What is the treatment for malignant spinal cord compression?

From the Guidelines

Malignant spinal cord compression requires immediate treatment with high-dose corticosteroids, typically dexamethasone 16mg/day, as well as prompt evaluation for surgical decompression or radiation therapy. The treatment approach should be individualized based on factors such as performance status, extent of compression, and presence of spinal instability. According to the most recent and highest quality study 1, surgery is considered for a carefully selected group of patients with single-level malignant spinal cord compression and neurological deficits. Radiation therapy is the first-line treatment for the majority of patients, providing back pain relief in 50-58% of cases. The optimal radiation therapy schedule remains unknown, but hypofractionated regimens can be considered the approach of choice. Pain management is essential and may require opioid analgesics titrated to effect, as well as thromboprophylaxis with low molecular weight heparin for immobilized patients.

Some key points to consider in the management of malignant spinal cord compression include:

• Immediate initiation of high-dose corticosteroids, such as dexamethasone, to reduce edema and inflammation around the spinal cord 2
• Prompt evaluation for surgical decompression or radiation therapy, with surgery preferred for patients with good performance status, single-level compression, and spinal instability 1
• Radiation therapy as the first-line treatment for the majority of patients, with hypofractionated regimens considered the approach of choice 1
• Pain management with opioid analgesics titrated to effect, as well as thromboprophylaxis with low molecular weight heparin for immobilized patients 2
• Early initiation of physical therapy to maintain function and prevent further decline 3

It is essential to note that the urgency of treatment cannot be overstated, as neurological recovery depends on the severity and duration of compression before treatment; patients who are ambulatory before treatment have better outcomes than those who have already lost the ability to walk 3.

From the Research

Treatment Options for Malignant Cord Compression

• The treatment of malignant cord compression typically involves a combination of medical management, surgical decompression, radiation therapy (RT), and rehabilitation 4.
• Radiotherapy is the treatment of choice in most cases, whereas surgery is advised only in selected patients, such as those who require stabilization, have already received radiotherapy in the same area, or have vertebral body collapse causing bone impingement on the cord or nerve roots 5.
• High-dose dexamethasone is recommended for the treatment of malignant extradural spinal cord compression, but the use of moderate-dose steroids is inconclusive 6.
• The optimal radiation schedule has not been defined, but hypofractionated radiotherapy regimens have been shown to be effective and can be used without increasing radiation-induced myelopathy 5, 7.

Surgical Intervention

• Circumferential surgical decompression followed by RT provides superior clinical outcomes than RT alone for patients with motor deficits 4.
• Initial surgery is recommended for patients without a previous cancer diagnosis or with a remote cancer, unstable spine or bony cord compression, or inability to receive further irradiation 8.
• New surgical data suggest that patients with irradiation-resistant tumors and a single site of compression may have improved function with initial surgery and reconstruction followed by irradiation, compared with irradiation alone 8.

Radiation Therapy

• The selected RT schedule should be personalized to each patient and commonly is 30 Gy in 10 fractions, 20 Gy in 5 fractions, or 8 Gy in 1 fraction 4.
• Stereotactic body radiation therapy (SBRT) has been used for high-grade MESCC in patients with relatively intact neurologic function, but is generally not feasible for most clinical practices 4.
• SBRT may be advantageous for low-grade MESCC, recurrence, or in the post-operative setting 4.

Diagnosis and Follow-up

• Magnetic resonance imaging is the best tool for diagnosing metastatic spinal cord compression and is able to identify spinal cord compression in patients with back pain, bone metastases, and normal neurologic examination 5.
• A close post-treatment follow-up is suggested using clinical parameters, and magnetic resonance imaging should be performed only when a second metastatic spinal cord compression and/or myelopathy are clinically suspected 5.