Cord Compression & Cauda Equina

• Weakness with a sensory level and sphincter loss means cord compression: get an emergent MRI, give dexamethasone 16 mg only for neurological symptoms or haematological malignancy (NICE NG234 2023; not for pain alone, and controversial in trauma), and arrange urgent decompression; single-fraction 8 Gy RT remains standard for malignant disease.
• Cauda equina: saddle anesthesia with retention/overflow means MRI within hours; a surgical emergency.
• Neurogenic shock: bradycardia + hypotension + warm skin; pressors (noradrenaline) ± atropine.
• Cervical injuries: watch for respiratory failure; C3–5 keeps the diaphragm alive.

Initial Approach to Suspected Spinal Cord Injury (SCI)/Acute Myelopathy

• SCI or myelopathy suspected: new weakness (both legs or all four extremities) · sensory deficits · cerebral function intact · sphincter dysfunction (check rectal tone, catheterize the bladder)
• Initial stabilization: immobilize when cervical or thoracic cord lesions · manage airway, breathing, circulation
• Imaging: CT of spine for suspected bony abnormalities (fractures) · MRI of spine when soft tissue or cord involvement possible (hematoma, abscess, neoplasms)
• Trauma: neurosurgery consult
• Epidural hematoma: neurosurgery consult · immediately reverse anticoagulation using guideline-directed reversal (e.g., 4-factor PCC + vitamin K for warfarin; specific reversal agents for DOACs when indicated)
• Epidural abscess: broad spectrum antibiotics · neurosurgery consult · search for a source (blood cultures, echocardiogram, CT)
• Tumor or metastases: dexamethasone 10 mg IV, then 4 mg IV q 6 hours · neurosurgery consult · search for the primary tumor
• Demyelinating lesions: neurology consult · methylprednisolone 1 g IV daily for 5 days
• Spinal cord infarct: neurology consult · consider anticoagulation (with known embolic source) · consider lumbar drain · consider keeping mean arterial pressure >70–80 mm Hg