Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

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1st line – corticosteroid

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1st line – 

corticosteroid

Corticosteroids should be initiated as soon as possible for people with neurologic symptoms or signs of MSCC, ideally within 12 hours of onset of symptoms, with the aim of improving or stabilizing neurologic deficits ahead of definitive treatment.[47]​ There is consensus that treatment with corticosteroids plus radiation therapy is more effective than radiation therapy alone.[60]

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.[60]​[61]​​[62] US National Comprehensive Cancer Network guidelines and guidelines from the UK National Institute for Health and Care Excellence recommend dexamethasone.[47]​​[55] Canadian guidance from 2012 also recommends dexamethasone, but advises against using high-loading-dose corticosteroids, due to the risk of serious adverse effects.[63]

After starting treatment with radiation therapy 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 radiation therapy.[7]​​[19][47]​​[60]

Primary options

dexamethasone sodium phosphate: 10 mg intravenously as a loading dose, followed by 16 mg/day given in divided doses every 6 hours

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Plus – radiation therapy

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radiation therapy

Treatment recommended for ALL patients in selected patient group

Treatment comprises radiation therapy with or without surgery. Indications for radiation therapy alone include: radiosensitive tumors (small cell lung carcinoma and myeloma); no spinal instability; rapidly progressive neurologic decline with limited life expectancy; and the presence of significant medical comorbidities. Radiation therapy on its own is associated with fewer complications than surgery, but may not be as effective.

Radiation therapy may be given as palliative treatment for patients with a poor prognosis; urgently as first-line treatment to prevent further neurologic deterioration; or after surgery, with the aim of reducing local recurrence.

Palliative treatment 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][55][67]

For patients with a better prognosis, 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][68][69]​​

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 tumor recurrence.[61] One meta-analysis reported no evidence of differences in motor response, bladder dysfunction, or overall survival between single-fraction and multi-fraction radiation therapy for patients with MSCC and a limited prognosis.[70]

One randomized controlled trial (RCT) reported that a single 10 Gy fraction was noninferior to 20 Gy in five fractions in preserving mobility at 5 weeks in patients with MSCC not having surgical decompression.[71] In another RCT, a single dose of 8 Gy did not meet the criterion for noninferiority for the primary outcome (ambulatory at 8 weeks), compared with 20 Gy of radiation therapy 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.[72]

Potential benefits of single-fraction radiation therapy include decreased treatment burden for patients with limited life expectancy and improved treatment adherence. Radiation therapy standard regimens can alter blood supply to the bone, leading to avascular necrosis, which can affect activities of daily living.[67]

Consider – surgery

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surgery

Treatment recommended for SOME patients in selected patient group

Surgery in addition to radiation therapy is indicated for: patients who have a life expectancy of more than 6 months, have some useful neurologic function preserved (i.e., MRC manual muscle motor test grade 3 and above), and are fit for general anesthetic; tissue diagnosis needed; spinal instability; limited sites of spinal involvement; radio-resistant tumors.

The Spinal Instability Neoplastic Score (SINS) is a classification system for assessing spinal instability and whether surgical evaluation is required.[20][33][36][37][38] The Spine Oncology Study Group recommends surgical evaluation for all patients with a SINS score above 7.[36] Other tools that can be used to assess whether surgery is indicated include the NOMS (neurologic, oncologic, mechanical stability, and systemic disease) framework, and the Tokuhashi and Tomita scoring systems.[29][65][66]

The aims of surgery are to achieve decompression of the spinal cord, and to reconstruct and stabilize the spinal column if required.

There are a number of approaches to decompression surgery, but limited evidence is available about which is the most effective.[45][55][76][77] 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.[78]

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][63]

Posterior decompressive laminectomy was 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 stabilization is recommended.[79]

In separation surgery, the spine is stabilized and a portion of the tumor is resected to create a margin around the spinal cord, with the aim of reducing potential damage from subsequent radiation therapy.[33][80]

Percutaneous stabilization methods 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.[81]

Potential complications of surgery include infection, spinal instability, hemorrhage, 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.[82][83]

Consider – external bracing

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external bracing

Treatment recommended for SOME patients in selected patient group

External bracing with spinal orthoses can be considered as a conservative treatment option for pathologic vertebral compression fractures and pain related to spinal metastases. Bracing provides support and may assist patients in adhering to precautions (no bendling, lifting, twisting).[57][58] Literature guiding the use of bracing for management of pathologic compression fractures is limited; however, an International Spine Oncology Consortium report endorses external bracing as a suggested treatment option for patients with spinal metastases.[59]

Plus – prevention of venous thromboembolism

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prevention of venous thromboembolism

Treatment recommended for ALL patients in selected patient group

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

Pharmacologic prophylaxis should be used unless contraindicated; non-pharmacologic measures (e.g., graduated compression stockings, intermittent pneumatic compression devices) may be used for patients at high risk for bleeding.[84]

See Venous thromboembolism (VTE) prophylaxis.

Plus – maintenance of volume and blood pressure

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maintenance of volume and blood pressure

Treatment recommended for ALL patients in selected patient group

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

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 pharmacologic treatments.

Plus – prevention of gastric stress ulcers

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prevention of gastric stress ulcers

Treatment recommended for ALL patients in selected patient group

Prevention of stress ulceration with a proton-pump inhibitor (e.g., omeprazole) or an H2 antagonist (e.g., famotidine) is indicated for at least 4 weeks following spinal cord surgery.[86]

Primary options

omeprazole: 20-40 mg orally once daily

OR

famotidine: 40 mg orally once daily; 20 mg intravenously every 12 hours

Plus – bladder and bowel management

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bladder and bowel management

Treatment recommended for ALL patients in selected patient group

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 catheterization 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 catheterization is not feasible.[87][88]

A bowel program, laxatives and/or bowel evacuation may be required.[89]

Plus – other supportive therapies

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other supportive therapies

Treatment recommended for ALL patients in selected patient group

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 mobilize 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.

Plus – rehabilitation

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rehabilitation

Treatment recommended for ALL patients in selected patient group

Rehabilitation efforts are focused on addressing symptoms and physical impairments. These efforts should be patient focused, with the goals of maximizing function and preventing future complications.[7]​​[19][47] Interventions may include physical 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.[90] Patients with spinal cord tumors who took part in rehabilitation programs showed improvements in function, mood, quality of life, and survival in one study, but the authors noted that access to such programs can be limited.[21]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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