What are the treatment options for spinal cord compression?

Treatment of Spinal Cord Compression

Initiate high-dose dexamethasone (96 mg IV daily) immediately upon clinical suspicion of spinal cord compression, even before imaging confirmation, followed by urgent MRI of the entire spine and definitive treatment with either surgery plus radiotherapy or radiotherapy alone depending on specific clinical factors. 1

Immediate Management

Corticosteroids

• Start dexamethasone 96 mg IV daily immediately upon clinical suspicion, before radiographic confirmation. 1
• Taper over 14 days, though this regimen carries significant toxicity risk. 1
• High-dose dexamethasone before radiotherapy significantly improves ambulation rates (81% vs 63% at 3 months) compared to no corticosteroids. 2

Urgent Imaging

• Obtain MRI of the entire spine urgently to confirm diagnosis and identify all sites of compression. 1
• MRI has sensitivity 0.44-0.93 and specificity 0.90-0.98 for diagnosing malignant spinal cord compression. 2
• Myelography is an alternative with sensitivity 0.71-0.97 and specificity 0.88-1.00. 2

Definitive Treatment Selection

Surgery Plus Radiotherapy (Preferred for Selected Patients)

Surgery followed by radiotherapy is superior to radiotherapy alone for patients meeting ALL of the following criteria: 1

• Age <65 years
• Single level of compression
• Neurologic deficits present for <48 hours
• Predicted survival ≥3 months

Additional absolute indications for surgery: 2, 1

• Frank spinal instability
• Bony retropulsion or bone fragments causing cord compression 2
• Neurologic deficits with osseous compression

Surgery improves ambulatory status: Patients receiving surgery plus radiotherapy maintain ambulation longer than radiotherapy alone (P=0.006). 2

Surgical Approach

• Anterior vertebral body resection for anterior or anterolateral tumors 3
• Laminectomy for posterior or posterolateral deposits 3
• Modern instrumentation allows immediate stabilization and ambulation 3

Important Surgical Caveats

• 30-day postoperative mortality: 0-13% 2
• Postoperative complications: 0-54% (higher for vertebral body resection 10-54% vs laminectomy 0-10%) 2
• Avoid surgery before radiotherapy when possible: Patients receiving radiotherapy before surgery have doubled complication rates (39% vs 20%). 2

Radiotherapy

Standard Radiotherapy

• Standard regimen: 30 Gy in 10 fractions 2, 1
• Alternative regimens include 37.5 Gy in 15 fractions, 40 Gy in 20 fractions, or 28 Gy in 7 fractions—no regimen demonstrates superiority. 2
• Administer radiotherapy post-operatively once surgical healing has occurred. 1
• Pain relief may be delayed up to 2 weeks following treatment. 2

Radiotherapy for Specific Scenarios

• Patients with life expectancy <6 months, poor performance status, or extensive visceral metastases: Use external beam radiotherapy for painful stable fractures or impending epidural compression. 2
• Radioresistant tumors: Radiotherapy remains effective; tumor radiosensitivity does not strongly predict post-treatment ambulation on multivariate analysis. 2

Re-irradiation for Recurrent Compression

• Re-treatment of previously irradiated areas is feasible with acceptable neurologic outcomes (90% ambulatory rate in ambulatory patients, 43% in non-ambulatory). 2
• Only one episode of radiation myelopathy reported when cumulative spinal cord dose <100 Gy. 2

Stereotactic Body Radiotherapy (SBRT)

• Provides higher radiation doses with potentially greater tumor control 2
• Major caveat: Significantly higher vertebral compression fracture risk (11-39%) with median time to fracture 2-25 months 2
• Dose-dependent complications: ~40% with 24 Gy in 1 fraction vs ~10% with 24 Gy in 2 fractions 2

Emergency Situations

Spinal Cord Compression Emergency Protocol

For acute spinal cord compression with neurological deficits: 2

• High-dose dexamethasone immediately
• Simultaneous local radiotherapy started as soon as possible
• Surgery if bone fragments are within the spinal canal

Prognostic Factors

Critical Determinant of Outcome

Pretreatment ambulatory status is the strongest prognostic factor for overall survival and post-treatment ambulation. 1

Expected Recovery Rates

• Ambulatory patients: 96-100% remain ambulatory after treatment 2
• Non-ambulatory patients: Only 30% regain ability to walk 1
• Paraplegic patients: Only 2-6% regain ambulatory function 1
• Patients with slower development of motor deficits (>14 days) have better functional outcomes than rapid progression (<14 days). 2

Treatment Delays and Recognition

Minimize Diagnostic Delay

• Manage patients with suspected spinal cord compression to minimize treatment delay. 2
• 70% of patients experience loss of neurologic function between symptom onset and treatment initiation. 2
• Two-thirds of delays are attributed to patients not recognizing symptoms as urgent. 2

High-Risk Populations Requiring Surveillance

• Patients with extensive bone metastases (>20 lesions) have 32-44% risk of malignant spinal cord compression. 2
• Most common primary cancers: lung (24%), breast (21%), prostate (20%). 2

Adjunctive Management

Pain Management

• Pregabalin 150-600 mg/day for neuropathic pain associated with spinal cord injury, starting at 75 mg twice daily and titrating based on response. 4

Bone-Directed Therapy

• Zoledronic acid 4 mg IV over 15 minutes monthly or pamidronate 90 mg IV over 2 hours monthly for bone disease. 2
• Vertebroplasty or kyphoplasty for severe back pain from vertebral compression fractures. 2

Unknown Primary Site

• Surgical decompression may be performed to obtain tissue diagnosis while decompressing the cord, though no direct evidence supports this over biopsy plus radiotherapy. 2