Paeds · neurology-neurodisability-and-neuromuscular
Spinal cord compression and transverse myelitis
Also known as Malignant spinal cord compression · Metastatic spinal cord compression · Acute transverse myelitis · Longitudinally extensive transverse myelitis · Epidural spinal cord compression · Spinal epidural abscess
A fellowship approach to the child with an acute or subacute spinal cord syndrome. The first act is to recognise that a new back pain with a neurological deficit is a cord emergency until an emergency whole-spine MRI proves otherwise, and to separate the two great threats to the cord - a structural compressive lesion (tumour, epidural abscess, disc, haematoma) that is a surgical emergency from an intrinsic inflammatory transverse myelitis (idiopathic, neuromyelitis optica spectrum disorder, myelin-oligodendrocyte-glycoprotein antibody-associated disease, multiple sclerosis, post-infectious) that is a medical emergency. Treat the compressive lesion with dexamethasone and surgical decompression within twenty-four to forty-eight hours, plus radiotherapy or antibiotics as indicated, and treat the inflammatory lesion with high-dose intravenous methylprednisolone escalating to intravenous immunoglobulin or plasma exchange. Ambulation at presentation is the single strongest predictor of outcome, so the emergency MRI is never delayed while workup tests return.
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Red flags
- Any child with new or progressive back pain plus a neurological deficit - weakness, a sensory level, or sphincter disturbance - has a spinal cord syndrome until an emergency whole-spine MRI with gadolinium proves otherwise, and the imaging is never delayed while bloods or a lumbar puncture are organised
- Nocturnal back pain that wakes the child or is worse lying flat, in any child with a known malignancy or unexplained weight loss, is malignant spinal cord compression until excluded - the dexamethasone is started and the neurosurgical and oncological referral made in parallel with the imaging
- Back pain with fever, raising inflammatory markers, or an immunocompromised host is a spinal epidural abscess until excluded - Staphylococcus aureus predominates and the treatment is surgical drainage plus intravenous antibiotics
- Acute urinary retention with a sensory level, a rapidly progressive paraparesis, or spinal shock (a flaccid paraparesis with absent reflexes and a distended bladder) is an established cord lesion with a narrow window for salvage - move to emergency MRI within hours
- A spinal cord lesion spanning three or more vertebral segments on MRI is a longitudinally extensive transverse myelitis pointing to neuromyelitis optica spectrum disorder or myelin-oligodendrocyte-glycoprotein antibody-associated disease - never start a multiple-sclerosis disease-modifying therapy before the AQP4 and MOG antibody status is known
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Acute paediatric medicine
- Neurology and Neurodisability
- Neurology - recognise the acute spinal cord syndrome and the emergency whole-spine MRI principle
- Neuro-oncology and Neurosurgery - distinguish compressive from inflammatory cord lesions and lead the decompression and steroid pathway
- Acute care - lead the dexamethasone and surgical decompression or methylprednisolone pathway
- Neurology 5-8
- Emergency care
- Clinical Applications
- Long Cases
- Short Cases
- 9. Neurology: acute spinal cord syndromes
- 10. Surgery: surgical emergencies of the spine
- 1. Clinical evaluation and communication
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- Neurodisability
- Communication
- History
- General Pediatrics Content Outline - D15 Neurology (6%)
- General Pediatrics Content Outline - D17 Oncology (5%)
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Medical Knowledge 2: Neurologic Disorders
- Systems-Based Practice 1: Patient Safety
- Medical Expert
- Pediatrics: Neurology - acute spinal cord syndromes
- Pediatrics: Hematology/Oncology - oncologic emergencies
A previously well nine-year-old wakes in the night with thoracic back pain that will not settle, and by morning is dragging her left leg; her bladder will not empty. Across town, a four-year-old being treated for Ewing sarcoma refuses to walk, and a feverish teenager with an indwelling central line develops acute urinary retention and a band of numbness around the chest. In every one of these rooms the unifying question is the same - is the spinal cord being crushed from outside or inflamed from within, and is there still time to save it? The fellowship task is to convert that bedside alarm into one action - the emergency whole-spine MRI - and then into the matched treatment: dexamethasone and the operating theatre for a compressive lesion, high-dose methylprednisolone for an inflammatory one. [1] [7]
Anchor the whole topic with CORD - Compression versus inflammation is the fork that only the emergency MRI resolves, Order the whole-spine MRI the moment you suspect a cord syndrome and never delay it for bloods, Recognise the symptom sequence of pain then weakness then a sensory level then sphincter loss, and Dexamethasone for compression, methylprednisolone for inflammation - with decompression within twenty-four to forty-eight hours and ambulation at presentation as the single predictor of outcome. [1] [7]
Overview & Definition
The clinician's first act is to recognise that an acute or subacute spinal cord syndrome is not one disease but two threats that share a presentation and diverge in treatment. The two threats are a structural compressive lesion, in which something outside the cord presses on it, and an intrinsic inflammatory lesion, in which the immune system attacks the cord substance itself. Both produce the same bedside picture - back pain, limb weakness, a sensory level, and bladder and bowel disturbance - and both can destroy the cord within hours to days. The single test that separates them is the emergency whole-spine MRI with gadolinium, which shows the mass or abscess outside the cord in the compressive case and a swollen, enhancing lesion within the cord in the inflammatory case. [1] [7]
Why does this fork matter at the bedside? Because the two threats need opposite treatments and the wrong treatment loses the cord. A compressive lesion is a surgical emergency: the mass must be removed or the cord decompressed within twenty-four to forty-eight hours, backed by dexamethasone to buy time and by radiotherapy or antibiotics matched to the cause. An inflammatory transverse myelitis is a medical emergency: the attack is calmed with high-dose corticosteroids, escalating to intravenous immunoglobulin or plasma exchange when steroids fail. Giving steroids alone to a child with an abscess or a tumour, or sending a child with transverse myelitis to the operating theatre, are the two errors the emergency MRI is designed to prevent. [1] [9]
What makes this group worth knowing in depth is that the modern antibody-led framework has transformed the inflammatory side of the fork. A transverse myelitis is no longer a single waste-basket diagnosis: it is now classified by its cause into idiopathic disease and the antibody-associated disorders - neuromyelitis optica spectrum disorder driven by aquaporin-4 IgG, myelin-oligodendrocyte-glycoprotein antibody-associated disease driven by MOG-IgG, and the spinal-cord attacks of multiple sclerosis - each with a different long-term treatment and a different prognosis. The general paediatrician's role is to secure the emergency MRI, begin the matched acute treatment, and hand over to neurosurgery or paediatric neurology with the cause already in flight. [3] [5]
References12ShowHide
- [1]Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology, 2002.PMID 12236201
- [2]Pidcock FS, Krishnan C, Crawford TO, Salorio CF, Trovato M, Kerr DA, et al. Acute transverse myelitis in childhood: center-based analysis of 47 cases. Neurology, 2007.PMID 17470749
- [3]Wingerchuk DM, Banwell B, Bennett JL, Cabre P, Carroll W, Chitnis T, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology, 2015.PMID 26092914
- [4]Banwell B, Bennett JL, Marignier R, Kim HJ, Brilot F, Flanagan EP, et al. Diagnosis of myelin oligodendrocyte glycoprotein antibody-associated disease: International MOGAD Panel proposed criteria. Lancet Neurol, 2023.PMID 36706773
- [5]Marignier R, Hacohen Y, Cobo-Calvo A, et al. Myelin-oligodendrocyte glycoprotein antibody-associated disease. Lancet Neurol, 2021.PMID 34418402
- [6]Thompson AJ, Banwell BL, Barkhof F, Carroll WM, Coetzee T, Comi G, et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol, 2018.PMID 29275977
- [7]Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol, 2005.PMID 15629272
- [8]Savage P, Sharkey R, Kua T, et al. Malignant spinal cord compression: NICE guidance, improvements and challenges. QJM, 2014.PMID 24336849
- [9]Loblaw DA, Laperriere NJ. Emergency treatment of malignant extradural spinal cord compression: an evidence-based guideline. J Clin Oncol, 1998.PMID 9552073
- [10]Ertekin M, Temuroglu A, Aksoy GR, et al. Spinal cord compression at initial presentation in pediatric oncology patients: neurological sequelae and survival outcomes. J Neurooncol, 2026.PMID 41826763
- [11]Riquelme A, Werner J, Zimmermann M, et al. Non-Hodgkin lymphoma presenting with spinal cord compression: A population-based analysis of the NHL-BFM study group. Pediatr Blood Cancer, 2024.PMID 38961598
- [12]Darouiche RO. Spinal epidural abscess. N Engl J Med, 2006.PMID 17093252