Carl Maronich (Host): This is Expert Insights from the Carle Foundation Hospital. I'm Carl Maronich. And joining me today is Dr. Jacob Tony, a neurologist from Carle Foundation Hospital, and we'll be talking about spinal cord compression. Dr. Tony, welcome to the podcast.

Jacob Tony, MD: Thank you, sir.

Host: Now, Doctor, when clinicians hear spinal cord compression, what exactly are we talking about from a pathophysiology standpoint?

Jacob Tony, MD: Well, basically, the spinal cord compression is a type of myelopathy. Myelopathy is when the spinal cord is involved either due to a compressive or a noncompressive lesion. What I'm trying to limit in this talk is predominantly something that compresses the spinal cord and, thereby, reduce the circumference of the spinal cord and produce a compressive lesion. But when you put under the bigger umbrella of myelopathy, you have noncompressive as well as compressive myelopathy. So, I'm not going much into the noncompressive one, but I'm going more into the compressive one.

When I'm talking about a compressive myelopathy, it basically means there is something structural. So when we talk about structural, anything that structurally affect the spine in such a way that there is reduction in the circumference or narrowing of the spinal cord compressing the spine. For example, it could be an osteoarthritis affecting the bones or the vertebrae producing bone spurs that press onto the spinal cord or it could be a disc that is migrating and pressing onto the spinal cord.

Now, other than that, you can have spondylolisthesis. In other words, one vertebrae moving in relation to a caudal vertebrae, either anteriorly or posteriorly pressing onto the spinal cord. So, that is also a structural lesion pressing onto the spinal cord. Now, it is not always the bones, but the ligaments in the spinal cord. For example, the posterior longitudinal ligament and ligamentum flavum can be calcified or ossified, and they themselves can press onto the spinal cord. In addition, we also had to make sure that, particularly in the setup of a trauma, there is no fracture or dislocation of the vertebra pressing onto the spinal cord.

Finally, we also have to think about other causes. For example, a person who has an immunosuppressed stage who is prone to get infection can have an infection like an osteomyelitis or an epidural abscess if they have fever and signs of infection and it presses on the spinal cord, that is pretty urgent. You have to take care of that. And also, sometimes this could come from things like an arachnoid cyst pressing onto the spinal cord. And in the background of cancer, anybody with, say, breast cancer, lung cancer, prostate cancer, if they develop sudden acute pain in the spine, radicular pain and developed weakness, one has to be extremely careful not to miss a spinal cord compression.

So, these are all structural things. And very rarely, vascular lesions like arteriovenous malformations can also press onto the spinal cord. So, these are all structural spinal cord lesions whereby the spinal cord is compressed because of a structural problem.

Host: Now, Doctor, you mentioned pain, but are there other key clinical signs or symptoms that should immediately raise suspicion for spinal cord compression?

Jacob Tony, MD: Yes. When we take the history, I would just sort of put the history under various categories. One is sensory symptoms, motor symptoms, gait problems and, finally, bladder problems. So, these are the four subheadings that a clinician has to be looking for.

So, sensory symptoms, neck pain or back pain may or may not be there. If it is there, it is useful. Sometimes they get radicular pain, a pain shooting either from the neck or back, depending upon where the spinal cord compression is. So, it's a shooting pain, a radicular pain, which is particularly worse when a patient is coughing or sneezing. So, that is another clue that there is a radicular pain. They may get parasthesia or sometimes tingling and numbness. It can affect the hands, particularly in a glove and stoking fashion. Occasionally, if they have a parasthesia in that area, one has to think about a spinal cord problem.

Now, as far as the motor symptoms are concerned, most of the spinal cord problems in terms of statistics affect the cervical spinal cord. Therefore, if a cervical spinal cord is affected, what you see is what they call a myelopathy hand. So, you start seeing some difficulty with hand movement, buttoning, unbuttoning, putting the zipper on or fine motor movement. So when you start seeing that in a person with some neck pain or radicular pain, you should immediately raise suspicion that they may be developing some cervical myelopathy.

And then, as time goes on, they can develop difficulty with getting up from the chair, going up and down the stairs, and then generalized weakness, both affecting the upper and lower extremities.

Now, as it progresses, the gait will be affected—tripping, falling, losing balance, ataxic gait, sometimes spastic gait. And the most important thing is never ever miss a bladder symptom. Because if the patient develops bladder symptoms, which could be urgency, retention, frequency of urination, or incontinence, that is a red flag. You know, that means the spinal of cord compression is progressing rapidly and one has to get urgent consultation if they develop urinary symptoms. So, these are some of the symptoms that we look for in patients with the spinal cord problems.

Host: And, Doctor, how do you start distinguishing spinal cord compression from things like peripheral neuropathy or even brain lesions?

Jacob Tony, MD: Yeah, that's a very good question. I think what I'm trying to concentrate on today's talk is basically clinical examination, history and clinical examination, okay? Now, in a spinal cord compression, once you have got this history, you start physical examination. Again, physical examination come under the same categories. What are the sensory findings? What are the motor findings? What are the reflex findings? And what are the gait findings?

Let us start with the sensory findings. What we need is nothing but a tuning fork and a safety pin. So, a patient comes with sensory symptoms, one has to use the safety pin and gradually go up to see if there is a sensory level. Now, that's very important. And for knowing the sensory level, we should know about the dermatomes.

So for example, to easily remember the various dermatomes, our nipple is at the level of T4. On the other hand, the belly button, the umilicus is at T10. So, thoracic 10 is belly button. Groin is L1, lumbar 1. If you go to the knee, in other words, you can say, "We kneel on L3." The knee where we kneel on is L3, lumbar 3. And we stand on S1. So, when we talk about various dermatomes as we go up, if it is, let's say, T10 level or T8 level or T4 level or you go farther up to C5 or C6—so, one has to know the dermatomal level to localize the lesion. That is number one. This is as far as sensation is concerned. So, safety pin, go all the way up and find a sensory level, number one.

Number two, the motor functions, as I told you, they may have weakness in the upper and lower extremities. But as I said, the classic scenario is usually the cervicothoracic spine is compressed. And therefore, you get upper motor neuron findings in the lower extremity, so they will have hyperreflexia. So, we all have to carry a patellar hammer, a knee hammer, And then, you just tap onto the knee or the ankle, you see the reflexes are 4+ or 3+. Then Babinski sign, you know, the Babinski will be positive. Hoffman's sign will be positive. What does that mean? That means the patient has all upper motor neuron signs in the lower extremities. Hyperreflexia, positive ankle reflex, ankle clonus, patellar reflex, positive Babinski sign, Hoffman sign. When you licit all these signs, which are clinical signs that clinicians elicit, you know that there is an upper motor oral lesion in the cervicothoracic spine.

Then, you go to the bladder symptoms as I already told you, they're mostly symptoms. Gait, very important. I remember when I was doing my neurology residency, the first question our chairman will always ask is, "Did you make your patient walk?" The most important, make the patient walk, and it gives a lot of clues. How are they walking? Are they tripping and falling? Do they have a foot drop? Do they have spastic gait? Do they have an ataxic gate? Can they walk on a straight line? These are all the clues that will lead us to a diagnosis of spinal cord compression.

Now, the second part is how do you differentiate from a neuropathy, a radiculopathy, a plexopathy, or a brain lesion? Well, if it is a neuropathy, generally speaking, it is a lower motor neuron lesion. Therefore, you will see a glove and stocking pattern of sensory loss affecting the feet and the hands. You will see the reflexes being lost or hyperreflexia. The knee and angle reflexes are either less or completely lost. You'll see the sensations, either vibration or the pinprick sensation is lost. And obviously, you don't see hyperreflexia there, you don't see a positive Babinski there, you don't have bladder symptoms there, then you think about a peripheral neuropathy. So, it's a lower motor neuron finding there. Reflexes are gone. Sensations are impaired.

Now, to answer the question about radiculopathy, again, we should know the various dermatomes and the myotomes. Just to give an example, whenever we say sciatica, it's actually a radiculopathy affecting the L5 and the S1. I told you before, we stand on our feet and that corresponds to S1, right? And so if somebody complains of, say, back pain shooting down to the leg, and they have sensation in that particular radicle, for example, L5-S1, they will have pain going down to the dorsum of the foot, where the plantar aspect is S1 and L5 foot drop, that suggests a radiculopathy.

In radiculopathy, you see, again, lower motor neuron lesions, so the ankle reflex is lost there. The reflexes are lost. Sensation is in a dermatomal fashion. You don't have a myotomal distribution with a sensory or motor or reflex level. And clearly, you don't have any bladder symptoms in a radiculopathy.

Now, plexopathy is a situation where multiple nerves coming from the plexus, say for example, brachial plexus, you have the lateral cord, the posterior cord, you also have the medial cord. So, when you see multiple nerves affected, then it is a plexopathy. And as I told you before, spinal cord compression, on the other hand, they have a sensory level which you go by using the safety pin or a vibration tuning fork. They have a motor level. You go up and you find where it ends. You have a reflex level. So if you just keep checking the reflexes, you'll find that there is hyperreflexia below the level of the lesion. So, you have a sensory level, a motor level, as well as a reflex level and, of course, the gait is spastic or ataxic to make a diagnosis of a myelopathy.

Now, brain lesions, there should also be associated probably cognitive functions, aphasia, speech disturbances, dysarthria, diplopia, because cranial nerves are usually affected. If the brain is affected, you will also see one of the cranial nerves being affected, or they may have aphasia, they may have associated cognitive decline, they may have seizure, all those things. So, it's easy to differentiate a brain lesion from a spinal cord lesion, from a radiculopathy, plexopathy, or even a neuropathy.

The key to diagnosis is knowing the dermatomes. The dermatomes, as I already told, whether it is C5 or C6 or T1, or T4 or T10, one should know the dermatomes. And one should also know the reflex levels. For example, when we elicit the biceps, we know it is C5. And then, you go to brachioradialis, which is C6, if you elicit the triceps. So if those reflexes are lost, then you know it is a radiculopathy affecting those radicles. So, an awareness of the myotome and dermatome and the various tracts of the spinal cord are important.

You know, those tracts, the motor tracts are basically the perimeter tracts. Then, you have the lateral spinothalamic tract, which carries pain and temperature, and the posterior column, which carries vibration position sense. So depending upon where the cord is affected, sometimes you can get hemicord lesions, half of the cord is affected. If that's the case, on the same side, there will be weakness and loss of position and vibration. But on the opposite side, they may have loss of sensation of pain and temperature. So, it depends upon the understanding of the dermatomes, myotomes, reflexes, and the various tracts in the spinal cord.

Host: So, Doctor, with regard to all these diagnostic issues, when should a clinician escalate care urgently or emergently? And what are the don't-wait scenarios?

Jacob Tony, MD: Well, anybody who has a cauda equina lesion, which is when the lesion is further down in the lumbar area and they have weakness with the absent ankle reflex and knee reflex. Also, significant bladder symptoms, fecal incontinence, bladder incontinence, or their sexual activity is affected, and they have also loss of sensation in what we call saddle anesthesia, which is in the perianal area, that's an emergency. The patient should immediately be treated by the spinal surgeon or sent to the ER if you cannot get a spine surgeon.

Now, anybody who has a sensory level, a motor level, a reflex level, like what I told, one has to be very careful. The reason is this, when we talk about the pathophysiology of a compressive or structural myelopathy, the caveat is also understand it's not always static because we are moving around, right? So if suddenly we are hyperextending our neck or somebody rear-ended our car, or you go to a chiropractor or you had a deep massage, or you went to a dentist who hyperextended your neck to do sort of dental examination, that will produce a dynamic stress on an already compromised spinal cord. So, anybody in that situation comes back and say, "Doctor, my weakness is getting worse," immediately take care of that. And then, you have to immediately refer the patient to the neurosurgeon, or if that's not possible, you have to send the patient to the ER.

Now, bladder symptoms is a red flag. Anybody with spinal correlation, you are following it. If they do level up bladder symptom, yes, you have to take it very seriously and send the patient immediately. Now, activities of daily living, if they find that it is progressively getting worse, they're progressively falling down, they cannot use their arms, they cannot use their hand for fine motor functions, so activities of daily living are affected, immediate care is needed.

Also, remember, spinal cord compression can be from an abscess like an epidural abscess, so somebody with HIV or immunosuppression or diabetes, or who had a renal transplant or on an immunosuppressant develops fever and develops sudden weakness, one has to think about the possibility of a spinal cord compression from an epidural abscess. And that has to be immediately taken care of.

So, all these things are very important, abscess, infections. And as I already told before tumor, anybody with an underlying cancer, breast cancer, lung cancer, prostatic cancer suddenly develops weakness in the arms and legs with the myelopathic changes, we have to escalate the care and immediately send the patient to the surgeon and also call the radiation oncologist.

Host: Doctor, how do you approach patient education around spinal cord compression?

Jacob Tony, MD: Well, I would always say that anybody who has a change in the way they walk, for example, they're tripping or they are falling, or they are having strange sensory symptoms, which is creeping up. I can give some example. In the last six years, I have picked up at least seven or eight spinal cord compressions in the office. I think those patients, we could have prevented the progression of those spinal cord compression. Because some of them, the diagnosis was neuropathy. It's not neuropathy. The patient is clearly telling they are losing sensation into their tummy, going up to the chest. No neuropathy will produce loss of sensation in the tummy, then going up to the chest. That means the patient has a spinal cord compression. As we go up, you find actually a level. It could be T4 or T10, so that's very important. Neuropathy will not produce symptoms creeping up all the way to the chest or abdomen. That is number one.

Number two, neuropathy or other conditions should not produce bladder symptoms. So, new bladder symptoms, yes, we have to tell the patients, educate them. And finally, if anything suddenly is aggravated by trauma, like sudden movements of the neck, you are having a rough ride or somebody rear-ended you, or you went to a chiropractor and they did some chiropractic manipulations in the neck and things got worse. So, we had to warn them that there may be some spinal cord problem going on, but things can get worse because of some dynamic things that's happening, which is compromising the structural integrity of the spinal cord.

Host: Yeah. So, all those things are a way of saying that early detection, like with so many other medical conditions, is really a key thing with spinal cord compression.

Jacob Tony, MD: Oh yeah, it is. In fact, spinal cord compression of an acute nature or a subacute nature should be considered as a medical emergency. We should not sit on that. They can lose function of their muscles, right? They can become weak or paralyzed. They can lose control of their bladder. So, there should be a high index of suspicion. High index of suspicion for spinal cord compression, and they should be carefully watched and immediately referred to a spine surgeon.

Host: What role does multidisciplinary care play in the treatment of spinal cord compression?

Jacob Tony, MD: Well, that is only in the early stage. The multidisciplinary physical therapy and stuff like that, I would say it is in the stage of radiculopathy. When, for example, somebody has a cervical radiculopathy, they get radicular pain. And at that stage, yes, we can involve physical therapy, we can give muscle relaxants, we can send to pain clinic for epidural injection. But when they develop myelopathy, then it is more of a surgical care there. We have to involve a spine surgeon. So at the stage of radiculopathy, it's okay. We can do all these things, physical therapy, muscle relaxants, medications, maybe even injections of the, that's all for radiculopathy. Once radiculopathy progresses into a myelopathy, I think we to take it very seriously.

Host: Doctor, speak, if you would, to how important continuous medical education is in staying updated with the best practices for managing spinal cord compression?

Jacob Tony, MD: Well, preaching to the choir, in my opinion, because there is a specific reason why I picked this up. I have seen, as I told you in the last few years, many acute spinal cord compressions picked up in my office. They came as routine referrals. And meanwhile, I remember a 44-year-old lady who was having a spastic gait. And she had gone to the ER, they did some cardiac workup. By the time she came here, she has lost sensations, she was having hyperreflexia, her husband divorced her, and she was left with her 12-year-old child. These are sad situation. That should not happen. And that is why we have to have a high index of suspicion, and we should be having ongoing continuing medical education.

Going back to the beauty and splendor of clinical neurology, we are clinicians at the end of the day. We don't just wait for some blood test or MRI. Well, what we do is a good history and a good physical examination, the good old history, the good old physical examination, and then come to a clinical diagnosis. And then, based on the clinical diagnosis, appropriate treatment.

So, what I would say is that we should have a good understanding of neuroanatomy about the dermatomes, the myotomes, the reflexes, and the various differential diagnoses. And why we should not miss a myelopathy is because patient could be paralyzed. There are a lot of social implications on that. So, I would suggest in every patient there should be a high index of suspicion. And if you suspect myelopathy, immediately get attention from a surgeon, spinal surgeon, because these are compressive myelopathies. I'm not talking about noncompressive myelopathies today. I'm talking about compressive myelopathies in an office setting. And if you cannot get that, most of the patients I was talking about, I immediately called the ER and I called the neurosurgeon, the patient got admitted. And out of the six patients I'm talking about, at least five of them had surgery on the same night or the next day. One or two patients, they had to have the surgery in the next two weeks or something.

So, this is something that we had to have a high index of suspicion. Do not miss it. And if you cannot find a spine surgeon doing it, send the patient to the ER. This is in the best benefit to the patient, because we don't want some young people or even older people being paralyzed because of misdiagnosis.

Host: Absolutely. Dr. Jacob Tony, thank you so much for joining us today and sharing all this great information and education about spinal cord compression.

Jacob Tony, MD: It is my pleasure. Thank you very much.

Host: For more information and to get connected with one of Carle's providers, visit carle.org or for a listing of Carle providers and to view Carle-sponsored education activities, head over to the website at carleconnect.com. This has been Expert Insights with the Carle Foundation Hospital. Thanks for listening.