This study is very helpful for oncologists, spine surgeons and neurologists managing metastatic cancer of the spine.
This study suggests that early surgical decompression for metastatic spinal tumours with symptomatic neurocompression is pivotal for the successful restoration of mobility.
Intractable back pain and paralysis are dreaded complications of metastatic disease of the spine. Since the spine is the most common site of bone metastasis1,2 and more patients are surviving their disease by modern therapy, it is expected that more patients will develop neurological complications and necessitate expert and prompt treatment.
Unfortunately three audit reports of clinical practices for cancer patients3,4,5 revealed unacceptable delays in diagnosis and investigation, poor ambulatory status, poor assessment of pain and lack of clear plans for the majority of patients with malignant spinal cord compression and preventable neurological complications. Recommendations included the development of regional guidelines for referral and treatment. These findings demonstrate inappropriate variations of care and suboptimal practices with detrimental results for cancer patients.
Most evidence in the literature confirms the fact that surgery should no longer be a contentious issue and should always be considered when managing patients with oncological neurocompression of the spine. Since cancer patients suffering from pain can greatly benefit from decompression6,7 surgery should not be contraindicated even in the presence of paraplegia.
In a landmark randomised trial study, Patchel R et al8 compared decompressive surgery and post operative radiation with radiotherapy alone. The patients in both groups were treated within 24 hours of entering the study. The proportion of patients who were able to walk after treatment was significantly higher in the group who were treated surgically compared with those who received radiotherapy (84% vs 57%, p = 0.001). Those treated surgically had better restoration of mobility (62% with surgery vs 19% in the radiotherapy group), greater improvement in pain, muscle strength, functional status and survival rates (median survival 126 day in the surgery group vs 100 days in the radiotherapy group).
Likewise, Chaichana et al9 have demonstrated that when surgery was instituted within 48 hours after the onset of symptoms and was followed by post-operative radiotherapy, it was more likely that patients would regain mobility. However, pre-operative radiation for patients who had lost their mobility compromised the effectiveness of surgery.
This study by Fürstenberg et al addressed the timing of surgery by comparing retrospectively the effectiveness of decompression when undertaken less or more than 48 hours after the development of symptoms in 35 patients with incomplete tetraplegia and paraplegia, caused by metastatic spinal cord compression. They showed that when patients were operated soon after the onset of symptoms there was significantly better neurological recovery (improvement 71.4%, unchanged 28.6%) compared with those with delayed surgical treatment (improvement 28.6%, unchanged 42.8%, deterioration 28.6%). Furthermore, the mobility of patients having early surgical treatment improved compared with those who underwent surgery later. The latter were also more likely to have a deterioration of mobility. Normal bladder function was a reliable index of good surgical outcome after decompression for neurological compromise. Conversely, patients with a dysfunctional bladder had a poorer prognosis. Thus bladder function can be considered as a good prognostic factor for neurological recovery after decompression.
However, the present study has not shed any light on the influence of surgery on bladder and/or on bowel control. Furthermore it was not designed to assess the best surgical approach nor deal with pain relief and survival. Two caveats of this study are its retrospective nature and the small number of patients. The authors indicated that a large series would be required. However, investigators should be wary of the ethical considerations when deciding to conduct a larger and more persuasive study that may deprive some patients with cancer from the benefits of early surgery. Since a larger prospective study seems unlikely, the present study is a useful addition to the literature.
I hope the important contribution of this paper on the place of early surgical decompression will be used in guidelines for managing metastatic cancer of the spine in patients with neurological involvement and particularly those whose mobility is compromised.
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3. McLinton A, Hutchison C. Malignant spinal cord compression: a retrospective audit of clinical practice at a UK regional cancer centre. Br J Cancer 2006;94:486-91.
4. Levack P, Graham J, Collie D, et al. Scottish Cord Compression Study Group. Don’t wait for a sensory level-listen to the symptoms: a prospective audit of the delays in diagnosis of malignant cord compression. Clin Oncol 2002;14:472-80.
5. DJ Husband. Malignant spinal cord compression: prospective study of delays in referral and treatment. BMJ 1998;317:18-21.
6. Abel R,,Keil M, Schlager E, Akbar M. Posterior decompression and stabilization for metastatic compression of the thoracic spinal cord: is this procedure still state of the art? Spinal Cord 2008;46:595-602.
7. Wise JJ, Fischgrund JS, Herkowitz HN, Montgomery D, Kurz LT. Complication, survival rates, and risk factors of surgery for metastatic disease of the spine. Spine 1999; 24:1943-1951.
8. Patchel RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366:643-8.
9. Chaichana KL, Woodworth GF, Sciubba DM, et al. Predictors of ambulatory function after decompressive surgery for metastatic epidural spinal cord compression. Neurosurgery 2008;62:683-92.
Hadjipavlou A, Professor
University of Crete, Crete, Greece