Rationale

There are two treatment modalities available for metastatic spinal cord compression: radiation and decompressive surgery. Decompressive surgery for metastatic spinal cord compression is an invasive and risky intervention relative to radiation alone, thus operative intervention may be justified only if the functional outcomes for the patient are improved when decompressive surgery is combined with radiation. This question of whether to offer surgery is pondered over daily by all physicians who regularly care for patients with metastatic spinal cord compression.

Clinical comment

For the patient in this scenario, making a shared, informed decision with his healthcare team of whether to undergo the risks of decompressive surgery versus pursuing radiation treatment alone is a critical branch point in his treatment course and can only be made once he understands what the benefits might be of taking on the risk of surgical decompression.

Available literature and quality of the evidence

There is one level I randomized controlled trial that addresses the question at hand published by Patchell et al. in 2005 comparing ambulatory function, urinary continence, muscle strength, functional status, corticosteroid and opioid analgesic use, and short‐term (30‐day) survival between patients undergoing radiotherapy alone and direct decompressive surgery followed by radiotherapy for metastatic extradural spinal cord compression.¹ The study enrolled only adult patients with tissue‐proven noncentral nervous system (CNS) origin metastatic spinal cord compression affecting only a single area of the spine with at least one neurological sign or symptom (inclusive of pain) and who had not been paraplegic for greater than 48 hours prior to study enrollment and who did not have a particularly radiosensitive tumor (lymphoma, leukemia, multiple myeloma, germ cell tumor). This is the only level I evidence available.

Findings

The primary outcome from Patchell’s study is ambulatory function post treatment.¹ In the radiotherapy alone group, post‐treatment ambulatory rate was 57% (29/51) versus 84% (42/50) in the surgery followed by radiotherapy group. The odds ratio (OR) for post‐treatment ambulatory function with surgery followed by radiotherapy was 6.2 (95% confidence interval [CI]: 2.0–19.8) with p = 0.001. This fell below the predetermined criteria for early termination, so the trial was stopped early. Patients who underwent surgery plus radiation also retained the ability to ambulate for a longer period of time (median 122 days vs 13 days; p = 0.003).

In terms of secondary outcomes, patients who underwent surgery plus radiation maintained urinary continence for longer (156 days vs 17 days) with relative risk (RR) of 0.47 (95% CI: 0.25–0.87). Surgical patients also maintained their functional status for longer, as measured by the ASIA score (566 days vs 72 days) with RR = 0.28 (95% CI: 0.13–0.61). Survival time was longer in patients undergoing surgery of 126 days vs 100 days with RR = 0.60 (95% CI: 0.38 – 0.96). All differences were statistically significant at p <0.05.

Resolution of clinical scenario

• In patients with metastatic carcinoma resulting in spinal cord compression at a single level who have not been paraplegic for greater than 48 hours, direct decompressive surgery followed by radiation results in an increased rate of ambulation, increased rate of retaining the ability to ambulate (if relevant), decreased rate of urinary incontinence, increased rate of preservation of neurologic functional status, and increased survival time relative to radiation alone.
  
• Patients who meet these criteria should be offered direct decompressive surgery followed by radiation.
  
• This recommendation cannot necessarily be made for patients who are deemed to be poor candidates for surgery, have myelomatous disease (or other highly radiosensitive tumors), do not have any neurologic compromise, have had a more extended period of paraplegia, or who have multiple sites of spinal cord compression.

Rationale

The local tumor burden within the spine from metastatic disease occupies space within the spinal elements and can thus be a destructive presence that compromises the stability of the spine itself, but determining when spinal stability has been compromised by metastatic disease to the point of potentially benefiting from surgical stabilization is difficult to ascertain.

Clinical comment

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