the spinal cord, often missed by physicians. Cervical vertebrae bodies or atlas anterior subluxation relative to the second cervical vertebra (C2) is able to cause significant damage to the spinal cord, including death in case of compression after small injuries (whiplash, cervicocranial syndrome and whiplash neck injury). In a minor case in patient may develop chronic compressive myelopathy, similar to those in cervical spondylosis. Separation of the C2 vertebra's odontoid process can cause narrowing (stenosis) of the spinal canal's upper levels with compression of the medulla and spinal cord connections site, especially in neck flexion with the head forward tilt.

 

 

If you have any questions on the diagnosis or treatment of spinal cord compression, you can ask them to our neurosurgeon or neurologist:
(499) 130–08–09

 
 

 

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