• In patients with mild weakness and urinary hesitancy, especially if history of cancer, have high index of suspicion

Symptoms and signs

• Acute (usually symmetrical) weakness of arms or legs or both
• weakness of the arms only is rare but apparently normal strength in the legs does not rule out spinal cord compression
• Sensory level
• may be absent or at least difficult to pick up in high cervical spine compression
• Hyperreflexia and extensor plantar responses
• because of spinal shock these may not be present at outset
• Bowel/bladder dysfunction
• Erectile dysfunction in males
• Local spinal pain and/or tenderness +/- radicular pain
• In patient with diagnosed cancer, certain symptoms strongly suggest spinal metastases:
• cervical or thoracic pain
• progressive or unremitting severe lumbar pain
• nocturnal spinal pain preventing sleep

Examination

• Full neurological examination with clear documentation on ASIA chart
  • if device linked to a printer, print off electronic copy of ASIA chart
• Upper and lower limb strength and reflexes
• Sensory examination of upper and lower limbs and perineum

Investigations

• Refer such patients IMMEDIATELY to a spinal specialist
• do not delay referral until a scan has been done
• If spinal cord compression suspected, request immediate MRI scan of whole spine
• if MRI scan required out-of-hours. See Imaging: Who2Call guideline
• FBC, U&E, LFT, ESR, CRP, Bone profile including albumin and calcium levels, clotting profile
• If infection suspected, blood cultures. See Collection of blood culture specimens guideline
• Chest X-ray
• If malignant cause of cord compression suspected from MRI scan:
  • CT head/chest/abdomen/pelvis

Differential diagnosis

• First exclude spinal cord compression
• Transverse myelitis
• Cord ischaemia
• Guillain-Barré syndrome
• Intrinsic spinal cord lesion such as intramedullary tumour
• Intracranial lesion

• If malignancy suspected or proven, refer immediately to musculoskeletal cancer team
• Optimise spinal cord perfusion by treating hypovolaemic or neurogenic shock
• ideally keeping MAP ≥75-80 mmHg
• Both because of potential for spinal instability, and to optimise cord perfusion, ensure patient is nursed flat
• with turns side-to-side for pressure area care
• Catheterise the bladder. See Urethral catheterisation guideline
• If symptoms and signs suggest high cervical spinal cord compression, be aware of potential for respiratory failure

Dexamethasone in malignant spinal cord compression (MSCC)

• Once MRI scan performed and infective cause excluded, and after discussion with on-call spinal surgery team, give dexamethasone sodium phosphate 6.6-10 mg (Hameln brand) IV or 16 mg oral immediately
  • then 8 mg oral or 6.6 mg IV twice daily at breakfast and lunchtime 
  • with concomitant administration of a PPI (e.g. omeprazole or lansoprazole)
  • if oral route inappropriate, continue dexamethasone 6.6 mg IV twice daily at breakfast and lunchtime
• Review need for dexamethasone at 48 hr 
• If patient requires surgery +/- radiotherapy, review dose

Thromboprophylaxis

• TEDS, Flowtron
• No anticoagulation for the first 24 hours until a decision regarding surgery is made

• If surgery not indicated, and patient has cancer, refer immediately to oncology team
• share treatment decisions with oncology, but this need not delay urgent surgery
• Further management will be decided by spinal team or oncology team, as patients may receive radiotherapy after or as an alternative to surgery