Surgery better than radiation alone for metastatic spinal compression

Significantly more patients treated with surgical decompression and radiotherapy regained walking ability than with radiotherapy only.

Treating metastatic epidural spinal cord compression using direct decompressive surgery followed by radiotherapy yields significantly better outcomes than radiotherapy alone, a new study shows.

Metastatic epidural spinal cord compression (MESCC) is a common, debilitating complication of cancer, occurring in 5% to 14% of cancer patients. The standard treatment has involved corticosteroids and radiotherapy. Simple laminectomy had also been used, but was largely abandoned after studies showed no benefit when used alone or combined with radiotherapy.

However, laminectomy may not have been the best surgical option for MESCC patients because the causing metastases are located anterior to the spinal cord in the vertebral body, according to the study.

“Laminectomy involves the removal of posterior elements of the spinal column and does not remove the tumor, and thus often does not result in immediate decompression,” the study authors said.

Roy A. Patchell, MD, a neurosurgeon and professor of surgery at the University of Kentucky College of Medicine in Lexington, compared the efficacy of immediate circumferential decompression alone and in combination with radiotherapy for MESCC.

He conducted the study with colleagues at the university and at several other institutions in the United States. They published their results in The Lancet.

Randomized study

The researchers randomized 101 patients with MESCC to one of two treatment groups. Group one included 50 patients treated with surgery followed by radiotherapy; group two included 51 patients who received radiotherapy alone.

Once diagnosed, all patients received 100 mg of dexamethasone followed by 24-mg doses every six hours until beginning treatment. Once treatment began, surgeons reduced the dose of corticosteroids but continued their administration until completing radiotherapy, according to the study. Reduced corticosteroid doses were used when appropriate, the authors noted.

For both groups, the researchers initiated either radiotherapy or surgery within 24 hours of randomization.

For the surgery group, the study protocol did not specify what operative techniques or fixation devices were to be used.

“[The] aim of surgery was to provide immediate direct circumferential decompression of the spinal cord. The operation was tailored for each patient depending on the level of the spine involved and the patient's circumstances,” the study authors said. All surgery patients underwent radiotherapy within 14 days postop. The researchers applied the same radiotherapy treatments for both patient groups, which involved 10 fractions of 3 Gy of radiation.

The primary outcome measure was patients’ abilities to walk following treatment. Secondary endpoints included effects on urinary continence, muscle strength and functional status, according to the study.

“A patient was deemed ambulatory if he or she could take at least two steps with each foot unassisted, even if a cane or walker was needed,” the authors said.

Study terminated early

Initially, 123 patients met eligibility requirements for inclusion in the study. However, the researchers ended the trial early after an interim data analysis showed significantly more surgery patients were reaching the study's primary endpoint.

In the surgery group, 42 of the 50 patients (84%) could walk following treatment compared with 29 of the 51 patients (57%) in the radiotherapy-only group (P=.001).

Patients treated with surgery also retained their walking ability significantly longer. These patients retained walking ability for a mean of 122 days vs. a mean of 13 days for radiotherapy-only patients.

In addition, more patients who underwent surgery regained the ability to walk and maintained that ability significantly longer than radiotherapy-only patients. Of 32 patients who entered the study unable to walk (16 in each group), 10 patients (62%) in the surgery group and three (19%) in the radiotherapy-only group regained walking ability (P=.01). Surgery patients retained walking ability for a mean 59 days compared with zero days for radiotherapy-only patients (P=.04), according to the study.

The authors noted that surgery patients had a lower 30-day mortality rate (6%) compared to radiotherapy-only patients (14%). Also, surgery did not increase hospitalization, which averaged 10 days for both groups.

“Surgery allows most patients to remain ambulatory for the remainder of their lives, whereas patients treated with radiation alone spend a substantial proportion of their remaining time paraplegic,” the study authors said, noting surgery also increased patients’ survival times.

“Clearly, first-line treatment with surgery was superior. For these reasons, the best treatment for spinal cord compression caused by metastatic cancer is surgery as an initial treatment, followed by radiotherapy.”

For more information:
Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet. 2005;366:643-648.