Malignant Spinal Cord Compression Research Articles

Re-inventing the wheel: Assessing malignant spinal cord compression outcomes

Re-inventing the wheel: Assessing malignant spinal cord compression outcomes

Re-inventing the wheel: Assessing malignant spinal cord compression outcomes

Re-inventing the wheel: Assessing malignant spinal cord compression outcomes

Radiotherapeutic management of spinal metastases

Radiotherapy remains the primary treatment of malignant epidural spinal cord compression. Therapeutic success depends on diagnosis before the development of neurological compromise and the prompt initiation of radiotherapy. Radiotherapy alone is effective in over 85% of cases of spinal cord compression that occur in highly radioresponsive tumors (multiple myeloma, germ cell or lymphoproliferative tumors). In the more common tumors, like breast, prostate, and lung cancer, response to radiotherapy is based on presenting neurologic deficits, extent of disease, duration of symptoms, and overall clinical status, including other sites of metastatic involvement. Surgery is recommended in addition to radiotherapy in selected cases, and further study is needed to better define the prognostic and neurological parameters for the surgical management of spinal cord compression. Improvements in outcome in the treatment of spinal cord compression will require approaches like combined modality therapy because of the limitations primarily imposed by the radiation tolerance of the spinal cord.

Outcome after spinal reirradiation for malignant epidural spinal cord compression

Radiotherapy is effective for most cases of spinal cord compression. Although recurrent spinal cord compression is a common problem, little is known about whether reirradiation preserves neurologic function and what risk of radiation myelopathy it carries. To investigate this question, we reviewed patients at the Mayo Clinic between 1975 and 1992 undergoing two or more courses of radiotherapy to the same segment of the spinal column with radiographically documented epidural disease at the time of reirradiation to determine outcome as measured by the ability to walk and by survival. Fifty-four patients met the study criteria. Radiation doses for the first course ranged from 2,250 to 5,400 cGy (median, 3,000 cGy), and total dose for all courses to the reirradiated spinal segment ranged from 3,650 to 8,089 cGy (median, 5,425 cGy). All patients were ambulatory following the first course of radiation, 40 (74%) were ambulatory at the onset of reirradiation, and 42 (78%) were ambulatory at the end of reirradiation. Thirty-seven patients (69%) remained ambulatory at their last follow-up 6 days to 80 months following reirradiation (median, 4.7 months). Five patients eventually became nonambulatory 6.5 to 35 months following reirradiation. Median survival for all patients following reirradiation was 4.2 months. We conclude that for cancer patients with progressive epidural disease following radiotherapy, reirradiation frequently preserves ambulation and carries minimal risk of radiation myelopathy during the patients' lifetime.

The barthel index in assessing the response to palliative radiotherapy in malignant spinal cord compression: A prospective audit

A prospective study of functional assessment of response to palliative radiotherapy (RT) in malignant spinal cord compression (SCC) is reported. The relevant components of the Barthel Activities of Daily Living Index (ADLI: walking, transfer, and bladder and bowel control) were used to assess functional capacity, and compared with a standard neurological assessment. Fifty-one consecutive patients (38 men, 13 women; mean age 63.9 years) were assessed, all of whom were treated by primary or postoperative radiotherapy. Five of the 51 patients had had decompressive laminectomy prior to RT. Median survival was 34 days (range 2–570). Walking improved in only five of 12 patients who had an improvement in motor power. The ability to transfer from bed to chair improved in 11 patients. Ambulation at presentation was the single most important determinant of outcome. Of the eight patients ambulatory at presentation, all were alive at 1 month and seven remained ambulatory. Of the 43 non-ambulatory patients, only four were able to walk following treatment (all prostatic carcinomas). Only four patients regained urinary continence, and none regained bowel control after this was lost. Functional assessment using ADLI and standard neurological examination provide a more useful guide to outcome in malignant SCC than neurological examination alone.

Two patterns of malignant epidural spinal cord compression from lung cancer: Radiation treatment on functional outcome : Kim, RY, Spencer, SA, Meredith, RF, Salter, MM. University of Alabama at Birmingham, Birmingham, AL. USA

Two patterns of malignant epidural spinal cord compression from lung cancer: Radiation treatment on functional outcome : Kim, RY, Spencer, SA, Meredith, RF, Salter, MM. University of Alabama at Birmingham, Birmingham, AL. USA

Malignant epidural spinal cord compression associated with a paravertebral mass: Its radiotherapeutic outcome on radiosensitivity

Purpose : To evaluate clinical characteristics and functional outcome of malignant epidural spinal cord compression associated with a paravertebral mass. Methods and Materials : Between 1987 and 1990, 136 patients with epidural spinal cord compression were treated with irradiation. Of these, 25 patients (18%) had epidural spinal cord compression associated with a paravertebral mass. This report is based on analysis of these 25 patients. Fourteen patients received 3000 cGy in 10 fractions. Seven received 4000 cGy in 16 fractions. Four received 2000 cGy in 5 fractions. Motor function was evaluated by five grades. Results : Lung cancer accounted for the majority of epidural spinal cord compression with a paravertebral mass (60%) followed by lymphoma (8%) and kidney tumor (8%). This pattern of epidural spinal cord compression has a longer duration of pain before developing neurologic symptoms and has a high propensity of the upper thoracic spine involvement by an apical lung cancers. The functional outcome of radiation treatment reveals a significant difference between moderately radiosensitive tumors (lung, prostate, cervix, esophagus) and very radiosensitive tumor (lymphoma). None of the nonambulatory patients became ambulatory following radiotherapy except for the very radiosensitive tumors. Higher doses of radiation treatment (4000 cGy in 16 fractions) did not improve functional outcome. Conclusion : Due to the larger tumor burden, radiation treatment for epidural spinal cord compression associated with a paravertebral mass is not as effective as treatment of epidural spinal cord compression without a paravertebral mass except for the very radiosensitive tumor. Therefore, combined treatment modality might be beneficial for improving functional outcome.

Malignant spinal cord compression: A prospective evaluation

Purpose : To determine the influence of treatment on ambulancy, pain control and functional outcome of patients with Malignant Spinal Cord Compression. Methods and Materials : One hundred and thirty-seven patients with Malignant Spinal Cord Compression presenting or referred to the Department of Radiation Oncology, Westmead Hospital between August 1, 1989 and August 1, 1990 were studied prospectively. Patients were treated with palliative radiation therapy alone, surgery followed by radiotherapy or surgery alone. Two patients were not treated. Post-treatment outcome was assessed in terms of ambulatory status, improvement in pain and functional independence using the Functional Independence Measure. Results : Thirteen of 16 patients (81%) who were ambulant pre-treatment remained ambulant after treatment. Two of 16 patients (16.5%) who were non-ambulant pre-treatment became ambulant following treatment. Pain improved following treatment in 22 of 30 patients (73%). This benefit was seen equally for ambulant and non-ambulant patients. A high level of functional independence was maintained in patients who remained ambulant. Conclusion : We conclude that prompt treatment of patients with Malignant Spinal Cord Compression while still able to walk is effective in maintaining ambulancy and functional independence, and that treatment improves pain in most patients.

Metastatic spinal cord compression secondary to lung cancer.

Metastatic spinal cord compression (MSCC) is a disabling complication to cancer, the optimal treatment for which is not settled. An analysis was performed for all patients with MSCC secondary to lung cancer in East Denmark from 1979 to 1988. The total series included 102 cases with small-cell carcinoma (SCLC; 40%), adenocarcinoma (ACL; 26%), squamous cell carcinoma (SQLC; 18%) and large-cell carcinoma (LCC; 9%). Symptoms, clinical presentations, and therapeutic results are described. The outcome of treatment depended fundamentally on the patient's neurologic condition at the time of the diagnosis. All patients with SCLC who were able to walk at the time of MSCC remained ambulatory, whereas 15% of the nonambulatory SCLC patients regained walking ability. In non-SCLC, 95% of patients continued to be able to walk, whereas 22% regained the ability to walk. No major differences in the immediate outcome of treatment between the various histologic types of lung cancer and the different treatment modalities were observed; however, 82% of the patients with non-SCLC benefited from treatment with laminectomy followed by radiotherapy (RT) compared with either laminectomy (47%) or RT (39%) alone (P = .03, chi 2 test). The group of patients who were treated with laminectomy followed by RT had a better survival (median value, 3.5; range, 0 to 132 months) than patients who were treated with either laminectomy (median value, 1.5; range, 0 to 32 months) or RT (median value, 1; range, 0 to 59 months) alone (P = .03, log-rank test). No significant difference was observed in survival between the various histologic types of lung cancer (P = .18, log-rank test). Despite a short survival, early diagnosis and immediate treatment is crucial because it may preserve the gait function in 97% of lung cancer patients who develop malignant spinal cord compression.

Sensitivity and specificity of MRI in detecting malignant spinal cord compression and in distinguishing malignant from benign compression fractures of vertebrae

The accuracy of magnetic resonance (MR) imaging in the detection of metastatic compression of the spinal cord and the cauda equina (MCCE) in 75 patients with known primary maglignancy outside the central nervous system is determined retrospectively by comparing the MR results with findings of myelography, surgery, clinical follow-up and autopsy. The sensitivity is 93%, the specificity 97% and the overall accuracy 95%. The signal intensity measured in the sagittal MR images of a collapsed vertebral body is divided by that of an average of three adjacent normal vertebrae to form a signal intensity ratio (SIR). The SIRs of 41 metastatic and 15 post-traumatic collapsed vertebrae are calculated. A ratio of 0.8 has the most differentiating power. All benign and one malignant compressed vertebrae have SIRs greater than 0.8.

The role of needle biopsy in the management of malignant spinal compression.

With the changing management of malignant spinal cord compression there has been a reduction in numbers of patients treated by conventional laminectomy. This has resulted in a move either to the use of radiotherapy or to the use of more major surgical procedures such as the transthoracic approach. In both of these situations a more logical approach to deciding on the treatment modality to be used can be achieved by determining the histology of the lesion by percutaneous needle biopsy. This paper describes the technique of needle biopsy and presents evidence that shows that a reliable and immediate diagnosis can be achieved by the use of smear histology.

The role of vertebral body collapse in the management of malignant spinal cord compression.

The management of malignant spinal cord compression has been reviewed recently and attention drawn to the adverse effects of laminectomy. Data from that review suggested that the presence of vertebral body collapse could have an important negative effect on the outcome of laminectomy. However, there was only scant evidence available in the literature to support that conclusion. Eighty consecutive patients with thoracic spinal cord compression due to a single metastasis treated by laminectomy are reported here. It is seen that the presence of vertebral collapse signified: a much reduced chance of regaining the ability to walk; a much greater possibility of further neurological deterioration; and a major increase in the incidence of post-operative spinal instability. The role of laminectomy in the management of such patients needs to be further questioned and alternative therapeutic measures such as radiotherapy, posterior spinal instrumentation or anterior surgery should be strongly considered in the presence of vertebral body collapse.

Impact of myelography on the radiotherapeutic management of malignant spinal cord compression.

From December 1981 through August 1984, 24 patients with spinal cord compression syndrome due to epidural neoplasms were evaluated for radiotherapy with clinical examination, radiographs of the spine, and myelography. All plain films were reviewed, and mock radiotherapy fields designed using specific criteria for margins. The same patients were reviewed a second time considering the additional information provided by myelography. The initial treatment fields were found to be inadequate in 69% of the patients. Even in patients with discrete bony lesions, the results of myelography affected the treatment 45% of the time. A history of previous spinal irradiation significantly influenced port design in only 1 of the 7 patients who had received previous radiotherapy. Although invasive, myelography is essential in planning the treatment of spinal cord compression.

Impact of myelography on the radiotherapeutic management of malignant spinal cord compression

Impact of myelography on the radiotherapeutic management of malignant spinal cord compression

Treatment outcome and complications in patients treated for malignant epidural spinal cord compression (SCC).

Sixty-seven episodes of spinal cord compression (SCC) were retrospectively evaluated regarding presenting features and treatment outcome. They were divided into three motor function groups. Group 1 consisted of 35 ambulatory patients, group 2 of 29 non-ambulatory patients and group 3 of three paraplegic patients. Lower extremity weakness was usually a late presenting feature and was frequently rapidly progressive. We suggest that SCC is an emergency, as successful treatment is unlikely if motor function is poor. All of the group 1 patients completing treatment remained ambulatory, in contrast to group 2 patients, in which only 25% regained the ability to walk, and group 3 patients, none of whom regained the ability to walk. Initial surgery or initial radiotherapy appeared to be equally effective in restoring or maintaining the ability to walk. Survival of patients ambulatory at completion of treatment was superior to that of non-ambulatory patients (p less than 0.03). Analysis of steroid-related complications suggested that frequent, severe and sometimes fatal complications can result from prolonged use with these drugs.

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.