The physical sign of spinal cord compression is a sensory level, but this tends to occur late in the course of cord compression. Remember, however, that a normal neurological examination does not exclude a diagnosis of cord compression. If, on the basis of the patient's symptoms you suspect cord compression, arrange for a magnetic resonance imaging (MRI) without delay.
Imaging in Suspected Cord Compression
While plain x-rays of the cervical, thoracic, and lumbar spine can show vertebral metastases in over 80% of symptomatic patients, MRI allows accurate identification and localisation of metastases and is the imaging modality of choice.
In the majority of patients initial treatment consists of pain relief, cortiscosteroids, and androgen deprivation (if not already started), followed by radiotherapy.
Dexamethasone is the steroid of choice (Greenberg et al. 1980, Sorensen et al. 1994). It reduces vasogenic oedema. Very high doses may be required (100 mg bolus of i.v. dexamethasone,
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followed by doses every 6 hours of between 4 to 24 mg). Androgen deprivation therapy may be in the form of either radical orchidectomy (which produces a rapid response) or maximal androgen blockade with an antiandrogen combined with an LHRH agonist.
Surgical decompression (laminectomy) is used in patients with a life expectancy of >6 months who have had previous radiotherapy at the involved site, for those whose neurology deteriorates during radiotherapy, or for those who have a cord compression of unknown histology.
Patients who are still able to walk by the time they receive treatment have a high chance (70-90%) of remaining ambulatory after treatment. Of those patients who present with complete paralysis prior to onset of treatment, only 20% to 40% will regain the ability to walk (Tazi et al. 2003). Of those presenting with urianry retention prior to onset of treatment, only 40% will regain normal voiding after treatment.