Synopsis
Recognise a time-critical compressive myelopathy, localise its level and coordinate imaging, spinal precautions and cause-specific decompression before irreversible cord injury develops.
- Compression may arise from trauma, tumour, epidural abscess, epidural haematoma, a large disc, degenerative stenosis, vertebral collapse or an intradural mass; treatment depends on the cause.
- Pain often precedes neurological loss and may be local, radicular or mechanical, but painless compression occurs and must not be dismissed when objective cord signs are present.
- Cord dysfunction produces bilateral upper-motor-neurone signs below the lesion, a sensory level and autonomic disturbance; early spinal shock can temporarily cause flaccidity and absent reflexes.
- High cervical compression threatens diaphragmatic function and can impair cough before oxygen saturation falls; serial vital capacity and critical-care review may be needed.
- MRI is the definitive first-line study in most non-traumatic cases and should cover the clinically relevant region, commonly the whole spine when multifocal disease is possible.
- CT defines fractures and bony alignment when trauma or instability is suspected, but it cannot reliably exclude cord, epidural soft-tissue or cauda-equina compression.
- Do not give corticosteroid reflexively to every compression. Dexamethasone has a defined role in suspected metastatic compression with neurological signs, not routine traumatic injury, haematoma or untreated epidural infection.
- Epidural abscess requires blood cultures, prompt antibiotics after appropriate sampling and urgent spinal surgical discussion; neurological deficit must not wait for a completed microbiology work-up.
- Epidural haematoma requires urgent anticoagulant reversal where relevant and decompression assessment, balancing haemorrhage control against the original antithrombotic indication.
- Neurological status at treatment strongly predicts outcome, so repeated examination and rapid escalation are more important than finding a single perfectly specific red flag.
Key red flags
Bilateral weakness and long-tract sensory change occur below a definable truncal level with brisk reflexes or extensor plantars once spinal shock has passed, often accompanied by retention or constipation.
Severe focal spinal pain with fever, systemic illness, raised inflammatory markers or infection risk progresses to radicular symptoms and neurological deficit; the complete classic triad may be absent.
Sudden severe neck or back pain is followed by rapidly evolving motor and sensory loss after anticoagulation, coagulopathy, trauma or a neuraxial procedure.
A high-energy mechanism, midline tenderness, deformity or neurological deficit raises fracture-dislocation and requires movement restriction and trauma imaging even if the patient can move limbs initially.
Tetraparesis, weak cough, shallow breathing, accessory-muscle use, bradycardia or hypotension suggests cervical cord compromise with respiratory and autonomic risk.
Transverse myelitis, spinal-cord infarction and metabolic myelopathy can produce a level without external compression; MRI distinguishes intramedullary and extrinsic patterns and redirects treatment.
Investigation priorities
Show cord or cauda-equina compression, lesion extent, cord signal and epidural, vertebral or intradural pathology.
Management branches
Acute or progressive cord signs make external compression possible.
- Perform ABCDE, give titrated analgesia, check glucose, document a timed neurological baseline and use spinal precautions when trauma, collapse or movement-related instability is plausible.
- Call the local spinal or neurosurgical service and radiology immediately, identifying respiratory, bladder, cancer, infection and bleeding features that determine urgency and imaging coverage.
- Arrange urgent MRI, adding CT for fracture or bony definition, and create a monitored transfer plan that avoids unnecessary movement or delays for routine investigations.
- Prevent pressure injury and venous thrombosis when safe, drain clinically significant retention and keep the patient nil by mouth if urgent surgery is likely.