›Laminectomy and debridement plus antibiotics
›Without deficit: antibiotics alone may be considered in selected cases
›With deficit: surgical decompression strongly preferred
›Cauda equina syndrome
›Microdiscectomy or laminectomy as appropriate
›CES-R (retention): within 24–48 hours maximizes recovery of bladder function
›CES-I (incomplete): urgent within 24 hours
›Surgical decompression for MSCC — Patchell trial evidence
›Surgery plus radiation superior to radiation alone (Lancet 2005)
›Ambulatory rate: 84% surgery + RT vs 57% RT alone
›Duration of ambulation: 122 vs 13 days
›Bladder function retention: 78% vs 57%
›Surgical candidacy criteria
›Life expectancy greater than 3 months
›Solitary site of compression
›Radioresistant tumor (renal cell, melanoma, sarcoma)
›Spinal instability (SINS score 13 or greater)
›Prior maximum spinal radiation dose received
›External beam radiation therapy (EBRT) for MSCC
›Indication: MSCC in radiosensitive tumors not requiring surgery
›Radiosensitive: lymphoma, myeloma, seminoma, small cell lung, prostate
›Begin within 24 hours of diagnosis when possible
›Standard fractionation regimens
›30 Gy in 10 fractions — most common for good prognosis patients
›20 Gy in 5 fractions — rapid treatment for limited prognosis
›8 Gy in single fraction — palliation, very poor prognosis
›ASTRO guideline: EBRT recommended for bone metastases with cord compression (2024)
›Stereotactic body radiation therapy (SBRT)
›Highly conformal, high-dose-per-fraction treatment
›24 Gy in 2 fractions or 24–27 Gy in 3 fractions
›Superior local control vs conventional EBRT for radioresistant histologies
›Preferred after surgical stabilization when durable local control needed
Antibiotic therapy for epidural abscess
›Empiric antibiotic therapy
›Initiate after blood cultures but before imaging if rapidly deteriorating
›Vancomycin 25–30 mg/kg IV every 8–12 hours (target AUC 400–600)
›Covers MRSA and MSSA
›Adjust dose for renal function
›Ceftriaxone 2 g IV every 12 hours — gram-negative coverage
›Duration: 6–12 weeks total antibiotic therapy typical
›Definitive therapy based on culture and sensitivity
›MSSA: nafcillin or oxacillin 2 g IV every 4 hours
›MRSA: vancomycin or daptomycin 6 mg/kg IV daily
›Gram-negative: cefepime 2 g IV every 8 hours or meropenem 1 g IV every 8 hours
Supportive and pain management
›Pain management
›Opioids for severe pain — titrate to effect
›Morphine 0.1 mg/kg IV every 4 hours; adjust for renal function in elderly
›Hydromorphone 0.5–1 mg IV every 3–4 hours alternative
›Neuropathic agents
›Gabapentin 300 mg oral three times daily, titrate up as tolerated
›Pregabalin 75–150 mg oral twice daily
›NSAIDs — use with caution given GI and renal risks on steroids
›Spinal immobilization
›Cervical collar for cervical cord compression until stability determined
›Log-roll precautions for thoracolumbar injury
›Hard collar for known or suspected cervical instability
›VTE prophylaxis
›High risk in spinal cord injury — prophylaxis mandatory
›LMWH enoxaparin 40 mg SC daily (or 30 mg twice daily in high-risk SCI)
›Begin within 24–72 hours of injury when bleeding risk acceptable
›Sequential compression devices until pharmacologic prophylaxis initiated
›Bladder management
›Intermittent catheterization every 4–6 hours preferred over indwelling
›Reduces UTI risk in chronic SCI
›Monitor for autonomic dysreflexia in lesions above T6
›Bowel regimen
›Stool softener docusate sodium 100 mg twice daily
›Bisacodyl 10 mg oral or suppository as needed
›High-fiber diet and adequate hydration