Spinal cord compression medical therapy: Difference between revisions
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{{CMG}} ; {{AE}} {{ADG}} | {{CMG}} ; {{AE}} {{ADG}} | ||
==Overview== | ==Overview== | ||
All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with adjuvant therapy. In cases of compression caused by metastasis the treatment is mostly palliative. Antibiotics are indicated in cases of compression caused by an epidural abscess. | All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with [[adjuvant therapy]]. In cases of compression caused by [[metastasis]] the treatment is mostly palliative. [[Antibiotics]] are indicated in cases of compression caused by an [[epidural abscess]]. | ||
==Medical treatment== | ==Medical treatment== | ||
All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with adjuvant therapy. In cases of compression caused by metastasis the treatment is mostly palliative. Antibiotics are indicated in cases of compression caused by an epidural abscess. Adjuvant therapy includes:<ref name="pmid8410001">{{cite journal |vauthors=Johnston RA |title=The management of acute spinal cord compression |journal=J. Neurol. Neurosurg. Psychiatr. |volume=56 |issue=10 |pages=1046–54 |year=1993 |pmid=8410001 |pmc=1015230 |doi= |url=}}</ref><ref name="RopperLongo2017">{{cite journal|last1=Ropper|first1=Alexander E.|last2=Longo|first2=Dan L.|last3=Ropper|first3=Allan H.|title=Acute Spinal Cord Compression|journal=New England Journal of Medicine|volume=376|issue=14|year=2017|pages=1358–1369|issn=0028-4793|doi=10.1056/NEJMra1516539}}</ref> | All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with adjuvant therapy. In cases of compression caused by metastasis the treatment is mostly [[Palliative therapy|palliative.]] [[Antibiotics]] are indicated in cases of compression caused by an [[epidural abscess]]. Adjuvant therapy includes:<ref name="pmid8410001">{{cite journal |vauthors=Johnston RA |title=The management of acute spinal cord compression |journal=J. Neurol. Neurosurg. Psychiatr. |volume=56 |issue=10 |pages=1046–54 |year=1993 |pmid=8410001 |pmc=1015230 |doi= |url=}}</ref><ref name="RopperLongo2017">{{cite journal|last1=Ropper|first1=Alexander E.|last2=Longo|first2=Dan L.|last3=Ropper|first3=Allan H.|title=Acute Spinal Cord Compression|journal=New England Journal of Medicine|volume=376|issue=14|year=2017|pages=1358–1369|issn=0028-4793|doi=10.1056/NEJMra1516539}}</ref> | ||
===Epidural abscess=== | |||
===Antibiotics=== | ===Antibiotics=== | ||
*Preferred regimen (1): vancomycin 15-20 mg/kg IV q8-12h '''and''' metronidazole 500 mg IV q6h '''and''' cefotaxime 2 g IV q6h | *Preferred regimen (1): [[vancomycin]] 15-20 mg/kg IV q8-12h '''and''' [[metronidazole]] 500 mg IV q6h '''and''' [[cefotaxime]] 2 g IV q6h | ||
===Maintenance of fluid volume=== | ===Maintenance of fluid volume=== | ||
*Goal is to maintain systolic | *Goal is to maintain [[systolic blood pressure]] above 100 mmHg and an adequate [[urine output]] (0.5 mL/kg/hour) using fluid resuscitation, and vasopressors. | ||
*Preferred regimen: volume resuscitation using fluid replacement with isotonic crystalloid solution to a maximum of 2 L is the initial treatment of choice. | *Preferred regimen: volume resuscitation using fluid replacement with isotonic crystalloid solution to a maximum of 2 L is the initial treatment of choice. | ||
* | *Failure to improve with IV fluids [[Dopamine]] 1-50 micrograms/kg/minute IV q8h can be administered. | ||
===Corticosteroids=== | ===Corticosteroids=== | ||
*Preferred regimen: Methylprednisolone 30 mg/kg intravenously as a bolus given over 15 minutes followed by 5.4 mg/kg/hour intravenous infusion for 24 hours (if <3 hours since injury) or for 48 hours (if 3-8 hours since injury) | *Preferred regimen: [[Methylprednisolone]] 30 mg/kg intravenously as a bolus given over 15 minutes followed by 5.4 mg/kg/hour intravenous infusion for 24 hours (if <3 hours since injury) or for 48 hours (if 3-8 hours since injury) | ||
===Supportive treatment=== | |||
===Prophylaxis for venous thromboembolism=== | ===Prophylaxis for venous thromboembolism=== | ||
*Preferred regimen: Enoxaparin 40 mg subcutaneously q24h | *Preferred regimen: [[Enoxaparin]] 40 mg subcutaneously q24h | ||
*Alternative regimen (1): Heparin 5000 units subcutaneously q8-12h | *Alternative regimen (1): [[Heparin]] 5000 units subcutaneously q8-12h | ||
* | *[[Inferior vena cava filter|IVC filter]] in patients with contraindications to anticoagulation. | ||
===Prevention of stress ulcers=== | ===Prevention of stress ulcers=== | ||
*Preferred regimen (1): Omeprazole 40 mg orally q24h | *Preferred regimen (1): [[Omeprazole]] 40 mg orally q24h | ||
*Preferred regimen (2): Cimetidine 300 mg orally/intravenously q6h | *Preferred regimen (2): [[Cimetidine]] 300 mg orally/intravenously q6h | ||
*Preferred regimen (3): Famotidine 40 mg orally q24h (or) 20 mg intravenously q12h | *Preferred regimen (3): [[Famotidine]] 40 mg orally q24h (or) 20 mg intravenously q12h | ||
===Supportive therapies=== | ===Supportive therapies=== | ||
*Nutritional support | *[[Nutritional supplement|Nutritional support]] | ||
*Compression stockings or pneumatic intermittent compression | *[[Compression stockings]] or pneumatic intermittent compression | ||
*Bladder catheterization | *Bladder [[catheterization]] | ||
*Frequent repositioning of the patient for the prevention of pressure ulcers every 2 hours | *Frequent repositioning of the patient for the prevention of pressure ulcers every 2 hours | ||
Latest revision as of 14:53, 24 April 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]
Overview
All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with adjuvant therapy. In cases of compression caused by metastasis the treatment is mostly palliative. Antibiotics are indicated in cases of compression caused by an epidural abscess.
Medical treatment
All the patients with acute spinal cord compression must be admitted. The mainstay of treatment includes surgery along with adjuvant therapy. In cases of compression caused by metastasis the treatment is mostly palliative. Antibiotics are indicated in cases of compression caused by an epidural abscess. Adjuvant therapy includes:[1][2]
Epidural abscess
Antibiotics
- Preferred regimen (1): vancomycin 15-20 mg/kg IV q8-12h and metronidazole 500 mg IV q6h and cefotaxime 2 g IV q6h
Maintenance of fluid volume
- Goal is to maintain systolic blood pressure above 100 mmHg and an adequate urine output (0.5 mL/kg/hour) using fluid resuscitation, and vasopressors.
- Preferred regimen: volume resuscitation using fluid replacement with isotonic crystalloid solution to a maximum of 2 L is the initial treatment of choice.
- Failure to improve with IV fluids Dopamine 1-50 micrograms/kg/minute IV q8h can be administered.
Corticosteroids
- Preferred regimen: Methylprednisolone 30 mg/kg intravenously as a bolus given over 15 minutes followed by 5.4 mg/kg/hour intravenous infusion for 24 hours (if <3 hours since injury) or for 48 hours (if 3-8 hours since injury)
Supportive treatment
Prophylaxis for venous thromboembolism
- Preferred regimen: Enoxaparin 40 mg subcutaneously q24h
- Alternative regimen (1): Heparin 5000 units subcutaneously q8-12h
- IVC filter in patients with contraindications to anticoagulation.
Prevention of stress ulcers
- Preferred regimen (1): Omeprazole 40 mg orally q24h
- Preferred regimen (2): Cimetidine 300 mg orally/intravenously q6h
- Preferred regimen (3): Famotidine 40 mg orally q24h (or) 20 mg intravenously q12h
Supportive therapies
- Nutritional support
- Compression stockings or pneumatic intermittent compression
- Bladder catheterization
- Frequent repositioning of the patient for the prevention of pressure ulcers every 2 hours
References
- ↑ Johnston RA (1993). "The management of acute spinal cord compression". J. Neurol. Neurosurg. Psychiatr. 56 (10): 1046–54. PMC 1015230. PMID 8410001.
- ↑ Ropper, Alexander E.; Longo, Dan L.; Ropper, Allan H. (2017). "Acute Spinal Cord Compression". New England Journal of Medicine. 376 (14): 1358–1369. doi:10.1056/NEJMra1516539. ISSN 0028-4793.