Article reviewed and approved by Dr. Ibtissama Boukas, physician specializing in family medicine
Back pain can be mild but also hide a serious pathology such as non-traumatic spinal cord compression. At the established spinal cord compression stage, specific signs appear and can quickly lead to irreversible sequelae, making this pathology a diagnostic and therapeutic emergency.
This article provides information on everything you need to know about spinal cord compression of non-traumatic origin, from the anatomical reminder through the causes and diagnostic means to the various ways to improve the patient's quality of life after the treatment.
Contents
Contents
Definition
Non-traumatic spinal cord compression, as its name suggests, is pressure exerted on the spinal cord by several non-traumatic mechanisms. It leads to a deformation of the spinal cord and causes various clinical signs. These signs can range from simple sensory deficit or motor deficit to complete paralysis. This makes non-traumatic spinal cord compression a diagnostic and therapeutic emergency.
To understand: Anatomical reminder
The signs of spinal cord compression stemming intimately from the anatomical and functional organization of the spinal cord, it is important to make an anatomical reminder of the spinal cord.
The spinal cord, or spinal cord (from the Latin medulla) is a structure of the central nervous system located inside the spine. It allows the transmission of information between the brain and the body. The spinal cord starts from the foramen magnum (nape of the neck). It extends into the spinal canal and ends at vertebrae lumbar precisely at the upper edge of the second vertebrate lumbar (L2).
From the spinal cord come the spinal cord nerves (spinal nerves) which exit through openings called foramina. After the terminal cone of the spinal cord, the last spinal roots going from the second (L2) to the fifth lumbar vertebra (L5) as well as the sacral roots (of the sacrum) constitute the cauda equina. The osteo-ligament canal through which the spinal cord passes is inextensible.
The spinal cord is surrounded by three membranes called meninges, making a thick cylindrical sheath. The pia mater is the innermost meninge, next comes thearachnoid, the intermediate meninge and then the dura mater (outermost meninge). The space outside this meninge, commonly called the extradural space, is filled with fatty substance and vessels, especially the veins. In the subarachnoid space (between the pia mater and the arachnoid) circulates the cerebrospinal fluid (CSF) or cerebrospinal fluid (CSF).
The spinal cord is organized transversely into metamers and longitudinally into long fibers. They have sensory fibers and motor fibers. The spinal cord has two bulge areas: the cervical bulge, from which the nerves for the upper limbs emerge and the lumbosacral bulge, from which the nerves for the lower limbs originate
Spinal Cord Functions
The transmission of nerve information is the role of the spinal cord. The latter fulfills this role through the ascending nerve pathways, which correspond to the sensory neurons. These neurons transmit sensory information to the brain. Descending nerve pathways correspond to motor neurons and transmit motor impulses to different regions of the body.
The spinal cord also acts as a reflex coordination center and is involved in so-called reflex reactions.
Symptoms of non-traumatic spinal cord compression
The patient with spinal cord compression presents with a variety of symptoms depending on the exact location of the compression. Typically, three groups of symptoms are observed:
A lesional syndrome with regard to the compression
It includes localized pain in the specific area innervated by the spinal nerve affected by the compression (root pain). These pains are isolated at the beginning, of invariant topography, (cervico-brachial neuralgia, belt chest pain). They occur more at rest, especially at night, at fixed times. The lesional syndrome therefore makes it possible to determine the level of compression and to orient the neurological and radiological assessments.
A sublesional syndrome
The sublesional syndrome includes motor, sensory and sphincter disorders.
As regards the motor disorders, it can be a simple tendency to get tired when walking or difficulty running. These signs fade when stopped. A non-painful intermittent lameness can be observed. Then gradually there may be a reduction in walking distance and in the worst case paralysis by spastic paraplegia or tetraplegia.
Fullerenes sensory disorders in the sublesional syndrome occur late. It is basically paresthesias which are manifested by several signs: tingling, tingling, sensations of tightening, of a vice, of streaming of icy water, burns sometimes exacerbated on contact, impression of walking on cotton or rubber with more marked discomfort when closing the eyes.
Fullerenes sphincter disorders as for them, they occur late and can be constant in advanced forms of spinal cord compression. These sphincter disorders are manifested by urinary disorders (urgent need to urinate or even urinary incontinence, discomfort or pain when the patient urinates), sexual disorders or anorectal disorders (constipation, incontinence).
spinal pain syndrome
In spinal cord compression, the patient presents with permanent and fixed, localized or more diffuse pain such as tightness, heaviness or stiffness of the spine. They are little or not relieved by the usual painkillers. One can note a deformation of a segment of the rachis with type of kyphosis, Scoliosis ou torticollis.
In addition, the patient feels pain in the muscles and vertebrae next to the level of spinal cord compression, exacerbated by palpation and percussion during the doctor's examination.
Causes of non-traumatic spinal cord compression
Extradural causes (outside the dura)
– Vertebral neoplastic metastases
– Benign primary vertebral tumors (hemangioma, chondroma…) or malignant (sarcoma)
- Myelopathy cervicoarthrosis
- Spondylodiscitis and infectious epiduritis: usually due to the bacteria responsible for tuberculosis
- Epidural hematoma : when using an anticoagulant drug or after a lumbar puncture.
Extramedullary intradural causes (inside the dura mater but outside the spinal cord)
Spinal cord compression at this level is caused by benign tumors such as meningioma and neuroma. Other causes of intradural extramedullary spinal cord compression are arachnoiditis (inflammation of the meninges) and sequelae of meningitis or sarcoidosis.
Intramedullary causes (affecting the spinal cord)
- Tumors (ependymoma, astrocytoma)
- Vascular malformations (cavernoma, angioma, arteriovenous fistula)
- Syringomyelia (appearance of a cavity filled with fluid in the spinal cord)
Diagnosis of non-traumatic spinal cord compression
Non-traumatic spinal cord compression is a diagnostic emergency for the specialist. To do this, he will ask for magnetic resonance imaging (MRI) with injection of contrast product, which is the first-line complementary examination.
MRI will then make it possible to study the spinal cord in both spatial planes and to observe the surrounding structures. It will also make it possible to determine the level of compression as well as the topography of the lesions in question (extra or intra dural, intra or extra medullary). Adjacent skeletal abnormalities may be highlighted.
Other examinations can be carried out in the absence of availability of MRI or in addition to it. These are the scanner, the myeloscanner, standard spinal radiographs. The somatosensory and motor evoked potentials do not constitute diagnostic examinations but allow the functional state of the nerve pathways to be assessed.
Treatment: How to treat spinal cord compression?
surgery
Spinal cord compression constitutes a neurosurgical therapeutic emergency because the picture can worsen in a few hours, causing complete and irreversible paraplegia or quadriplegia.
The principle of surgical treatment for spinal cord compression is to decompress the spinal cord while eliminating the pathology in question. The neurosurgeon will then open the spinal canal to resect a tumour. He will correct a malformation and reduce a vertebral displacement if necessary. He will perform a drainage in case of epidural hematoma.
Case of metastatic tumors
In oncologists, the treatment of non-traumatic spinal cord compression of metastatic origin will aim to preserve or improve neurological function, especially walking autonomy; reduce pain and improve quality of life.
In addition to the decompression and stabilization surgery mentioned above, two other means allow oncologists to achieve these three objectives. These are corticosteroid therapy (dexamethasone) and radiotherapy. Corticosteroid therapy is involved in reducing edema, inhibiting the inflammatory response, stabilizing vascular membranes and relieving pain.
Prognosis
After surgery followed by drug treatment or radiotherapy, total recovery is possible, but sequelae may occur. They can be a type of decrease in muscle strength, loss of sensitivity, urinary incontinence, etc. Physiotherapy will then be a means of mitigating the long-term consequences through strengthening and balance exercises. A perineal rehabilitation will be proposed in case of incontinence.
Social and psychological support from relatives or professionals (psychologist, sexologist, social worker) is necessary for the accompaniment of patients operated on for non-traumatic spinal cord compression.
Conclusion
What should be remembered about non-traumatic spinal cord compression is that it constitutes a diagnostic and therapeutic emergency. It is therefore not necessary to wait for the appearance of the characteristic triad of established spinal cord compression (lesional syndrome, sub-lesional syndrome, spinal pain syndrome) before carrying out magnetic resonance imaging.
The most common causes are tumor metastases and benign tumors (meningioma, neuroma). Spinal decompression surgery is the treatment of choice, followed by corticosteroid therapy and radiotherapy.
The call for professionals such as the physiotherapist, the sexologist and the social worker could be necessary to improve the quality of life of the patient after the surgery.
medical doctor
Republic of Benin
