Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial

The management of metastatic epidural spinal cord compression (MESCC) can be challenging. Radiotherapy is a well accepted standard, but the role of surgery remains variable. The paper by Patchell et al. (see note 1) stimulated debate on the role of surgery in these patients. The study compared surgical resection plus radiotherapy with radiotherapy alone in the treatment of spinal cord compression due to metastatic cancer. All eligible patients had a tissue proven diagnosis of cancer and MRI confirmation of displacement of the spinal cord, as well as one other neurological sign or symptom (including pain). Attention should be paid to the exclusion criteria, such as patients with radiosensitive tumours, those with pre-existing neurological problems not directly related to MESCC, patients who had previously received spinal radiation and those with multiple discrete compressive lesions. This possibly resulted in selection bias. Patients were assigned to surgery plus radiotherapy vs. radiotherapy alone. The groups were well matched. The primary end point was the ability to walk after treatment. Survival time after treatment was also recorded. Two notable differences between the groups became areas of controversy: first, the difference in the median time between diagnosis of primary tumour and development of MESCC (7 months in the radiation group, whilst only 3 months in the surgery group) and, secondly, the relatively greater delay between development of motor symptoms and the commencement of treatment. The delay was an average of 2 days longer in the radiotherapy only group compared to the surgery group. There is ample evidence to suggest that the earlier cord compression is relieved the better the outcome. Based on an interim analysis, the study was stopped prematurely as surgical superiority was identified. The combined posttreatment ambulatory rate in the surgery group was 84% (42/50) and only 57% (29/51) in the radiation group (p1⁄4 0.001). In a subgroup of patients who could walk at entry to the study, 94% in the surgery group and 74% in the radiation group continued to walk after treatment. These patients continued to walk for a median of 153 and 54 days, respectively. Sixteen patients in each group were unable to walk on entry into the study; of these, 10 patients in the surgery group and three patients in the radiation group regained the ability to walk. Secondary end points were all in favour of the surgery group. Surgical patients were less susceptible to complications associated with paraplegia. The median survival in the surgical group was 4.2 months compared with 3.3 months in the radiation only. Patchell’s study is a significant attempt to improve palliative care for a condition. The study is helpful in defining the role of surgical treatment for metastatic spinal cord compression. The study only looked at a narrow part of the spectrum of patients with MESCC and the findings cannot be extrapolated to all patients with MESCC. The National Institute for Health and Clinical Excellence is in the process of producing guidelines for the diagnosis and management of patients with metastatic spinal cord compression.