Spinal emergencies

Refers to spinal emergencies that can cause permanent neurologic injury if not diagnosed and treated in a timely fashion.

Except for trauma and malignancies, the most common spinal emergencies are spinal epidural abscess, cauda equina syndrome, and spontaneous spinal epidural hematoma.

Spinal emergencies often present with non-specific symptoms and or a diagnostic challenge.

Clinically neural compression in the spinal canal at the spinal cord level from the occiput to L1 can lead to upper motor neuron dysfunction.

Nerve root compression in the foramina at any level or within the central canal of the spine caudal to L1 typically leads to lower motor neuron dysfunction.

Nerve compression at the cervical level can result in axial pain, neck stiffness, and neurologic syndromes including monotadiculopathy, myelopathy, and myeloradiculopathy.

Cervical monoradiculopathy is caused by an isolated single nerve root abnormality producing a clinical syndrome that distributes neurologic findings by the sensory alteration in a single dermatome or weakness of muscles innervated by a specific nerve root.

Cervical myelopathy is due to compression of the spinal cord within the central canal and is typified by bilateral sensory findings including paresthesias, numbness, and altered proprioception, and motor changes of weakness, increased muscle tone in the upper and possibly all four extremities.

Additional potential findings include impaired hand dexterity,, balance and gait difficulties, and rarely urinary problems.

Upper motor neuron signs include: spasticity, hyperreflexia, Hoffman’s sign, inverted radial reflex, clonus, or extensive plantar response which correlate with cervical cord dysfunction but are not always present in this setting up acute cord compression.

Myelopathy can occur in conjunction with dysfunction of one or more nerve roots to produce cervical myeloradiculopathy.

Compression of a single nerve root in the thoracic region can produce torso radicular symptoms and may cause truncal paresthesias/dysesthesias in the dermatomal distribution or chest pain that can be difficult to diagnose.

Spinal cord compression at the thoracic level can produce a thoracic myelopathy.

Compression of a single or multiple nerve roots at the lumbar level can produce low back pain, radiculopathy in the lower limbs, often referred to as sciatica, or neurogenic claudication.

Lumbar ridiculopathy is typically produced by nerve compression in the foramina or lateral aspect of the spinal canal by diac herniation or spondylitic changes.

Long standing central canal stenosis beyond the termination of the spinal cord, that is below the L1-2 level is most commonly produced by spondylosis, and typically manifests as neurogenic claudication.

When the caudal nerve roots are subjected to acute compression in the central spinal canal the cauda equina syndrome may develop.

Spinal epidural abscess is a pyogenic infection of the space between the vertebral body/ligamentous complex and the dura mater of the spine.

Spinal epidural abscess is becoming increasingly common.

Patients with spinal epidural abscess most commonly present with axial pain, present in more than 2/3 of patients.

The classic triad of spinal epidural abscess consists of fever, axial pain, and neurological deficit is seen only an 8% of patients.

MRI with gadolinium or CT with myelography are the two imaging modalities used to evaluate epidural abscesses.

Management is based on the patient’s medical history, the infectious organisms, the location and size of the abscess, and most importantly the neurologic examination.

Emergency referral to spine and infectious disease specialists are our warranted.

Decompression and debridement surgery followed by long-term antibiotics is the treatment of choice and significantly improves the outcome in patients with neurological compromise.

MRI is the diagnostic imaging modality of choice as it is less invasive and provides improve soft tissue detail. Management requires drainage and antimicrobial therapy.

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