What is the role of surgery in the treatment of malignant spinal cord compression?
The role for surgery has long been controversial in malignant spinal cord compression from metastatic prostate cancer. It is acknowledged that the outcomes with radiotherapy alone are suboptimal, especially if patients are non-ambulatory or paraplegic at presentation. However, clinicians had concerns subjecting patients who are often unwell with a poor median survival to the rigors of surgery for a non-quantifiable degree of benefit. Also, it was not known whether surgery should consist of a decompression laminectomy alone (to relieve pressure on the spinal cord) or the more aggressive circumferential decompression laminectomy where the entire affected vertebrae is removed. Decompressive laminectomy should be considered when radiotherapy cannot be given due to previous treatment or progression during or shortly after radiotherapy.
There are only two randomised trials comparing surgery with radiotherapy versus radiotherapy alone.The Patchell study of 101 patients (16% with prostate cancer) compared radiotherapy alone with direct circumferential decompression (with spinal stabilisation if spinal instability present) followed by radiotherapy.
The Patchell study demonstrated a clinically significant improvement with the addition of aggressive surgery to radiation only and was stopped early as it met pre-set termination criteria. For ambulatory patients at presentation, 94% versus 74% were walking post-treatment in the surgery and radiotherapy arms respectively. For non-ambulatory patients, the rates were 62% versus 19%. There was a median survival improvement of 126 versus 100 days (p=0.03) and a significant improvement in pain levels as judged by median mean daily morphine doses (p=0.002) with surgery.
Patients have to be carefully selected for the aggressive approach outlined in the Patchell study. They need to be fit for aggressive surgery, have a life expectancy of more than three months, have a single site of cord compression, have neurologic symptoms present, and have surgery within 48 hours if paraplegic. To be considered for this approach, hospitals would need adequate neurosurgical services and appropriate supportive care. This is likely to be available only in major teaching hospitals. The role of aggressive surgery for early malignant spinal cord compression seen on imaging but not causing neurologic symptoms is unclear.
The Young study of 29 patients (14% had prostate cancer) compared radiotherapy alone with laminectomy plus radiotherapy. This underpowered study demonstrated no benefit in ambulation or bladder function with the addition of a decompression laminectomy to radiotherapy. The Young study differed from the Patchell study in having significantly less aggressive surgery.
Evidence summary and recommendations
|There is one randomised trial demonstrating a significant clinical benefit with the addition of aggressive surgery (direct circumferential decompression) to radiotherapy for appropriate patients with symptomatic malignant spinal cord compression||II|||
|The role of decompression laminectomy prior to radiotherapy is unknown, with one small trial demonstrating no benefit.||II|||
For highly selected patients with malignant spinal cord compression, vertebrectomy with
spinal stabilisation prior to radiotherapy should be considered. The role of decompression laminectomy prior to radiotherapy is unknown.
- Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2017 Nov 18;366(9486):643-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16112300.
- Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 1980 Dec;53(6):741-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/7441333.