UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Treatment and prognosis of neoplastic epidural spinal cord compression, including cauda equina syndrome

Authors
David Schiff, MD
Paul Brown, MD
Mark Edwin Shaffrey, MD
Section Editor
Patrick Y Wen, MD
Deputy Editors
April F Eichler, MD, MPH
Diane MF Savarese, MD

INTRODUCTION

Neoplastic epidural spinal cord compression (ESCC) is a common complication of cancer that can cause pain and potentially irreversible loss of neurologic function. Although the degree of thecal sac compression required for the designation of ESCC has been variably defined, we consider any radiologic evidence of indentation of the thecal sac to be evidence for ESCC [1,2]. High-grade ESCC refers to deformation of the spinal cord itself.

The treatment and prognosis of ESCC are discussed here. The clinical features and diagnostic approach to patients with possible ESCC are discussed separately. (See "Clinical features and diagnosis of neoplastic epidural spinal cord compression, including cauda equina syndrome".)

PRIMARY TREATMENT

The goals of treatment for patients with ESCC include pain control, avoidance of complications, and the preservation or improvement of neurologic function utilizing treatments appropriate to the patient's burden of disease, life expectancy, and values.

Impact of treatment delay on posttreatment ambulation — The single most important prognostic factor for regaining ambulation after treatment of an ESCC is pretreatment neurologic status [3-11]. In a review of 1392 patients presenting between 1963 and 1982, only 32 percent were ambulatory at the onset of therapy [12]. Similar results were noted in a study published in 1998 in which only 33 percent of patients were ambulatory and 53 percent catheter-free at the time of therapy, indicating that little improvement had been made in the early detection of ESCC [13]. These patients had back pain for a median of two months before ESCC was diagnosed, and there was a 10-day delay between the onset of neurologic symptoms and the start of therapy. The majority of patients had deterioration of motor or bladder function during the delay.

Thus, educating cancer patients and their families as well as responsible health care providers about symptoms that warrant immediate evaluation, particularly otherwise unexplained back pain, might improve neurologic outcomes. More recent data suggest that these numbers are improving; in a 2010 study, 62 percent of patients who presented with an ESCC were ambulatory at the time of diagnosis [14].

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Aug 15 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Loblaw DA, Perry J, Chambers A, Laperriere NJ. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: the Cancer Care Ontario Practice Guidelines Initiative's Neuro-Oncology Disease Site Group. J Clin Oncol 2005; 23:2028.
  2. Schiff D, O'Neill BP, Wang CH, O'Fallon JR. Neuroimaging and treatment implications of patients with multiple epidural spinal metastases. Cancer 1998; 83:1593.
  3. Maranzano E, Latini P. Effectiveness of radiation therapy without surgery in metastatic spinal cord compression: final results from a prospective trial. Int J Radiat Oncol Biol Phys 1995; 32:959.
  4. Bach F, Larsen BH, Rohde K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107:37.
  5. Helweg-Larsen S, Johnsen A, Boesen J, Sørensen PS. Radiologic features compared to clinical findings in a prospective study of 153 patients with metastatic spinal cord compression treated by radiotherapy. Acta Neurochir (Wien) 1997; 139:105.
  6. Maranzano E, Latini P, Beneventi S, et al. Comparison of two different radiotherapy schedules for spinal cord compression in prostate cancer. Tumori 1998; 84:472.
  7. Kim RY, Spencer SA, Meredith RF, et al. Extradural spinal cord compression: analysis of factors determining functional prognosis--prospective study. Radiology 1990; 176:279.
  8. Greenberg HS, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: results with a new treatment protocol. Ann Neurol 1980; 8:361.
  9. Maranzano E, Latini P, Checcaglini F, et al. Radiation therapy of spinal cord compression caused by breast cancer: report of a prospective trial. Int J Radiat Oncol Biol Phys 1992; 24:301.
  10. Maranzano E, Latini P, Checcaglini F, et al. Radiation therapy in metastatic spinal cord compression. A prospective analysis of 105 consecutive patients. Cancer 1991; 67:1311.
  11. Martenson JA Jr, Evans RG, Lie MR, et al. Treatment outcome and complications in patients treated for malignant epidural spinal cord compression (SCC). J Neurooncol 1985; 3:77.
  12. Findlay GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry 1984; 47:761.
  13. Husband DJ. Malignant spinal cord compression: prospective study of delays in referral and treatment. BMJ 1998; 317:18.
  14. Rades D, Huttenlocher S, Dunst J, et al. Matched pair analysis comparing surgery followed by radiotherapy and radiotherapy alone for metastatic spinal cord compression. J Clin Oncol 2010; 28:3597.
  15. Fadul CE, Lemann W, Thaler HT, Posner JB. Perforation of the gastrointestinal tract in patients receiving steroids for neurologic disease. Neurology 1988; 38:348.
  16. George R, Jeba J, Ramkumar G, et al. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database Syst Rev 2008; :CD006716.
  17. Loblaw DA, Mitera G, Ford M, Laperriere NJ. A 2011 updated systematic review and clinical practice guideline for the management of malignant extradural spinal cord compression. Int J Radiat Oncol Biol Phys 2012; 84:312.
  18. Ushio Y, Posner R, Kim JH, et al. Treatment of experimental spinal cord compression caused by extradural neoplasms. J Neurosurg 1977; 47:380.
  19. Delattre JY, Arbit E, Rosenblum MK, et al. High dose versus low dose dexamethasone in experimental epidural spinal cord compression. Neurosurgery 1988; 22:1005.
  20. Sørensen S, Helweg-Larsen S, Mouridsen H, Hansen HH. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomised trial. Eur J Cancer 1994; 30A:22.
  21. Vecht CJ, Haaxma-Reiche H, van Putten WL, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology 1989; 39:1255.
  22. Graham PH, Capp A, Delaney G, et al. A pilot randomised comparison of dexamethasone 96 mg vs 16 mg per day for malignant spinal-cord compression treated by radiotherapy: TROG 01.05 Superdex study. Clin Oncol (R Coll Radiol) 2006; 18:70.
  23. Heimdal K, Hirschberg H, Slettebø H, et al. High incidence of serious side effects of high-dose dexamethasone treatment in patients with epidural spinal cord compression. J Neurooncol 1992; 12:141.
  24. Maranzano E, Latini P, Beneventi S, et al. Radiotherapy without steroids in selected metastatic spinal cord compression patients. A phase II trial. Am J Clin Oncol 1996; 19:179.
  25. Lee SH, Cox KM, Grant R, et al. Patient positioning (mobilisation) and bracing for pain relief and spinal stability in metastatic spinal cord compression in adults. Cochrane Database Syst Rev 2012; :CD007609.
  26. Wang JC, Boland P, Mitra N, et al. Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine 2004; 1:287.
  27. Mendel E, Bourekas E, Gerszten P, Golan JD. Percutaneous techniques in the treatment of spine tumors: what are the diagnostic and therapeutic indications and outcomes? Spine (Phila Pa 1976) 2009; 34:S93.
  28. Mut M, Schiff D, Shaffrey ME. Metastasis to nervous system: spinal epidural and intramedullary metastases. J Neurooncol 2005; 75:43.
  29. Fehlings MD, Furlan J, Bilsky M, et al. Defining spinal instability of the cervical spine: Can the available evidence guide clinical practice? Spine 2014 [in press].
  30. Weber MH, Burch S, Buckley J, et al. Instability and impending instability of the thoracolumbar spine in patients with spinal metastases: a systematic review. Int J Oncol 2011; 38:5.
  31. Fisher CG, DiPaola CP, Ryken TC, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976) 2010; 35:E1221.
  32. Fourney DR, Frangou EM, Ryken TC, et al. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol 2011; 29:3072.
  33. Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 1980; 53:741.
  34. Fehlings MG, Nater A, Tetreault L, et al. Survival and Clinical Outcomes in Surgically Treated Patients With Metastatic Epidural Spinal Cord Compression: Results of the Prospective Multicenter AOSpine Study. J Clin Oncol 2016; 34:268.
  35. Siegal T, Siegal T, Robin G, et al. Anterior decompression of the spine for metastatic epidural cord compression: a promising avenue of therapy? Ann Neurol 1982; 11:28.
  36. Harrington KD. Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy. Clin Orthop Relat Res 1988; :177.
  37. Sundaresan N, Sachdev VP, Holland JF, et al. Surgical treatment of spinal cord compression from epidural metastasis. J Clin Oncol 1995; 13:2330.
  38. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366:643.
  39. Sioutos PJ, Arbit E, Meshulam CF, Galicich JH. Spinal metastases from solid tumors. Analysis of factors affecting survival. Cancer 1995; 76:1453.
  40. Prasad D, Schiff D. Malignant spinal-cord compression. Lancet Oncol 2005; 6:15.
  41. Chi JH, Gokaslan Z, McCormick P, et al. Selecting treatment for patients with malignant epidural spinal cord compression-does age matter?: results from a randomized clinical trial. Spine (Phila Pa 1976) 2009; 34:431.
  42. Rades D, Rudat V, Veninga T, et al. A score predicting posttreatment ambulatory status in patients irradiated for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys 2008; 72:905.
  43. van den Bent MJ. Surgical resection improves outcome in metastatic epidural spinal cord compression. Lancet 2005; 366:609.
  44. Klish DS, Grossman P, Allen PK, et al. Irradiation of spinal metastases: should we continue to include one uninvolved vertebral body above and below in the radiation field? Int J Radiat Oncol Biol Phys 2011; 81:1495.
  45. Maranzano E, Bellavita R, Rossi R, et al. Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol 2005; 23:3358.
  46. Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes? Spine (Phila Pa 1976) 2009; 34:S78.
  47. Zelefsky MJ, Scher HI, Krol G, et al. Spinal epidural tumor in patients with prostate cancer. Clinical and radiographic predictors of response to radiation therapy. Cancer 1992; 70:2319.
  48. Rades D, Walz J, Stalpers LJ, et al. Short-course radiotherapy (RT) for metastatic spinal cord compression (MSCC) due to renal cell carcinoma: results of a retrospective multi-center study. Eur Urol 2006; 49:846.
  49. Rades D, Heidenreich F, Karstens JH. Final results of a prospective study of the prognostic value of the time to develop motor deficits before irradiation in metastatic spinal cord compression. Int J Radiat Oncol Biol Phys 2002; 53:975.
  50. Zaidat OO, Ruff RL. Treatment of spinal epidural metastasis improves patient survival and functional state. Neurology 2002; 58:1360.
  51. Helweg-Larsen S, Rasmusson B, Sørensen PS. Recovery of gait after radiotherapy in paralytic patients with metastatic epidural spinal cord compression. Neurology 1990; 40:1234.
  52. Katagiri H, Takahashi M, Inagaki J, et al. Clinical results of nonsurgical treatment for spinal metastases. Int J Radiat Oncol Biol Phys 1998; 42:1127.
  53. Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol 1978; 3:40.
  54. Tomita T, Galicich JH, Sundaresan N. Radiation therapy for spinal epidural metastases with complete block. Acta Radiol Oncol 1983; 22:135.
  55. Rades D, Lange M, Veninga T, et al. Preliminary results of spinal cord compression recurrence evaluation (score-1) study comparing short-course versus long-course radiotherapy for local control of malignant epidural spinal cord compression. Int J Radiat Oncol Biol Phys 2009; 73:228.
  56. Rades D, Stalpers LJ, Veninga T, et al. Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression. J Clin Oncol 2005; 23:3366.
  57. Maranzano E, Trippa F, Casale M, et al. 8Gy single-dose radiotherapy is effective in metastatic spinal cord compression: results of a phase III randomized multicentre Italian trial. Radiother Oncol 2009; 93:174.
  58. Rades D, Huttenlocher S, Šegedin B, et al. Single-Fraction Versus 5-Fraction Radiation Therapy for Metastatic Epidural Spinal Cord Compression in Patients With Limited Survival Prognoses: Results of a Matched-Pair Analysis. Int J Radiat Oncol Biol Phys 2015; 93:368.
  59. Rades D, Karstens JH, Hoskin PJ, et al. Escalation of radiation dose beyond 30 Gy in 10 fractions for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys 2007; 67:525.
  60. Rades D, Stalpers LJ, Schulte R, et al. Defining the appropriate radiotherapy regimen for metastatic spinal cord compression in non-small cell lung cancer patients. Eur J Cancer 2006; 42:1052.
  61. Rades D, Hoskin PJ, Stalpers LJ, et al. Short-course radiotherapy is not optimal for spinal cord compression due to myeloma. Int J Radiat Oncol Biol Phys 2006; 64:1452.
  62. Rades D, Šegedin B, Conde-Moreno AJ, et al. Radiotherapy With 4 Gy × 5 Versus 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE-2 Trial (ARO 2009/01). J Clin Oncol 2016; 34:597.
  63. Rades D, Fehlauer F, Schulte R, et al. Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression. J Clin Oncol 2006; 24:3388.
  64. Rades D, Veninga T, Stalpers LJ, et al. Outcome after radiotherapy alone for metastatic spinal cord compression in patients with oligometastases. J Clin Oncol 2007; 25:50.
  65. Rades D, Douglas S, Veninga T, et al. Validation and simplification of a score predicting survival in patients irradiated for metastatic spinal cord compression. Cancer 2010; 116:3670.
  66. Rades D, Douglas S, Huttenlocher S, et al. Validation of a score predicting post-treatment ambulatory status after radiotherapy for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys 2011; 79:1503.
  67. Rades D, Hoskin PJ, Karstens JH, et al. Radiotherapy of metastatic spinal cord compression in very elderly patients. Int J Radiat Oncol Biol Phys 2007; 67:256.
  68. Sahgal A, Atenafu EG, Chao S, et al. Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis with a focus on radiation dose and the spinal instability neoplastic score. J Clin Oncol 2013; 31:3426.
  69. Cunha MV, Al-Omair A, Atenafu EG, et al. Vertebral compression fracture (VCF) after spine stereotactic body radiation therapy (SBRT): analysis of predictive factors. Int J Radiat Oncol Biol Phys 2012; 84:e343.
  70. Thibault I, Al-Omair A, Masucci GL, et al. Spine stereotactic body radiotherapy for renal cell cancer spinal metastases: analysis of outcomes and risk of vertebral compression fracture. J Neurosurg Spine 2014; 21:711.
  71. Jin R, Rock J, Jin JY, et al. Single fraction spine radiosurgery for myeloma epidural spinal cord compression. J Exp Ther Oncol 2009; 8:35.
  72. Ryu S, Rock J, Jain R, et al. Radiosurgical decompression of metastatic epidural compression. Cancer 2010; 116:2250.
  73. Redmond KJ, Lo SS, Fisher C, Sahgal A. Postoperative Stereotactic Body Radiation Therapy (SBRT) for Spine Metastases: A Critical Review to Guide Practice. Int J Radiat Oncol Biol Phys 2016; 95:1414.
  74. Laufer I, Iorgulescu JB, Chapman T, et al. Local disease control for spinal metastases following "separation surgery" and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine 2013; 18:207.
  75. Burch PA, Grossman SA. Treatment of epidural cord compressions from Hodgkin's disease with chemotherapy. A report of two cases and a review of the literature. Am J Med 1988; 84:555.
  76. Wong ET, Portlock CS, O'Brien JP, DeAngelis LM. Chemosensitive epidural spinal cord disease in non-Hodgkins lymphoma. Neurology 1996; 46:1543.
  77. Hayes FA, Thompson EI, Hvizdala E, et al. Chemotherapy as an alternative to laminectomy and radiation in the management of epidural tumor. J Pediatr 1984; 104:221.
  78. Grommes C, Bosl GJ, DeAngelis LM. Treatment of epidural spinal cord involvement from germ cell tumors with chemotherapy. Cancer 2011; 117:1911.
  79. Boogerd W, van der Sande JJ, Kröger R, et al. Effective systemic therapy for spinal epidural metastases from breast carcinoma. Eur J Cancer Clin Oncol 1989; 25:149.
  80. Sasagawa I, Gotoh H, Miyabayashi H, et al. Hormonal treatment of symptomatic spinal cord compression in advanced prostatic cancer. Int Urol Nephrol 1991; 23:351.
  81. Kuether TA, Nesbit GM, Barnwell SL. Embolization as treatment for spinal cord compression from renal cell carcinoma: case report. Neurosurgery 1996; 39:1260.
  82. Sørensen S, Børgesen SE, Rohde K, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 1990; 65:1502.
  83. Rades D, Veninga T, Stalpers LJ, et al. Prognostic factors predicting functional outcomes, recurrence-free survival, and overall survival after radiotherapy for metastatic spinal cord compression in breast cancer patients. Int J Radiat Oncol Biol Phys 2006; 64:182.
  84. Huang J, Jatoi A. Morbidity and mortality in patients with cancer who become nonambulatory after spinal cord compression: a case series on end-of-life care. J Palliat Med 2009; 12:219.
  85. Savage P, Sharkey R, Kua T, et al. Malignant spinal cord compression: NICE guidance, improvements and challenges. QJM 2014; 107:277.
  86. Wang M, Jensen AB, Morgen SS, et al. Survival analysis of breast cancer subtypes in patients with spinal metastases. Spine (Phila Pa 1976) 2014; 39:1620.
  87. Tatsui H, Onomura T, Morishita S, et al. Survival rates of patients with metastatic spinal cancer after scintigraphic detection of abnormal radioactive accumulation. Spine (Phila Pa 1976) 1996; 21:2143.
  88. Bauer HC, Wedin R. Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients. Acta Orthop Scand 1995; 66:143.
  89. Loeffler JS, Glicksman AS, Tefft M, Gelch M. Treatment of spinal cord compression: a retrospective analysis. Med Pediatr Oncol 1983; 11:347.
  90. van der Sande JJ, Boogerd W, Kröger R, Kappelle AC. Recurrent spinal epidural metastases: a prospective study with a complete follow up. J Neurol Neurosurg Psychiatry 1999; 66:623.
  91. Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976) 2007; 32:193.
  92. Schiff D, Shaw EG, Cascino TL. Outcome after spinal reirradiation for malignant epidural spinal cord compression. Ann Neurol 1995; 37:583.
  93. Rades D, Rudat V, Veninga T, et al. Prognostic factors for functional outcome and survival after reirradiation for in-field recurrences of metastatic spinal cord compression. Cancer 2008; 113:1090.
  94. Wright JL, Lovelock DM, Bilsky MH, et al. Clinical outcomes after reirradiation of paraspinal tumors. Am J Clin Oncol 2006; 29:495.
  95. Nieder C, Grosu AL, Andratschke NH, Molls M. Proposal of human spinal cord reirradiation dose based on collection of data from 40 patients. Int J Radiat Oncol Biol Phys 2005; 61:851.
  96. Milker-Zabel S, Zabel A, Thilmann C, et al. Clinical results of retreatment of vertebral bone metastases by stereotactic conformal radiotherapy and intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys 2003; 55:162.
  97. Garg AK, Wang XS, Shiu AS, et al. Prospective evaluation of spinal reirradiation by using stereotactic body radiation therapy: The University of Texas MD Anderson Cancer Center experience. Cancer 2011; 117:3509.
  98. Maranzano E, Trippa F, Casale M, et al. Reirradiation of metastatic spinal cord compression: definitive results of two randomized trials. Radiother Oncol 2011; 98:234.
  99. Ang KK, Price RE, Stephens LC, et al. The tolerance of primate spinal cord to re-irradiation. Int J Radiat Oncol Biol Phys 1993; 25:459.
  100. Schultheiss TE, Stephens LC. Invited review: permanent radiation myelopathy. Br J Radiol 1992; 65:737.
  101. Sterzing F, Hauswald H, Uhl M, et al. Spinal cord sparing reirradiation with helical tomotherapy. Cancer 2010; 116:3961.
  102. Laufer I, Hanover A, Lis E, et al. Repeat decompression surgery for recurrent spinal metastases. J Neurosurg Spine 2010; 13:109.