Compression myelopathy is a severe complication of diseases of the nervous system, which is based on compression of the spinal cord by various formations: bone fragments of vertebrae in trauma, herniated disc, tumor, hematoma. The main symptoms of myelopathy are loss of motor and sensory function below the lesion site. In addition, there is a violation of the work of internal organs. Computed tomography, radiography, and myelography are used to diagnose compression myelopathy. Treatment of spinal cord compression is mainly operative.
ICD 10
G95.2 G99.2
General information
The term “compression myelopathy” refers to damage to the substance of the spinal cord due to pressure on it by any formation with the development of motor and sensory disorders. Compression myelopathy is not an independent disease, it occurs as a complication of various pathological processes in the spinal column or spinal membranes.
The main factors that lead to damage to the nerve pathways during compression of the spinal cord are: direct destruction of its substance by a pathological factor; compression of large blood vessels, due to which the nutrition of the nervous tissue is disrupted and necrosis develops. The longer the duration of compression, the more important the change in the intensity of blood flow plays.
Causes
Depending on the rate of development, compression of the spinal cord can be acute, subacute or chronic. Acute compression myelopathies develop with a sharp simultaneous compression of the brain substance with damage to its structures and pronounced neurological symptoms. From the moment of exposure to the damaging agent to the appearance of clinical symptoms, minutes or hours pass. The causes of this condition may be: spinal injuries, hemorrhage under the membranes of the spinal cord. Acute compression may also represent the outcome of a tumor process or an epidural abscess.
Among spinal injuries that can cause acute compression myelopathy syndrome, compression fractures of the vertebrae with dislocation of fragments occupy an important place. They occur with a strong axial load on the spine, for example, hitting the head on the bottom when diving in an unfamiliar place. Other injuries of the vertebral column are dislocations, subluxations, dislocations of the vertebrae relative to each other. In all these cases, the spinal cord is compressed by bone fragments or clamped in the spinal canal.
Hemorrhage under the membranes of the spinal cord can occur with back injuries, taking medications that reduce blood clotting activity (anticoagulants, for example, warfarin), as a complication of medical manipulations (lumbar puncture, epidural anesthesia). The spinal cord is located in a bone canal formed from holes in the vertebral body, and is surrounded by several shells. Blood from a damaged vessel, most often a vein, pours into the space between the bone and the dura mater of the spinal cord. Since the spinal canal is narrow enough, and the blood is not able to contract, the resulting hematoma pushes the spinal cord and squeezes it. Compression for several days to 1-2 weeks is conventionally called subacute compression. It can occur with the rupture of an intervertebral hernia, the rapid growth of tumor metastases, the formation of a purulent abscess.
A tumor of the spinal cord formed from its membranes or a neoplasm of vertebral tissues may not make itself felt for a long time. However, at the moment when the nerve tissue ceases to compensate for the damage, the syndrome of subacute compression of brain tissues develops. The same thing happens with the formation of purulent abscesses under the hard shell (most often occurs with tuberculosis and osteomyelitis of the spine). When the purulent swelling increases to a certain size, compression of the spinal cord occurs. With osteochondrosis of the spine, compression can be provided by fragments of a herniated disc or protrusion of a part of the fibrous ring, osteophytes (bone growths formed around the spinal canal and deforming it). A feature of chronic compression myelopathy is a slow increase in symptoms (over many years) and the ability of the spinal cord to compensate for damage for a long time.
Also, slow-growing tumors of the membranes and vertebrae can lead to gradual compression of the spinal cord.
Symptoms
In neurology, when making a diagnosis, the type of compression myelopathy is usually not indicated. However, in practice, it is customary to divide spinal cord injury from compression into 3 types: acute, subacute, chronic. Clinical manifestations of compression myelopathy directly depend on the type of compression, the spinal cord (cervical, thoracic, lumbar) and the location of the lesion in relation to the main nerve pathways.
The spinal cord is not functionally a homogeneous structure. In the front part of it there are motor neurons responsible for the movements of skeletal muscles; in the back there are sensitive nerve cells, and on the sides there are centers responsible for the work of internal organs. Depending on which part of the spinal cord is dominated by the pressure of the damaging factor, certain clinical symptoms will be expressed.
Acute, subacute and chronic forms of myelopathy differ in the rate of development of symptoms of the disease and the degree of severity of lost functions. The most severe in its manifestations is acute compression of the spinal cord. With it, there is a momentary loss of both the motor (flaccid paralysis develops) and the sensitive function of the parts of the body located below the damage zone, the work of the bladder and rectum is disrupted. This condition is called spinal shock. After a while, sluggish paralysis turns into spastic, pathological reflexes appear, convulsive muscle contractions, the development of persistent joint stiffness (contractures) is possible.
Compression in the cervical region. Chronic compression myelopathy, as a rule, begins with dull pains in the muscles of the neck, nape, upper chest, shoulders and arms. In the same areas, sensitivity disorders appear in the form of a feeling of crawling goosebumps, numbness. Later, muscle weakness in the hands joins, a decrease in tone, atrophy, twitching of individual muscle fibers may be observed. If the compression site is located in the first and second cervical segments, signs of facial nerve damage may be attached – a violation of sensitivity on the face. Cerebellar symptoms may occur – unstable gait, trembling of the hands.
Compression in the thoracic region. Spinal cord compressions in these parts occur relatively rarely. They are characterized by weakness and increased tone in the legs, as well as impaired sensitivity in the back, chest, and abdomen.
Compression myelopathy in the lumbar region. Chronic compression of the spinal cord in the lumbar region is characterized by pain in the muscles of the buttocks, hips, lower legs, changes in sensitivity in the same areas. With an increase in the time of exposure to the traumatic factor, weakness in the muscles, a decrease in their tone, a decrease in size (atrophy) is added. Gradually, a sluggish peripheral paresis develops in one or both legs.
Diagnostics
The gold standard in the diagnosis of compression myelopathy is the performance of CT and MRI of the spine. In the pictures, you can clearly see not only the causes that led to compression, but also the state of brain tissue.
If it is impossible to perform a tomographic examination, as well as if a spinal fracture or dislocation of the vertebrae is suspected, spinal x-ray column in three projections is used. According to the indications, a lumbar puncture is performed with a study of cerebrospinal fluid. Myelography can be used – a special radiological method based on the introduction of contrast into the subarachnoid space. After the distribution of the coloring substance, a series of images are taken, which allow us to determine at what level the compression of the spinal cord occurred.
Treatment
Acute and subacute myelopathy require immediate surgical treatment. Its purpose is to remove the agent injuring the spinal cord in the shortest possible time, allowing to reduce the degree of damage to the nerve pathways. Also, surgical intervention is necessary in case of chronic compression of the spinal cord by a tumor, regardless of the limitation period of the disease and the size of the neoplasm.
In chronic compression myelopathy caused by osteochondrosis, a neurologist can offer a two-stage treatment regimen. First, a course of conservative therapy is carried out, which includes: anti-inflammatory drugs; vitamins; drugs that restore cartilage tissue; physiotherapy; exercise therapy; wearing orthopedic corsets.
If conservative techniques do not have an effect or a progressive increase in symptoms of spinal cord compression is detected, surgical treatment is used. Depending on the cause of compression myelopathy, facetectomy, laminectomy, removal of a vertebral hernia and bone growths, replacement of a disk with an artificial endoprosthesis, removal of a hematoma and drainage of a spinal cord cyst, resection of an Urban wedge, etc. can be performed.
Regular spa treatment and annual rehabilitation courses in specialized medical institutions play an important role in the recovery of patients with compression myelopathy. Of great importance is the daily individual therapeutic gymnastics, compiled by a physical therapy doctor.
Prognosis and prevention
Despite the fact that acute compression myelopathy is the most severe form of pathology in its clinical manifestations, with timely treatment it is the most favorable prognosis. The reason for this is that in the acute form, deep changes in the muscles and peripheral nerves do not have time to occur. Therefore, with the elimination of the pathological factor, it is possible to quickly restore conduction through the spinal cord and complete the return of lost functions.
With chronic compression myelopathies, irreversible destructive changes occur in the muscles, nerves, as well as in the spinal cord itself – the proliferation of connective tissue, muscle atrophy. Therefore, even with the elimination of the squeezing factor, it is impossible to fully restore motor and sensory functions.
Taking into account the statistics of the causes leading to the development of spinal cord compression, the prevention of this serious complication is based on the correct diagnosis and treatment of spinal osteochondrosis and tumor diseases in the first place.