What is the treatment for cord compression?

Treatment for Spinal Cord Compression

The treatment for spinal cord compression should begin immediately with high-dose dexamethasone therapy, followed by surgery for patients with spinal instability or bony compression, and radiation therapy for those with neurologic impairment. 1

Initial Management

• High-dose dexamethasone should be administered immediately upon clinical suspicion of spinal cord compression, even before radiographic confirmation 1
• The standard regimen is 96 mg IV daily, tapered over 14 days, although this carries significant toxicity risk (up to 29% side effects, 14% serious complications) 1
• MRI of the entire spine (sagittal T1-weighted with or without gadolinium) should be performed urgently to confirm the diagnosis 1

Surgical Management

• Surgery is the standard of care for spinal cord compression with:
  • Frank spinal instability
  • Neurologic deficits
  • Bony retropulsion causing cord compression 1
• Surgical decompression followed by radiation therapy is superior to radiation therapy alone for patients with:
  • Age <65 years
  • Single level compression
  • Neurologic deficits present for <48 hours
  • Predicted survival of at least 3 months 1
• In multiple myeloma patients, if cord compression is due to bone fragments (rather than myeloma masses), surgery should be performed 1
• Surgical decompression, tumor excision, and stabilization can improve neurological status from non-ambulatory to ambulatory and provide pain relief 1

Radiation Therapy

• Radiation therapy is a mainstay treatment for spinal cord compression 1
• Standard regimen is 30 Gy in 10 fractions 1
• Shorter fractionation schedules (20 Gy in 5 fractions or 8 Gy in 1 fraction) are typically reserved for patients with poor performance status 1
• Radiation is particularly effective for radiosensitive tumors such as myeloma and lymphoma 2
• Patients who undergo surgery should receive radiation therapy post-operatively once healing has occurred 1

Treatment Algorithm

1. Immediate intervention upon suspicion:

   • Start high-dose dexamethasone
   • Obtain urgent MRI of entire spine 1

2. Treatment decision based on clinical presentation:

   • For spinal instability or bony compression: Surgical decompression followed by radiation therapy 1
   • For radiosensitive tumors without instability: Radiation therapy may be sufficient 2
   • For patients with poor surgical candidacy: Radiation therapy and medical management 1

3. Post-treatment:

   • Continue medical management including pain control
   • Monitor neurological status 1

Prognostic Factors

• Pretreatment neurologic status is the strongest prognostic factor for overall survival and ability to ambulate after treatment 1
• Recovery of neurologic function is highly dependent on pretreatment status:
  • Only 30% of non-ambulatory patients regain ability to walk
  • Only 2-6% of paraplegic patients regain ambulatory function 1

Important Caveats

• Delay in diagnosis and treatment can lead to irreversible neurologic deficits 1, 3
• The combination of surgery plus radiation therapy has shown better outcomes than radiation therapy alone in selected patients, but this remains controversial 1
• Stereotactic body radiation therapy (SBRT) provides higher radiation doses compared to conventional external beam radiation therapy but carries a higher risk of vertebral compression fracture (11-39%) 1
• Patients should be aggressively screened and educated about spinal cord compression, especially those with high-risk cancers (lung, breast, prostate, myeloma) 1, 3