Malignant Cord Compression Research Articles

Malignant Cord Compression and Timing of Post-Operative Radiotherapy

<h3>Purpose/Objective(s)</h3> Malignant spinal cord compression (MSCC) warrants prompt intervention that often involves neurosurgical decompression followed by radiation therapy (RT). However, post-surgical management including rehabilitation and time for wound healing can delay initiation of post-operative RT. This study aims to retrospectively review the time to initiation (TTI) of RT after surgical intervention for MSCC and its association with ambulatory status at 3 months post-treatment. We also compare TTI in patients discharged to home versus inpatient rehabilitation or skilled nursing facility. <h3>Materials/Methods</h3> We queried our institutional database for patients with solid malignancies and spinal metastases with Bilsky 2 or 3 MSCC who underwent surgical intervention and post-operative RT between 2015-2021. In patients who were ambulatory peri-operatively, we computed the relative risk of decreased ambulation at 3-month follow up using different TTI cutoff values of 30, 42, and 56 days. P values were generated using a 2-sided Fisher's Exact Test. TTI was also evaluated in all patients who underwent post-operative RT based on their discharge to home, skilled nursing facility, or inpatient rehabilitation. <h3>Results</h3> We found 128 patients with MSCC who underwent surgery. Within this group, 68 were ambulatory peri-operatively, received post-operative RT, and had at least 3 months of follow up. Three-month ambulatory rates for TTI of ≤ 30 vs >30 days, ≤ 42 vs > 42 days, and ≤ 56 vs > 56 days were 86% vs 70% (p=0.218), 85% vs 59% (p=0.032), and 83% vs 50% (p=0.028), respectively. Relative risks for inability to ambulate are shown in Table 1. For all patients who received post-operative RT without wound complications causing delays in RT, TTI based on discharge to home (n=42), skilled nursing facility (n=3), or inpatient rehab (n=26) was 28 days (IQR 19-36.75), 21 days (IQR 15-21), and 37 days (IQR 25.25-52.5), respectively. Nine patients were found to have locally recurrent disease-causing cord compression; two recurred after post-operative RT while seven recurred prior to post-operative RT. <h3>Conclusion</h3> The relative risk of inability to ambulate after surgical resection for MSCC was significantly higher if RT was initiated at >42 days after surgery, and even lower at >56 days after surgery. Patients discharged to inpatient rehab had the longest interval between surgery and RT. Further studies evaluating the optimal timing of post-operative RT and causes for delay are needed.

Spinal Cord Compression Due to Epidural Malignancy Laminectomy: Does This Play any Role?

Summary: The role of laminectomy in patients with malignant cord compression and vertebral collapse is by no means clear. It has become widely accepted that laminectomy is a potentially dangerous operation for patients with anterior vertebral collapse, resulting both in a greater likelihood of major neurological deterioration and an increased incidence of painful spinal instability. Method: During the period 1989-1991 (N.G.H.) and 1986-1989 (K.I.), we observed 135 patients who underwent decompressive laminectomies for malignant epidural cord compression. Postoperatively, 68 patients could walk: 35 (51%) of the patients had no anterior vertebral collapse and 33 (49%) of them suffered anterior vertebral collapse. The presence of vertebral collapse did not appear to have an adverse effect on the outcome in these patients. Patients with lesions below T9 were significantly worse following laminectomy than those with lesions above T9. Results: Decompressive laminectomy, may, therefore, still have a role in the management of patients with malignant spinal cord compression in the upper dorsal spine, despite vertebral collapse, particularly if other techniques, such as percutaneous needle biopsy, and anterior decompressive surgery are not available. Nevertheless, anterior decompression would clearly appear to be the first choice treatment.

Is CT adequate to assess for malignant cord compression?

Purpose At the Beatson Oncology Centre, Glasgow there is a weekend emergency spinal cord compression service providing two magnetic resonance imaging (MRI) slots for patients throughout the West of Scotland. Out-of-hours MRI is not available at local hospitals. Patients are transferred to the Beatson for emergency MRI and emergency treatment with radiotherapy if required. The aim of this study is to identify the role of computed tomography (CT) as a screening tool for patients prior to transfer, to avoid unnecessary transfers. Methods and materials Patients who had undergone emergency weekend MRI scans for malignant spinal cord compression were identified between January 2014 and 2015. The radiology information system (RIS) was used to review previous imaging history and identify relevant contemporaneous CT imaging which was then reviewed. Results The study identified 27 patients as having a weekend MRI scan at the Beatson for possible malignant spinal cord compression. Of these, 13 had a positive MRI scan demonstrating malignant spinal cord compression. Of these 13 patients, 12 patients had a contemporaneous CT scan. In all 12 cases, CT readily identified the level of cord compression. Conclusion CT is available at all local sites and readily demonstrates the level of malignant spinal cord compression. It has a role in identifying patients who would benefit from transfer to the Beatson for further imaging with MRI. This will in turn reduce the number of patients undergoing unnecessary transfer from their local hospitals.

Malignant spinal cord compression secondary to testicular seminoma at the time of initial presentation and at relapse while on surveillance

We report cases of 2 pure seminoma patients who developed metastatic spinal cord compressions. One patient was diagnosed at age 33 years with stage 1 seminoma and, after undergoing an orchidectomy, chose to be followed on a surveillance protocol. He was lost to follow-up and presented again 22 months later with back pain, leg weakness and sensory loss when his disease recurred as a spinal cord compression. He was treated with urgent surgical decompression and subsequent standard chemotherapy. More than 2 years posttreatment, he is disease-free with normal neurologic function in his lower extremities. The second patient presented at age 44 years with back pain and rapid loss of leg strength and sensation. Investigations revealed a malignant cord compression with lymphatic and vertebral body metastases. On physical examination, the patient was found to have a 6-cm left testicular mass. He was treated with emergency radiotherapy to the region of his cord compression followed by a left inguinal orchidectomy. Pathology confirmed a pure classic seminoma. Postoperatively, he received standard chemotherapy and eventually regained neurologic function in his legs. Although it is rare for malignant spinal cord compression to occur in seminoma patients-either as the initial presentation of disease or as a site of disease recurrence in stage 1 patients on surveillance-it is crucial to consider seminoma as a possible etiology in young men diagnosed with malignant spinal cord compression because timely contemporary treatments for seminoma will cure most of these patients and offer them excellent functional recovery.

A13 Survival, function and quality of life after malignant cord compression

A13 Survival, function and quality of life after malignant cord compression

Malignant cord compression: A critical appraisal of prognostic factors predicting functional outcome after surgical treatment.

Objectives:Advanced tumor disease and metastatic spinal cord compression (MSCC) are two entities with a high impact on patients’ quality of life. However, prognostic factors on the outcome after primary decompressive surgery are less well-defined and not yet standardized. The aim of this review was to identify prognostic variables that predict functional or ambulatory outcomes in surgically treated patients with symptomatic MSCC.Materials and Methods:We conducted MEDLINE database searches using relevant keywords in order to identify abstracts referring to prognostic factors on ambulatory outcomes in surgically treated MSCC patients. Details of all selected articles were assembled and the rates of ambulation were stratified.Results:Evidence from five retrospective comparative trials and one observational prospective study summarizes different prognostic factors with a positive or negative influence on postoperative ambulatory status. Ambulatory patients maintaining ambulation status after decompression of the spinal cord constituted 62.1%. The overall rate of MSCC patients losing the ability to ambulate was 7.5% compared to 23.5 % who regained ambulation. Preoperative ambulation status, time to surgery, compression fracture and individual health status seem to be the most relevant prognostic factors for ambulatory outcome.Conclusions:There is a lack of standardized prognostic tools which allow predicting outcome in surgically treated patients. A quantitative score consisting of reliable prognostic tools is essential to predict loss and/or regain of ambulation and requires validation in future prospective clinical trials.

Suspected malignant cord compression – improving time to diagnosis via a ‘hotline’: a prospective audit

The aim of the study was to achieve earlier diagnosis of malignant cord compression (MCC) using urgent magnetic resonance imaging (MRI) for selected patients. A comparison was carried out of the current prospective audit of 100 patients referred by a general practitioner or a consultant over 32 months with both a previous national Clinical Research and Audit Group (CRAG) prospective audit (324 cases of MCC) and an earlier retrospective audit of 104 patients referred with suspected MCC. A telephone hotline rapid-referral process for patients with known malignancy and new symptoms (severe nerve root pain ± severe back pain) was designed. Patients were considered for urgent MRI after discussion with a senior clinician responsible for the hotline. Appropriate referrals were discussed with radiology and oncology ensuring timely MRI reporting and intervention. The main outcome measures are as follows: time from referral to diagnosis; time from the onset of symptoms to diagnosis; and mobility at diagnosis. A total of 50 patients (52%) of those scanned had either MCC (44) or malignant nerve root compression (6) compared with the earlier rate of 23 out of 104 patients (22%). Ten out of 44 MCC patients (23%) were paralysed at diagnosis, compared with 149 out of 324 (46%) in the CRAG audit. Time from reporting pain to diagnosis was 32 days compared with 89 days in the CRAG audit. Median time from referral to diagnosis was 1 day, again considerably shorter than the CRAG audit time of 15 days (interquartile (IQ) range: 3–66). In patients at risk of MCC, fast-track referral with rapid access to MRI reduces time between symptom onset and diagnosis, improves mobility at diagnosis and reduces the number of negative MRI scans.

What Happens to People after Malignant Cord Compression? Survival, Function, Quality of Life, Emotional Well-being and Place of Care 1 Month after Diagnosis

Aims To present further findings from the Scottish Cord Compression Study, in which the diagnosis, management and outcome of 319 patients with a definitive diagnosis of malignant cord compression (MCC) were examined. Materials and methods In total, 256 (80%) patients in the study consented to be interviewed shortly after diagnosis and at follow-up interviews. One hundred and twenty-eight patients were interviewed 1 month after diagnosis (40% of the total; 57% [128/224] of patients alive 1 month after diagnosis; 68% [128/188] of patients who also consented to follow-up). Survival data of the whole MCC population and data from interviewing 128 patients 1 month after diagnosis are presented. Results The median survival of all patients was 59 days (95% confidence interval [CI] 43–75 days). The median Karnofsky performance status was 50 (interquartile range 40–60), indicating a need for considerable nursing and medical care, and was poorest for patients with lung cancer (median 40; interquartile range 30–60). The place of care was dependent on mobility at diagnosis; patients walking at diagnosis were more likely to be at home, whereas patients requiring assistance or who were unable to walk were more likely to be in institutional care ( P = 0.019). Mobility and bladder function were determined by mobility and bladder function at diagnosis ( P < 0.001). Of those unable to walk at diagnosis, 7% regained full mobility. Of those catheterised at presentation, 28% regained full bladder function. Forty-seven per cent (56/120, 95% CI 40–54) of patients interviewed were in pain despite oncological treatment and 18% (22/120; 95% CI 8–19) reported the pain as severe (visual analogue scale >7). The median quality-of-life (Schedule for Evaluation of Individualised Quality of Life) score was 72/100, and was higher in patients with a better performance status ( P = 0.026). A minority of patients (8%) screened positive for anxiety and depression using the Hospital Anxiety and Depression scale. Conclusions Notwithstanding the difficulties in following up this group of patients, this paper reports valuable findings detailing the experience of patients with MCC 1 month after diagnosis and treatment.

Listen to the patient: quality of life of patients with recently diagnosed malignant cord compression in relation to their disability

Quality of life (QOL) was determined using the shortened version of the Schedule for the Evaluation of Individual Quality of Life (SEIQoL-Dw), in 180 patients, shortly after a diagnosis of malignant cord compression. The median SEIQoL score was 66 (maximum 100). Twenty-five per cent of patients had a score >83. SEIQoL correlated with KPS (P<0.004) but the range of scores for each level of performance was very wide. Although there was an association between SEIQoL and ability to walk, the difference was small and not significant. SEIQoL was adversely affected by emotional distress as measured using HAD (P<0.01), although few patients were identified as being severely depressed. The findings are a reminder that QOL as determined by the patient may not coincide with health professionals' opinions.

Epidural Spinal Cord Compression.

Epidural spinal cord compression is a neurologic emergency requiring immediate attention. The therapy instituted depends on several factors, including the patient's condition at the time of presentation, the nature of the underlying malignancy, the extent of systemic disease burden, and patient prognosis. The most essential aspect of treatment is the establishment of the diagnosis. If one suspects malignant cord compression an emergency, magnetic resonance imaging of the entire spinal axis is indicated. If magnetic resonance imaging is unavailable, post-myelographic computed tomography is an alternative. However, treatment should not be delayed until imaging is performed, particularly if neurologic deficits are present. Pain should be adequately addressed and opioids administered if necessary. Steroids should be given. If significant neurologic deficits are present, a high-dose corticosteroid bolus, followed by standing doses, should be given. However, if pain is the predominant symptom, steroids can be withheld pending immediate imaging or lower doses can be given without a bolus. Neurosurgical consultation should be obtained, and surgery should be considered if the patient's condition permits. This is particularly true if spinal instability or significant kyphosis is present or compression is secondary to bony fragments. Other indications include patients with limited systemic disease burden in whom better survival is predicted and possibly those with radioresistant tumors. The type of surgery performed should be tailored to the distribution of disease within the spine and accessibility through anterior body cavities. Radiation therapy, an effective noninvasive treatment that can be delivered quickly and safely, is an appropriate option as well. This is particularly true in radio-responsive tumors, such as myeloma and lymphoma, in which surgery may be avoided entirely. Chemotherapy may play a role as adjuvant therapy in some tumors.

Don't wait for a sensory level--listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression.

To report details concerning symptoms (especially pain) preceding the development of malignant cord compression (MCC); delays between onset/reporting of symptoms and confirmed diagnosis of MCC; accuracy of investigations carried out. A prospective observational study examined the diagnosis, management and outcome of 319 patients diagnosed with MCC at three Scottish cancer centres between January 1998-April 1999. The process was considered from the perspectives of the patient, the GP and the hospital doctor. At diagnosis, most patients (82%) were either unable to walk or only able to do so with help. Pain was reported by nearly all patients interviewed (94%) and had been present for approximately 3 months (median=90 days). It was severe in 84% of cases, with the distribution and characteristics of nerve root pain in 79%. The site of pain did not correspond to the site of compression. Where reported, weakness and/or sensory problems had been noticed by the patient for some time before diagnosis (median intervals 20 and 12 days, respectively). Most patients reported early symptoms to their General Practitioner (GP) and diagnosis was established, following referral and investigation, approximately 2 months (median=66 days) later. Patients who develop spinal metastases are at risk of irreversible spinal cord damage. Weakness and sensory abnormalities are reported late and identified even later, despite patients having reported pain for a considerable time. Patients with cancer who describe severe back or spinal nerve root pain need urgent assessment on the basis of their symptoms, as signs may occur too late. Plain films and bone scans requested for patients in this audit predicted accurately the level of compression in only 21% and 19% of cases, respectively. The only accurate investigation to establish the presence and site of a compressive lesion is magnetic resonance imaging (MRI). A referral guideline based on suspicious symptoms in addition to suspicious signs is suggested.

Why should patients with paraplegia secondary to malignant epidural cord compression (MESCC) rate their quality of life scores so high?

Why should patients with paraplegia secondary to malignant epidural cord compression (MESCC) rate their quality of life scores so high?

Synchronous Vertebral Decompression and Posterior Stabilization in the Treatment of Spinal Malignancy

Abstract Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.

Synchronous vertebral decompression and posterior stabilization in the treatment of spinal malignancy.

Thirty-four patients with metastatic tumors of the spinal column exhibiting vertebral collapse and posterior element disease were treated by a single-stage operation combining decompression of the vertebral body with posterior spinal instrumentation. Attention is drawn to the use of computed tomographic scanning in planning the operative approach. The indications for surgery were neurological deficit in 32 patients and pain in 2; 14 patients received preoperative radiotherapy. Of the 21 patients who were nonambulant preoperatively, 67% walked again, 21% regained sphincter control, and 68% had less pain. The surgical mortality was 12%; wound infection and dehiscence occurred in 15%. These results indicate that a single-stage decompression and posterior stabilization may improve neurological function dramatically in patients with malignant cord compression. The operative morbidity and mortality is comparable to that of laminectomy.

Adverse effects of the management of malignant spinal cord compression.

As a prelude to further work which attempts to improve the management of metastatic spinal cord compression the efficacy and adverse effects of existing therapy has been assessed. All papers dealing with the management of malignant spinal cord compression since 1960 have been reviewed. Data from this review is presented in a novel manner in order to identify not only the degree of successful return to ambulation achieved but more importantly the extent of the adverse effects which occur during existing management. It is seen that, while in general some 35% of patients treated in any manner retain or return to the ability to walk, some 20% to 25% sustain major neurological deterioration. In addition, those patients treated by laminectomy who do deteriorate may be subject to a significant rate of perioperative mortality and major structural complications related to the surgical wounds. In the light of the adverse factors described, the role of laminectomy as first-line management of malignant cord compression is questioned. Alternative modes of treatment are discussed and a tentative scheme of management described which it is hoped will lead to a better quality of survival of the group as a whole in addition to maintaining, or perhaps, improving the rate of successful return to ambulation.