Approach

The goals of treatment for patients with MSCC are to prevent clinical deterioration, to relieve pain and other symptoms, and to maintain or restore functional ability. Treatment involves corticosteroids initially, followed by radiotherapy with or without surgery.[19][54] A multidisciplinary approach involving medical oncology, radiation oncology, and neurosurgery is important for optimising treatment and patient outcomes.[40][55]

Treatment of MSCC may not be warranted under certain circumstances (e.g., in patients with paralysis of more than 1 week's duration, poor baseline performance status, and short life expectancy [days to weeks] due to underlying disease).[7] Any decision not to treat must be reached in collaboration with the patient.[7]

Positioning and bracing

External bracing with spinal orthoses can be considered as a conservative treatment option for pathological vertebral compression fractures and pain related to spinal metastases. Bracing provides support and may assist patients in adhering to precautions (i.e., no bending, lifting, twisting).[56][57]​ Literature guiding the use of bracing for management of pathological compression fractures is limited; however, an International Spine Oncology Consortium report endorses external bracing as a suggested treatment option for patients with spinal metastases.[58]

Corticosteroids

Corticosteroids should be initiated as soon as possible for people with neurological symptoms or signs of MSCC, ideally within 12 hours of onset of symptoms, with the aim of improving, or at least stabilising, neurological deficits ahead of definitive treatment.[40]​ Corticosteroids provide pain relief, reduce tumour-associated oedema, and may be oncolytic for some tumours.[19][54]​ There is consensus that treatment with corticosteroids plus radiotherapy is more effective than radiotherapy alone.[59]

Corticosteroids are contraindicated if there is confirmed, or a significant suspicion of, lymphoma.

There is a lack of evidence about which type of corticosteroid is preferred, or about optimal dose or duration of treatment.[59][60][61] US National Comprehensive Cancer Network guidelines and guidelines from the UK National Institute for Health and Care Excellence recommend dexamethasone.[40]​​[54] Canadian guidance from 2012 also recommends dexamethasone, but advises against using high-loading-dose corticosteroids, due to the risk of serious adverse effects.[62]

After starting treatment with radiotherapy or surgery, corticosteroids should be reduced gradually over several days and stopped, since there is limited long-term benefit and a risk of serious adverse effects. Corticosteroids should also be reduced gradually, with the aim of stopping treatment altogether, in patients who are not having surgery or radiotherapy.[7][19][40]​​[59]

Choice of treatment

Treatment comprises radiotherapy with or without surgery. A number of factors should be taken into account when deciding on definitive treatment. These include the patient's neurological status, degree of spinal cord compression, life expectancy, extent of metastatic disease, spinal stability, tumour radiosensitivity, and the patient's preferences.[7][54][60][63] Palliative care may be the preferred option in some cases.

The Spinal Instability Neoplastic Score (SINS) may be used for assessing whether surgical evaluation is required.[20][33][36][37][38][40]​ The Spine Oncology Study Group recommends surgical evaluation for all patients with a SINS score above 7.[36]

The NOMS (neurological, oncological, mechanical stability, and systemic disease) framework illustrates the need for a multidisciplinary approach to treating spinal involvement. The neurological and oncological elements determine surgical indications and approach to radiotherapy. Spinal mechanical instability alone is an indication for surgical intervention if a patient can tolerate it. The systemic component considers extent of systemic disease and its impact on treatment outcomes and tolerance.[29]

Other classification systems that assist in surgical decision-making are the Tokuhashi and Tomita scoring systems. The Tokuhashi scoring system is based on six prognostic parameters for patients with metastasis: general medical condition, number of extraspinal metastases, number of vertebral metastases, presence of visceral metastases, primary tumour type, and neurological deficits.[40][64] The Tomita scoring system uses three prognostic factors - grade of malignancy, visceral metastases, and bone metastasis - for treatment decision making.[65]

Indications for radiotherapy alone include:

  • Radiosensitive tumours (small cell lung carcinoma and myeloma)

  • No spinal instability

  • Rapidly progressive neurological decline with limited life expectancy

  • The presence of significant medical comorbidities.

Indications for radiotherapy plus surgery include:

  • Patients who have a life expectancy of more than 6 months, have some useful neurological function preserved (MRC manual muscle motor test grade 3 and above), and are fit for general anaesthetic

  • Tissue diagnosis needed

  • Spinal instability

  • Limited sites of spinal involvement

  • Radio-resistant tumours.

Radiotherapy

Radiotherapy on its own is associated with fewer complications than surgery, but may not be as effective. It may be given:

  • As palliative treatment for patients with a poor prognosis

  • Urgently as first-line treatment to prevent further neurological deterioration

  • After surgery, with the aim of reducing local recurrence.

Palliative radiotherapy for pain relief

Palliative treatment with radiotherapy for pain relief is appropriate for patients with a poor prognosis (e.g., with less than 6 months' life expectancy, poor performance status, and established paraplegia for more than 24 hours). A single dose of 8 Gy in one fraction is typical.[7][19][33][66]

Radiotherapy to improve function

A number of different regimes have been used with the aim of improving motor function, ambulatory status, and survival. Typical examples include 20 Gy in five fractions, or 30 to 40 Gy in 10 fractions. Longer-course schedules may be associated with lower in-field recurrence.[7][33][54][67][68]​​

One Cochrane review from 2015 concluded that the benefits of one dose of radiation (8 Gy), two doses (16 Gy), and eight doses (30 Gy) were probably similar for ambulant adults with MSCC who have stable spines and predicted survival of less than 6 months. However, it was unclear in the study whether one dose is as effective as two or more doses in preventing local tumour recurrence.[60] One meta-analysis reported no evidence of differences in motor response, bladder dysfunction, or overall survival between single-fraction and multi-fraction radiotherapy for patients with MSCC and a limited prognosis.[69]

One randomised controlled trial (RCT) reported that a single 10 Gy fraction was non-inferior to 20 Gy in five fractions in preserving mobility at 5 weeks in patients with MSCC not having surgical decompression.[70] In another RCT, a single dose of 8 Gy did not meet the criterion for non-inferiority for the primary outcome (ambulatory at 8 weeks), compared with 20 Gy of radiotherapy in 5 fractions, in patients with MSCC with an estimated life expectancy greater than 8 weeks, but not able to undergo surgery. The authors noted that the clinical importance of this finding was unclear.[71]

Potential benefits of single-fraction radiotherapy include decreased treatment burden for patients with limited life expectancy and improved treatment adherence. Radiotherapy standard regimens can alter blood supply to the bone, leading to avascular necrosis, which can affect activities of daily living.[66]

Stereotactic radiosurgery

Stereotactic radiosurgery is the delivery using imaging guidance of one or more high doses of radiation to a defined area that is contoured to the shape of the tumour. There is some evidence of superiority of stereotactic radiosurgery over conventional radiotherapy for spinal metastases, but little evidence of superiority for treating acute cord compression.[33][55][68]​​​​[72]​​[73]

Radioisotopes

Radioisotopes with affinity for bone, such as strontium-89, phosphorus-32, RAD001, or lutetium-177-labelled prostate-specific membrane antigen (Lu177-PSMA), represent an option for treating patients with bony metastases, primarily for pain.[74] These tumouricidal beta-emitters are administered intravenously.

Surgery

There are a number of approaches to decompression surgery, but limited evidence is available about which is the most effective.[46][54][75][76] The optimal approach will vary depending on factors such as the patient's ambulatory status, location of the lesion, presence of bony compression and spinal instability, comorbidities, technical surgical factors, and potential complications.[77]

Surgical techniques include the following:

  • Vertebrectomy: can be carried out via posterolateral or anterior approaches. This technique has been shown to be effective in improving ambulatory ability and relieving back pain.[19][62]

  • Posterior decompressive laminectomy: traditionally used to treat MSCC, but efficacy has been demonstrated only for posterior spinal cord compression, and it may cause spinal instability if used for lesions in other locations.[19][33] Therefore laminectomy with stabilisation is recommended.[78]

  • Separation surgery. The spine is stabilised and a portion of the tumour is resected to create a margin around the spinal cord, with the aim of reducing potential damage from subsequent radiotherapy.[33][79]

  • Percutaneous stabilisation methods. These are used for management of pathological vertebral compression fractures caused by metastatic disease, with the aim of reducing pain and functional disability. Techniques include vertebroplasty and kyphoplasty. They may be used alongside other treatments such as radiotherapy or radiosurgery.[80]

Potential complications of surgery include infection, spinal instability, haemorrhage, root/cord injury, respiratory complications, and wound breakdown. In kyphoplasty, there may be some leakage of the filling materials. The risk of different complications varies depending on the surgical approach.[81][82]

Supportive care

A number of supportive therapies may be appropriate, depending on the patient's circumstances.[19][40]​​

Prevention of venous thromboembolism

All patients should be given prophylaxis to prevent venous thromboembolism and possible pulmonary embolism.

Pharmacological prophylaxis should be used unless contraindicated; non-pharmacological measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[83]

See Venous thromboembolism (VTE) prophylaxis.

Maintenance of volume and blood pressure

Treatment of autonomic dysfunction and prevention of resultant hypotension may be required, particularly in patients with cervical involvement, as it may contribute to further neurological impairments. Based on literature in acute traumatic spinal cord injuries, mean arterial pressure (MAP) should be kept above 85-90 mmHg.[84]

In the acute setting, treatment consists of central line placement with volume resuscitation and/or vasopressors. Orthostasis may also impact patients after the first 7 days post cord compression. Management may include ensuring adequate hydration, use of compression stockings and abdominal binders, and pharmacological treatments.

Prevention of gastric stress ulcers

Prevention of stress ulceration with a proton-pump inhibitor or an H2 antagonist is indicated for at least 4 weeks following spinal cord surgery.[85]

Bladder and bowel management

Bladder and bowel function should be assessed and monitored. Management should be based on whether the pattern is indicative of upper or lower motor neuron damage.

If bladder catheterisation is needed, an intermittent catheter is preferred, as this is associated with lower rates of urinary tract infection and urethral trauma. An indwelling catheter may be used if intermittent catheterisation is not feasible.[86][87]

A bowel programme (to help to prevent involuntary bowel movements, constipation, and impaction of the bowels), laxatives, and/or bowel evacuation may be required.[88]

Other supportive therapies

Risk assessment for pressure ulcers should be carried out. Preventive approaches include regular manual or automatic turning for patients on bed rest, encouraging patients who are not on bed rest to mobilise regularly (every few hours), and use of pressure relieving devices. See Pressure ulcers.

Nutritional support should include isotonic feeds and evaluation of dysphagia.

Mechanically assisted ventilation or manually assisted cough may be required.

Rehabilitation

Rehabilitation efforts are focused on addressing symptoms and physical impairments. These efforts should be patient focused, with the goals of maximising function and preventing future complications.[7][19][40]​ Interventions may include physiotherapy and occupational therapy, prescriptions for durable medical equipment including bracing, recommendations on pain management, and recommendations on bowel and bladder management.

A high proportion of patients with MSCC are discharged home after treatment.[89] Patients with spinal cord tumours who took part in rehabilitation programmes showed improvements in function, mood, quality of life, and survival in one study, but the authors noted that access to such programmes can be limited.[21]

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