What is the treatment for spinal cord compression?

Treatment of Spinal Cord Compression

Initiate high-dose dexamethasone immediately upon clinical suspicion (before imaging confirmation), obtain urgent MRI of the entire spine, and pursue surgical decompression followed by radiotherapy for patients with single-level compression, neurologic deficits present <48 hours, and predicted survival ≥3 months. 1

Immediate Medical Management

• Administer dexamethasone 96 mg IV daily immediately upon clinical suspicion, even before radiographic confirmation, then taper over 14 days 1
• High-dose dexamethasone before radiotherapy significantly improves ambulation rates (81% vs 63% at 3 months) compared to no corticosteroids 1
• Minimize treatment delay as 70% of patients experience loss of neurologic function between symptom onset and treatment initiation 1
• Two-thirds of delays occur because patients do not recognize symptoms as urgent 1

Diagnostic Imaging

• Obtain MRI of the entire spine urgently to confirm diagnosis and identify all levels of compression 1, 2, 3
• MRI has sensitivity 0.44-0.93 and specificity 0.90-0.98 for diagnosing malignant spinal cord compression 1
• Myelography is an alternative with sensitivity 0.71-0.97 and specificity 0.88-1.00 when MRI is contraindicated 1

Surgical Indications (Absolute)

Surgery followed by radiotherapy is indicated for: 1

• Bony retropulsion or bone fragments causing cord compression 1
• Frank spinal instability 1
• Single level of compression with neurologic deficits present <48 hours 1
• Predicted survival ≥3 months 1
• Age <65 years 1

Surgical Outcomes

• Surgery plus radiotherapy maintains ambulation longer than radiotherapy alone (P=0.006) 1
• Early surgical decompression can be performed safely within 12 hours of injury with no increase in complications 4
• Incomplete injuries with persisting compression from dislocation with bilateral locked facets, burst fracture, or disc rupture should undergo early decompression, especially with neurological deterioration 4

Radiotherapy

For patients not undergoing surgery or post-operatively: 1

• Standard regimen: 30 Gy in 10 fractions 1, 5
• Alternative regimens include 37.5 Gy in 15 fractions, 40 Gy in 20 fractions, or 28 Gy in 7 fractions—no regimen demonstrates superiority 1
• Additional options for personalized treatment: 20 Gy in 5 fractions or 8 Gy in 1 fraction 5
• Pain relief may be delayed up to 2 weeks following treatment 1
• Radiotherapy alone provides modest neurologic outcomes in selected radiosensitive tumors 2

Stereotactic Body Radiation Therapy (SBRT)

• SBRT may be advantageous for low-grade compression, recurrence, or post-operative setting 5
• SBRT has been used for high-grade compression in patients with relatively intact neurologic function at centers with robust infrastructure for rapid treatment initiation 5
• SBRT carries higher risk of vertebral compression fracture 1

Prognostic Factors Critical to Decision-Making

• Pretreatment ambulatory status is the strongest prognostic factor: ambulatory patients have 96-100% chance of remaining ambulatory after treatment 1
• Only 30% of non-ambulatory patients regain ability to walk 1
• Only 2-6% of paraplegic patients regain ambulatory function 1
• Patients with slower development of motor deficits (>14 days) have better functional outcomes than rapid progression (<14 days) 1

Adjunctive Management

• Bone-directed therapy: zoledronic acid 4 mg IV over 15 minutes monthly or pamidronate 90 mg IV over 2 hours monthly for bone disease 1
• Vertebroplasty or kyphoplasty may be used for severe back pain from vertebral compression fractures 1
• Systemic therapy is typically reserved until after primary treatment of compression, but patients with chemoresponsive tumors may receive primary chemotherapy 5

Treatment Algorithm for Malignant Spinal Cord Compression

Step 1: Clinical suspicion → immediate dexamethasone 96 mg IV daily 1

Step 2: Urgent MRI entire spine 1, 2

Step 3: Assess surgical candidacy:

• If bony retropulsion, spinal instability, single-level compression, neurologic deficits <48 hours, survival ≥3 months, age <65 → surgery followed by radiotherapy 1
• If not surgical candidate → radiotherapy alone (30 Gy in 10 fractions) 1

Step 4: Post-treatment rehabilitation and bone-directed therapy 1

Critical Pitfalls to Avoid

• Delaying treatment while awaiting imaging: initiate dexamethasone immediately upon clinical suspicion 1
• Missing spinal instability: this is an absolute indication for surgery regardless of other factors 1
• Inadequate neurological examination: complete assessment is critical to avoid missing unstable fractures requiring urgent surgical intervention 6
• Treating only the symptomatic level: image and assess the entire spine as multiple levels of compression are common 1, 3
• Performing decompression without stabilization when pathological fracture and instability are present: results in higher reoperation rates and poor long-term outcomes 7