Loss of pinprick sensation or a different reaction to pinprick in the lower extremities. The patient may have a sensory “level” to pinprick. There may be a temperature “level” to a cool object, or a “sweat” level.

Altered position or vibration sensation below the level of the lesion.

Tenderness over the spine is a helpful sign in determining the level of the lesion.

Hyperreflexia below the level of the lesion. If the lesion is in the thoracic cord, legs are hyperreflexic compared with arms.

Signs are usually bilateral (i.e., both legs, both arms) rather than unilateral.

Definite weakness.

Definite hyperreflexia.

Upgoing toes.

A sensory level to pinprick, temperature, or vibration. It is often helpful to check vibration sense up and down the spine in search of a level. Check for a sweat level.

Loss of anal sphincter tone and voluntary contraction, absent abdominal reflexes, and absent bulbocavernosus reflex.

Urinary retention, or incontinence of bowel or bladder.

Loss of superficial abdominal reflexes.

Perform a careful neurologic examination and estimate the level of the cord lesion. Note that the lesion may lie above the sensory level, because of partial injury and lamination of sensory tracts. Also note that the dermatomal level does not correspond to the bony level because of the termination of the cord at about T12-L1 (Fig. 9.1).

Check for primary tumor sites (e.g., careful examination of breast, nodes, and prostate; chest radiograph; and routine laboratory studies, including complete blood count, liver function test, and prostate specific antigen). Consider at a later time further imaging with CT chest, abdomen, pelvis, PET scanning, but do not delay treatment for such investigations.

Plain films of the spine may reveal (i) vertebral collapse or subluxation, (ii) bony erosion secondary to tumor, or (iii) calcification (meningioma).

Urgent consultation with a neurologist or neurosurgeon, and a radiation therapist is needed.

Perform an MRI scan of the spine with sagittal cuts through the entire spine and axial cuts through suspicious areas. If the patient cannot tolerate an MRI, a computed tomographic myelogram usually is done. MRI has become the diagnostic study of choice in acute cord compression. If myelography is necessary and if a spinal block is seen on myelogram, image above the block using a cisternal puncture to examine the extent of disease.