Background for Fast Fact #238     Metastatic spinal cord compression (SCC) is a medical emergency; early treatment is associated with less functional disability. SCC-specific treatment options include corticosteroids, radiotherapy and surgery. Most patients with SCC require opioids for pain relief (1). This Fast Fact discusses management of SCC in adults. Fast Fact #237 discusses its diagnosis.

Corticosteroids    Dexamethasone is the most tested steroid in clinical trials. Studies have shown it provides analgesia and reduces vasogenic edema which may lead to better neurological outcomes (1). Treatment should be started as soon as diagnosis is made; studies in acute spinal cord injury suggest significant neurological improvement when used within 8 hours of injury. Historically, debate existed between using high dose dexamethasone (100 mg loading, then 96 mg daily) versus moderate dose (10 mg loading, then 16 mg daily). A randomized controlled trial comparing the two doses found no differences in efficacy and thus most give the lower dose (2).  Many studies give the steroids divided 4 times a day (total 16 mg daily). Most generally start IV and then switch to PO when patients are “clinically stable” and more definitive therapy (radiation or surgery) has been initiated.   Steroids should be tapered as soon as possible to prevent long term toxicities, most of the time they are tapered over 2 weeks as tolerated after completion of surgery and/or radiation therapy (3). Common short term side effects include hyperglycemia, insomnia and gastric distress.  Serious acute adverse effects such as gastrointestinal perforation or bleeding, psychosis, sepsis, and death are associated with high doses only (17%) (4).

Radiotherapy (RT)   In the absence of bony instability, RT has historically been the treatment of choice, preferably started within 24 hours of diagnosis. Dose schedule for RT ranges from single fraction 8 Gy to 20 fractions of 40 Gy. One or two fractions of 8 Gy may be preferable in patients with short prognoses and, in one study, had a similar outcome to more prolonged treatment (4). RT results in pain relief in 40-80% of patients and sphincter control in 45-90% of cases (4,5) when instituted in time. About 90% of ambulatory patients retain ambulation with RT alone, but less than 30% of patients who have lost the ability to walk by the time RT is initiated regain ambulation (3).

Surgery     Until recently, surgery was reserved for cases with SCC in a previously irradiated area, neurologic deterioration during RT, spinal instability, or bony compression. However, a meta-analysis (6) and a randomized controlled trial (7) found better functional outcomes with surgery plus post-operative RT as compared to RT alone. This trial used a newer surgical technique (circumferential decompression, reconstruction and immediate stabilization). 84% of the patients in the surgery group were ambulatory and retained ambulation for a longer time (a median of 122 days) after treatment compared to 57% in the RT group (median 13 days).  62% of the non-ambulatory patients regained the ability to walk after the surgery compared to 19% in the RT groups. The surgery group also maintained continence for a significantly longer time (median 156 days vs. 17 days). A more recent retrospective matched pair analysis of cancer patients with SCC comparing RT alone to surgery plus RT did not find any significant differences in outcome between the two treatments (8). Prompt, interdisciplinary evaluation by radiation oncologists and spine surgeons is indicated in order to identify the best treatment course.

Other treatments    Spinal Stereotactic Radiosurgery (SRS) has an investigational role in adult non-surgical patients with radio-resistant tumor or those with previously irradiated areas (9). Transarterial embolization is another novel investigational treatment used preoperatively for hypervascular spinal tumors causing compression, (10). In adults, chemotherapy has no role in the acute management even in chemo-sensitive cancers because of its slow effect. Although bisphosphonates reduce the incidence of skeletal complications of cancer, there are no data to suggest a benefit in treating SCC.

Prognosis      Median survival after developing SCC is between 3-6 months in adults. The Modified Baur Score identifies three prognostic groups (0-1; 2; 3-4) and is easily scored.  One point is given for a positive answer for 4 questions (absence of visceral metastases; solitary metastasis; primary cancer is not a lung cancer; primary cancer is breast or kidney cancer) (11). Median survival for a 0-1 point is 4.8 months; 2 points 18.2 points; 3-4 points 28.4 months (12). Other recognized poor prognostic factors for SCC include baseline non-ambulatory status, low serum albumin, and rapidity of developing motor symptom (worst if <7 days and better if more than 2 weeks after the onset of symptoms) (13,14).

Conclusion      

• A loading dose of dexamethasone 10 mg IV should be given as soon as possible after diagnosis of SCC, followed by maintenance dose of 4 to 6 mg every 6-8 hours.
• Patients younger than 65, with a single area of compression, paraplegia < 48 hours, and a predicted survival >6 months, should be urgently evaluated by neurosurgery (or at some institutions orthopedic surgery) for consideration of decompressive surgery followed by radiation therapy (4). 
• If surgery is contraindicated, palliative RT alone is indicated. Patients with a predicted survival of <6 months will probably benefit as much from one dose of 8Gy radiation compared with two doses or 8 doses; patients with longer prognoses will likely have less tumor recurrence with a longer course of radiation therapy (4).

References 

1. Goldstein NE, Morrison RS.  Evidence-based practice of palliative medicine (Ed 1). Philadelphia PA 2013, Elsevier Saunders.
2. Vecht CJ, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology. 1989;  39(9):1255-7.
3. Loblaw DA, Perry J, Chambers A, et al. Systematic review of the diagnosis and management of malignant extradural spinal cord compression: The Cancer Care Ontario Practice Guidelines Initiative’s Neuro-Oncology Disease Site Group. J Clin Oncol 2005; 23:2028-37.
4. George R, Jeba J, Ramkumar G, Chacko AG, Leng M, Tharyan P. Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD006716.
5. Maranzano E, et al.  Short-course versus split course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol. 2005; 23:3358–65.
6. Klimo P, et al.  A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol. 2005; 7(1):64-76.
7. Rades D, et al.  Validation and simplification of a score predicting survival in patients irradiated for metastatic spinal cord compression. Cancer. 2010; 116:3670-3.
8. Rades D, Huttenlocher S. Matched pair analysis comparing surgery followed by radiotherapy and radiotherapy alone for metastatic spinal cord compression. J Clin Oncol. 2010; 28(22):3597-3604.
9. Ryu S, Rock J, Jain R, et al. Radiosurgical decompression of metastatic epidural compression. Cancer. 2010; 116(9):2250-7.
10. Kato S, et al. Surgical management of aggressive vertebral hemangiomas causing spinal cord compression: long-term clinical follow-up of five cases. J Orthop Sci. 2010; 15(3):350-6.
11. Leithner A, Radl R, Gruber G, et al: Predictive value of seven preoperative prognostic scoring systems for spinal metastases. Eur Spine J 2008; 17:1488-1495.
12. Wibmer C, Leithner A, Hofmann G, et al: Survival analysis of 254 patients after manifestation of spinal metastases: Evaluation of seven preoperative scoring systems. Spine 2011; 36:1977-1986.
13. Lawton AJ, Lee KA, Cheville AL, et al.  Assessment and management of patients with metastatic spinal cord compression: a multidisciplinary review. J Clin Onc  2018; 37(1):61-71.
14. Rades D, et al.  Validation and simplification of a score predicting survival in patients irradiated for metastatic spinal cord compression. Cancer. 2010; 116:3670-3.

Author Affiliations:  University of Pittsburgh Medical Center, Pittsburgh, PA.
Version History: Originally published December 2010; Copy-re-edited November 2015; then again in February 2025.
Conflicts of Interest: None to report.