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Thoracic cord compression can be caused by vertebral fractures and tumours, including cancer that has spread to the spine (spinal metastases). Thoracic cord compression can cause back pain, leg weakness or stiffness, a sensory level on the trunk with altered sensation below it, and bladder or bowel dysfunction. If the compression is high in the thoracic cord (for example around T5, the fifth thoracic level), the intercostal muscles (the muscles between the ribs) below it can be weakened. There may then be reduced chest expansion on inspiration. The higher the level, the greater the effect on breathing.
MRI of the whole spine is the key scan for suspected cord compression from cancer. NICE advises doing it as soon as possible, and always within 24 hours when there are neurological symptoms or signs. CT is used if MRI is not possible. A plain spinal X-ray is not used to diagnose or rule out cord compression from cancer. After a spinal injury in an adult with neurological signs, CT is done first and MRI follows. Thoracic spinal cord compression requires urgent assessment, because the loss of function can become permanent. If a person with cancer has symptoms or signs of cord compression, NICE advises contacting the metastatic spinal cord compression (MSCC) coordinator immediately and treating it as an oncological emergency. The coordinator is the first point of contact for the specialist MSCC service. Treatment depends on the cause and is planned by a specialist team. In metastatic cord compression, NICE advises 16 mg of dexamethasone (a steroid) as soon as possible when there are neurological symptoms or signs. Definitive treatment is surgery or radiotherapy (treatment with targeted radiation). Surgery relieves the pressure on the cord (decompression) and can stabilise the spine. Urgent radiotherapy, within 24 hours, is offered if the compression is not suitable for surgery. Painkillers (analgesia) and other supportive care are given alongside.
Cervical myelopathy is spinal cord dysfunction (loss of normal cord function) caused by compression of the cord in the neck, when the cervical spinal canal narrows. When age-related wear of the spine is the cause, it is called degenerative cervical myelopathy. The most common cause is spondylosis (age-related wear of the spine, which can cause a prolapsed disc, ligaments that thicken or turn to bone, and bony spurs called osteophytes). Other causes include spondylolisthesis (one vertebra slipping forward over the one below), congenital stenosis (a spinal canal that is narrow from birth), trauma or a tumour. Cervical myelopathy classically presents with a loss of balance, poor coordination, decreased dexterity and limb weakness/numbness. It can cause Lhermitte’s phenomenon: intermittent ‘electric shock’ sensations down the spine or into the limbs, made worse by neck flexion (bending the neck forwards).
Cervical myelopathy is diagnosed with a thorough neurological examination and an MRI scan. All patients should be assessed by a specialist surgeon (a neurosurgeon or an orthopaedic surgeon). Surgery to relieve the pressure on the cord (decompression) is recommended for moderate and severe disease, and when the disease is getting worse. For mild, stable disease, either surgery or a supervised trial of structured rehabilitation can be offered, with regular follow-up. The rate of progression varies, so surgery is advised if neurological symptoms worsen.
Image - An MRI scan of the neck of a dog (a Doberman) with cervical myelopathy. This is a veterinary image, not a human scan.
Creative commons source by Filippo Adamo [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Whiplash is a forceful hyperextension (bending the neck backwards) and hyperflexion (bending it forwards) injury of the cervical spine. It affects the soft tissues of the neck, such as the ligaments and muscles. It is commonly caused by a rapid deceleration for example in a car crash. It presents with neck pain and can additionally cause shoulder pain, lower back pain and headache. Spinal cord injury is not a typical feature: neurological symptoms or signs, or other features of a serious neck injury such as a fracture or dislocation, need urgent assessment. About half of people recover fully within 6 months, but about half may still have symptoms up to a year after the injury. In uncomplicated cases, patients are advised to keep the neck mobile, continue with normal activities and avoid soft collars, because restricting activity may delay recovery. Over the counter painkillers such as paracetamol or ibuprofen can be used once serious injury has been excluded (clinicians use the Canadian C-spine rule, a decision tool that shows who needs imaging of the neck). Physiotherapy (exercise-based treatment) can be considered. Patients are followed up regularly until the symptoms have resolved.
Diagram - The pathophysiology (how the injury happens) behind whiplash injury
Creative commons source by BruceBlaus [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
A ‘Hangman’s fracture’ is a fracture through the pars interarticulares (the bony bridges between the upper and lower joint surfaces of a vertebra) of the axis (C2 vertebra). It is usually caused by forcible hyperextension of the neck (bending the head too far backwards), classically in hanging. It is also seen after high-energy trauma, such as a road traffic collision, particularly in younger adults. Spinal cord injury is less common than with other cervical injuries because the fracture itself widens the spinal canal, so it typically presents with neck pain alone. Neurological injury is more likely if the facet joints (the small joints between vertebrae) are also dislocated.
Diagnosis is confirmed with a CT scan, the first-line imaging for suspected cervical spine injury in adults. MRI is added if there are neurological signs or ligament injury is suspected. Treatment depends on whether the fracture is stable (unlikely to move further). Stable fractures are treated with external immobilisation (such as a neck collar or brace). Unstable fractures need surgery.
Diagram - An X-ray of a Hangman's fracture with the first 4 cervical vertebrae highlighted
Creative commons source by Lucien Monfils, edited by Dr. Thomas Burnell [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
A ‘Jefferson’s fracture’ is a fracture of the atlas (C1 vertebra) caused by axial loading (a force pushing down through the top of the head), e.g. diving into a shallow pool. It commonly presents with upper neck pain. Neurological deficits may be absent. A normal neurological examination does not mean the fracture is stable (unlikely to move further), and it does not rule out other injuries, such as injury to the vertebral artery (the artery that runs up through the neck vertebrae to the brain). Diagnosis is confirmed with a CT scan, the first-line imaging for suspected cervical spine injury in adults. MRI is used to check the transverse ligament (the band that holds the odontoid process, the peg-like projection of the axis, against the front of the atlas), because this decides whether the fracture is stable. Treatment depends on stability. Most atlas fractures are stable and are treated with a soft or hard neck collar. Fractures with a damaged transverse ligament are unstable. They are treated with a halo (a rigid frame fixed to the skull that holds the neck still) or with surgery, which surgeons increasingly prefer.
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
Edited by: Dr. Maddie Swannack
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