22.3 Spinal Cord Compression

CPHON TCO V.F.4 tests spinal cord compression as a time-critical neurologic emergency. This is not the sarcoma-staging chapter and not a physical-therapy referral for “deconditioning.” A mass in the canal or vertebral body crushes cord or cauda equina. Hours matter. The nurse who parks progressive weakness on the overnight list for a “morning MRI” is the item the outline is written to catch.

A 4-year-old with high-risk neuroblastoma who will not walk, a teenager with Ewing sarcoma and night back pain, a child with Burkitt lymphoma and a palpable bladder, and a 7-year-old after medulloblastoma with new saddle numbness from drop metastases are the same emergency in different costumes. ONCC uses generic drug names. Steroids, alignment, bladder, and a scanner that does not wait until daylight are the CPHON product.

Recognition: pain, weakness, level, sphincters

The classic cluster:

• Back pain that is constant, worse lying down or at night, and not explained by a sports bruise. Pain recumbent is a red flag because venous engorgement in the epidural space rises when the child is flat. Growing pain does not wake a child with known cancer every night and does not produce a sensory level.
• Weakness: new limp, refusal to walk, climbing difficulty, or ascending paralysis. Toddlers simply stop standing. Adolescents may hide bowel accidents; ask.
• A sensory level: a band on the trunk where sensation changes. Map it. You do not need a perfect dermatome lecture; you need to notice that the child cannot feel the sheet below the umbilicus.
• Bowel and bladder change: urinary retention (palpable bladder, overflow), incontinence, constipation that is new and dense. Sphincter change means the compression is already injuring long tracts. It is late, not “mild.”

Any one finding in a child with a tumor that likes bone, epidural space, or CSF is enough to start the emergency path. Do not wait for a complete four-item textbook picture. Do not send a newly weak child to the playroom in a wagon “to see if it loosens up.”

Who compresses the cord in pediatrics

Adult teaching centers on prostate, breast, and lung metastases. Pediatric teaching does not. High-yield masses:

• Neuroblastoma, including dumbbell tumors that grow through neural foramina from the adrenal or posterior mediastinum into the canal. A toddler with abdominal neuroblastoma who stops moving the legs has an epidural component until MRI says otherwise.
• Sarcoma: Ewing sarcoma of vertebra or pelvis, osteosarcoma metastases, and soft-tissue sarcomas that invade bone. Night pain in a teenager with Ewing is not growing pain.
• Lymphoma, especially bulky non-Hodgkin lymphoma / Burkitt, which can melt with chemotherapy once steroids and a diagnosis are in motion—but the cord cannot wait for a week-long workup if the child is weakening now.
• Drop metastases from embryonal CNS tumors (medulloblastoma, some germ-cell and ependymal diseases) seeding the cord. New back pain or sphincter change after a posterior-fossa tumor is cord disease, not “postoperative deconditioning.”

Leukemia can infiltrate the canal; the same steroid-and-MRI logic applies. Do not invent a claim that only one histology ever compresses a pediatric cord.

Time-critical first actions: steroids, MRI, then local therapy

Give corticosteroids immediately as ordered—typically dexamethasone—when cord compression is the working diagnosis, especially with progressive weakness. Steroids reduce vasogenic edema around the deposit and can buy neurologic function while imaging and local therapy start. They do not replace MRI, radiation, surgery, or chemotherapy. They are not withheld “so the MRI will still show the mass.” The mass will still be there; the child’s legs may not be.

Obtain urgent MRI, often of the whole spine when drop mets or multilevel disease is possible. Do not wait for a morning MRI if weakness is progressive. A child who walked at dinner and cannot stand at 02:00 is a now scan, a now steroid, and a now call to neurosurgery, radiation oncology, and the primary oncologist—not a comment that “MRI opens at 07:30.” If MRI is truly unavailable, the team may use the best local imaging and treat on clinical grounds; nursing’s job is not to delay the steroid and the call.

Local therapy depends on the tumor:

• Chemotherapy can be the primary cytoreductive move for highly chemosensitive disease (lymphoma, many neuroblastomas, Ewing sarcoma) once the diagnosis is known and the spine is not mechanically collapsing.
• Radiation treats radiosensitive deposits and is used when surgery is not the first mechanical answer.
• Surgical decompression (and stabilization) is chosen for unknown histology that needs tissue, radioresistant masses, or an unstable spine.

You will not be scored on reciting one cooperative-group radiation-fraction table as ONCC fact. You will be scored on giving steroids, getting the MRI, and not letting progressive weakness wait.

Walk the 4-year-old with high-risk neuroblastoma. Two days of back pain worse lying down; tonight the child will not bear weight and the bladder is palpable. Dexamethasone as ordered, logroll, Foley, urgent MRI, oncology and neurosurgery at the same hour. Do not schedule “MRI after breakfast” because the child is tired. Walk the 13-year-old with vertebral Ewing who has a sensory level at the umbilicus: same clock. Walk the 7-year-old with treated medulloblastoma and new overflow incontinence: think drop mets, image the spine, do not lecture about toilet training.

Nursing bundle: logroll, Foley, DVT, skin

Until the spine is cleared or stabilized:

• Logroll with enough hands to keep shoulders, hips, and spine aligned. No twisting transfers into the scanner or onto a parent’s lap.
• Foley catheter (or another ordered bladder plan) for urinary retention. A palpable bladder is a cord finding, not a “shy child.” Measure output. Watch for overflow wetting that families mistake for diarrhea.
• Deep-vein thrombosis (DVT) prevention in the immobilized child, especially the adolescent: mechanical prophylaxis as policy allows, pharmacologic prophylaxis only if the team judges the platelet count and bleeding risk safe. Do not invent a single ONCC platelet cutoff. Do not skip mechanical methods because “kids do not clot”—older immobilized children do.
• Skin, heels, bowel regimen, and a turning clock that still respects alignment. Pain control so the child can lie for MRI without writhing and further injuring an unstable segment.

Do not sit a child with suspected unstable compression bolt upright for a wheelchair trip across campus. Do not ambulate “to prove it is behavioral.” Do not perform an LP to “decompress the cord”—that is not how epidural compression is treated and may be unsafe.

The CPHON product for TCO V.F.4 is a steroid that did not wait for daylight, an MRI that did not wait for the morning list, a logroll that kept the spine in one piece, a Foley that found the retention, and a child whose weakness was treated as time-critical rather than as growing pain.