Less pain noted 3 months after metastatic epidural spinal cord decompression surgery

Despite gains in function and pain control associated with surgery in these patients in a prospective multicenter study, they had poor overall survival rates.

Michael G. Fehlings

ORLANDO, Fla. — Surgery proved effective at the 3-month follow-up for improving pain and disability in adults with metastatic epidural spinal cord compression, according to an investigator involved in a North American prospective multicenter controlled study.

Michael G. Fehlings, MD, PhD, FRCSC, of the University of Toronto, noted at the 2010 Annual Meeting of the North American Spine Society that those patients who had 3-month results available from among 70 patients enrolled in the study showed highly significant improvement in utility based on their EuroQual-5D utility scores.

“We see major improvements in the brief pain index, as well as the Oswestry Disability Index, and again this is heavily weighted toward pain,” he said in his presentation.

Surgery vs. radiotherapy

Until a 2005 study by Patchell and colleagues supported treating metastatic epidural spinal cord compression (MESCC) patients surgically, radiotherapy alone was the accepted approach, Fehlings said and added, “We have seen a shift where more and more patients are undergoing surgical treatment.”

The purpose of the investigation he and his colleagues are conducting, which is sponsored by AOSpine North America, is to assess efficacy, cost effectiveness and cost utility of de novo surgical treatment for patients with MESCC vs. nonoperative radiotherapy treatment alone.

While some results at 6 months postoperatively are being evaluated in the trial, Fehlings’ presentation focused solely on the 3-month findings.

Many types of cancer pathologies can result in MESCC. However, based on these results, patients in the AOSpine North America study most often had breast, lung or prostate cancer. The majority of patients were men and the median age was 58 years old.

Predictors of survivorship needed

“About one-third of patients will die within 3 months and about one-half of patients by 6 months,” Fehlings said.

Based on the findings, 36% of patients died prior to their 3-month follow-up. Those who survived to that point saw their baseline pain scores of 6 points on the Visual Analog Scale improve to 2 points after surgery.

“We do see, interestingly, improvements in pain, which is not surprising perhaps, but also a substantial improvement in emotional well being, which is gratifying to see,” Fehlings said.

He called the poor survivorship statistics “sobering,” noting they occurred in the hands of experienced clinicians.

Better predictors of survivorship need to be identified, particularly if performing surgery in MESCC cases is to be worthwhile, Fehlings said. “In these patients, it is clear that surgery and radiotherapy is associated with reduced pain, improved function as assessed by the Oswestry Disability Index and improved health utilities,” he said. – by Susan M. Rapp

References:

• Fehlings MG, Kopjar B, Vaccaro A, et al. The effect of surgery on health related quality of life and functional outcomes in patients with metastatic epidural spinal cord compression — Initial results of the AOSpine North America prospective multicenter study. Paper #80. Presented at the 2010 Annual Meeting of the North American Spine Society. Oct. 5-9, 2010. Orlando, Fla.
• Patchell RA, et al. Lancet. 2005;366(9486):643-648.

• Michael G. Fehlings, MD, PhD, FRCSC, is the Krembil Chair in Neural Repair and Regeneration. He can be reached in the Division of Neurosurgery, 27 King’s College Circle, Toronto, Ontario M5S 1A1 Canada; 416-603-5627; e-mail: michael.fehlings@uhn.on.ca.
• Disclosure: The study was supported by AO Spine.

This study has several notable messages. The primary take away is that the authors suggest that surgery for epidural metastases is probably not worthwhile if the patient’s life expectancy is less than 3 months. Many clinicians have heretofore used a 6-month time frame. Another finding of interest is that surgery had no appreciable impact on neurologic status. The most significant clinical improvement was in pain level. Thus, pain relief, not neurologic status appears to be the primary indication for surgery. Finally, although the authors did not perform a formal economic analysis, the cost per quality adjusted life year for a surgical intervention giving a 0.19 improvement in utility score for a time period of 3 months is likely to be quite high.

— David A. Wong MD, MSc, FRCSC
Past President North American Spine Society (NASS)
Co-Chairman NASS Value Task Force
Director Advanced Center for Spinal Microsurgery, Presbyterian St. Lukes Medical Center
Denver
Disclosure: He has no relevant financial disclosure.