A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis
Reviewer: Ryan Smith, MD
Last Modified: June 2, 2003
Presenter: R. Patchell Presenter's Affiliation: University of Kentucky Type of Session: Plenary
Cord compression by metastatic disease is a large problem in cancers that has the propensity to spread to bone.
As prostate cancer, breast cancer, and lung cancer all commonly spread to bone, this represents a huge problem
Cord compression is an oncologic emergency that, if not treated correctly and promptly, can and will result in many neurologic deficiencies with a resultant (dramatic) decrease in quality of life
Radiation therapy tends to arrest disease, but only rarely reverses neurologic sequelae
Previously, surgical treatment for cord compression consisted of laminectomy, which rarely helps and often results in spinal destabilization. However, new methods of direct decompression has been developed with increased efficacy demonstrated in smaller studies
This study investigates direct decompression on the treatment of cord compression
Materials and Methods
101 patients with cord compression from metastatic tumor spread comprised the study group
Patients were randomized to decompressive surgery followed by radiotherapy within 14 days vs. radiotherapy alone
Treatment was required to start within 24 hours of MRI diagnosis
Patients had to have at least one sign or symptom other than pain and were required to have only one site of cord compression (not cauda equinal)
Patients could not be paraplegic for >48 hours or have extremely radioresponsive tumors (e.g. lymphoma, myeloma)
Crossover into the surgical arm was allowed if deterioration of neurologic function continued after beginning radiation therapy
Primary endpoint was maintenance of ambulation, with secondary endpoints of continence, survival, the Frankel and American Spinal Injury Associated Scores (measuring neurologic function), and the ASIA score (measuring muscular function)
Patients treated with decompressive surgery retained the ability to walk significantly longer than those treated with radiation alone (126 days vs. 35 days, p=.006)
Patients treated with surgery had higher maintainenance of continence and higher neurological and muscular function scores
Patients treated with decompressive surgery had a 3 fold reduction in amount of corticosteroids required and a 12 fold reduction in the amount of narcotics used
There was a trend toward increased survival in the surgical arm (129 days vs. 100 days, p=.08)
In the 32 patients entered on study who had already lost the ability to walk, 56% regained function if treated by surgery
In the 10 patients who crossed over onto the surgical arm, 3 of them regained the ability to walk
Toxicities were minor
Patients with cord compression treated with decompressive surgery and postoperative radiation therapy maintained the ability to walk significantly longer than those treated with radiation alone
If function was already lost, there is a greater than 50% chance of regaining function with surgical decompression, which was three times the rate of radiation alone
There was a drastic reduction in steroid and narcotic use
Surgical decompression works better as an initial treatment, rather than salvage therapy
This report shows impressive results for surgical decompression with postoperative radiation therapy for patients with cord compression. This is an extremely important finding for patients in terms of quality of life. Noted is the patients' maintenance of their ability to walk was almost the length of their survival, meaning that patients had full function when they succumbed to their disease. Another impressive result is that >50% of patients regained the ability to walk with surgical treatment. This is substantially better than any data previously reported. In addition, there is much less narcotic use, leading to the assumption that surgery led to quicker or longer lasting pain relief. However, many patients with cord compression from metastatic spread have end-stage disease. Therefore, they are commonly very ill and lack the conditioning to undergo decompression, from either a surgical or anesthesia standpoint. Hence, though this data is impressive, the number of patients it will actually apply to remains to be seen. For the vast number of patients who will not be surgical candidates, immediate radiation therapy will remain the treatment of choice.
Oncolink's ASCO Coverage made possible by an unrestricted Educational Grant from Bristol-Myers Squibb Oncology.
Today - From 2000 to 2009 there was an increase in surgical treatment for spinal metastasis in the United States, which was accompanied by increased complication rates and costs, according to a study published in the Sept. 1 issue of The Spine Journal.