Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy

A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine

The anterior approach to the thoracic and lumbar spine for neoplastic disease is now a well-accepted procedure, with results, for the most part, superior to those achieved with laminectomy. However, the specific indications for anterior decompression and the selection of reconstruction techniques based on the location and extent of bony destruction have received surprisingly little attention. The authors report their experience with the operative management of 33 patients with benign and malignant tumors of the thoracic and lumbar spine, using the anterior transthoracic or retroperitoneal approach. The role of stabilization and the relative indications for anterior or posterior instrumentation are emphasized. The mean age of patients was 58 years. Twenty-three patients were male. Five patients had benign tumors, and the remainder had a variety of metastatic lesions. Twenty-nine patients had lower extremity motor deficits, although 25 were ambulatory preoperatively. Thirty-seven noncontiguous resections were performed in 33 patients. In 13 patients, the resected vertebral body was replaced with acrylic or bone without instrumentation; in 18, the acrylic was supplemented with anterior instrumentation; and in 6, both anterior and posterior instrumentation were used. Above T11, vertebral reconstruction techniques were used to restore stability after decompression. Between T11 and L4, anterior instrumentation was used to supplement vertebral reconstruction in all patients. Supplemental posterior instrumentation was used for three-column involvement. Motor function was stabilized or improved in 94% of patients, and 88% of patients were ambulatory postoperatively. Of 28 patients with malignant disease, 23 died after a mean survival of 10.2 months (range, 2-51 mo) and 5 are alive a mean of 34.4 months since their operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Early diagnosis and treatment of spinal epidural metastasis in breast cancer: a prospective study

This prospective study evaluated the usefulness of myelography in breast cancer patients who present with radiculopathy or myelopathy. A total of 124 consecutive myelograms were performed in 100 patients. Epidural metastasis (EM) was diagnosed in 67 myelograms (54%). Multiple epidural metastases were diagnosed in 15 (22%) of those, resulting in a total of 87 epidural lesions. A complete block was found in 13 EM (15%) and an incomplete block in 14 EM (16%). Clinical data could not predict the site of EM in 29 cases (33%). Fifteen asymptomatic EM were detected in myelograms with multiple EM. Plain radiographs were of no value in determining the site of EM in 29 cases (33%), including 13 cases (15%) without vertebral metastasis at the site of EM. Treatment consisted of radiotherapy (RT) with or without systemic treatment in 52 cases (80%), systemic treatment alone in 11 cases (17%) and surgery in two patients (3%). Clinical improvement was noticed in 72%, no change in 13%, and deterioration in 15%. No difference in response was noticed between RT and systemic therapy. Before treatment 21% and after treatment 15% of the patients could not walk. The one year survival was 42%. The ambulatory status at presentation was the most important prognostic factor. Examination of the spinal fluid, obtained at myelography, disclosed meningeal carcinomatosis in 9% of the patients. Imaging of the whole spinal canal with cytological examination of the spinal fluid is recommended in breast cancer patients suspected of epidural tumour with features of radiculopathy or myelopathy, irrespective of further clinical data and plain spinal radiographs.

Spinal epidural tumor in patients with prostate cancer. Clinical and radiographic predictors of response to radiation therapy

The authors retrospectively reviewed 50 episodes of spinal epidural tumor that occurred in 42 patients with metastatic prostate cancer and were treated with external-beam radiation. Treatment response was evaluated in terms of symptoms, neurologic status, and, in most cases, reduction of tumor on repeat myelography. At the completion of therapy, 92% of treated patients experienced pain relief and 67% had significant to complete improvement on neurologic examination. Thirty days after treatment, repeat myelography was performed in 40 of the 50 cases; compared with the initial findings immediately preceding radiation therapy (RT), the results of 58% of these studies had normalized completely, results were improved in 25%, and the results had not changed in 18%. The presence of a high-grade compression fracture of the vertebral body was an indicator of poor prognosis for tumor response on repeat myelography. The ability of a patient to walk before treatment and tumor response on repeat myelography were associated significantly with improved outcome of RT and with survival. The authors conclude that RT can effectively palliate epidural lesions from metastatic prostate cancer. The prognosis for the long-term response to therapy may be indicated by pretreatment ambulatory status and posttreatment imaging of the epidural space.

Preoperative embolisation, transpedicular decompression and posterior stabilisation for metastatic disease of the thoracic spine causing paraplegia

During a brief period from March 1988 to January 1990 we were faced with 13 patients with malignant vertebral neoplasms (metastasis) of the thoracic spine. Nine of these had progressive extradural spinal cord compression with motor, sensory and sphincter involvement of varying degrees and duration. After proper evaluation these 9 cases were aggressively managed by preoperative embolisation of the tumour, transpedicular decompression and a same stage posterior metallic fixation. The immediate results were encouraging, with 2 patients showing total recovery and 3 showing partial recovery. All of the 9 operated cases were pain free postoperatively and could sit up unaided and be easily transferred to the Cancer Institute for back up chemotherapy and radiotherapy. They also improved psychologically, and cooperated well in their subsequent rehabilitation programme.

The role of laminectomy in the combined treatment of metastatic spinal cord compression

A retrospective analysis of clinical data concerning 140 patients with spinal cord compression is presented. Treatment consisted of a surgical decompressive laminectomy followed by radiation therapy in 127 cases. Primary radiation therapy supported by steroids was applied in only 26 cases. A dose of 30-40 Gy in 15-20 fractions was delivered to all patients. Treatment outcome was analyzed by comparing motor function (categories: no deficit, mild deficit ambulatory, paraparetic not ambulatory, paraplegic), sphincter function, and pain relief before and after treatment in both modalities. Following laminectomy and radiation therapy, 82% of paraparetic patients regained their ability to walk, sphincter function improved in 68%, pain relief was achieved in 88%. Following radiation therapy alone, 64% of paraparetic patients became ambulatory, 33% showed a normalization of sphincter function, and 72% became pain free. Our results indicate that laminectomy should play a major role in the treatment of patients with metastatic spinal cord compression. The decision as to the treatment of choice has to be made individually for each patient taking into consideration his general condition, life expectancy, and origin of the primary.

Radiation therapy in metastatic spinal cord compression. A prospective analysis of 105 consecutive patients

One hundred thirty consecutive patients with metastatic spinal cord compression (MSCC) were entered in a therapeutic protocol in which radiation therapy (RT) played the main role. When MSCC is diagnosed by clinical-radiologic methods such as myelography with or without computed tomography (CT) or magnetic resonance imaging (MRI), steroids are given and RT treatment started within 24 hours. When diagnostic doubts exist or stabilization is necessary, surgery precedes RT. Chemohormonal potentially responsive tumors are also treated with chemotherapy or hormonal therapy. Twelve patients (9.2%) underwent surgery plus RT, and 118 (90.8%) received RT alone. Thirteen (11%) early death patients were not evaluable. The 105 evaluable cases that received RT alone were analyzed. Median follow-up was 15 months (range, 4 to 38 months). Response among patients with back pain was 80%. In cases with motor dysfunction, 48.6% improved, and in 33 of 105 patients (31.4%) without motor disability there was no deterioration. Forty percent of patients with autonomic dysfunction responded to RT. Median survival time was 7 months with a 36% probability of survival for 1 year. The median duration of improvement was 8 months. The most important prognostic factor was early diagnosis. Radiosensitivity of tumor was only important in paraparetic patients in predicting response to RT. Complete myelographic block significantly diminished response to RT. Vertebral collapse did not influence response or survival.

Utility of surgery in the treatment of epidural vertebral metastases

Treatment of vertebral epidural metastases has been in the past and still remains the object of special attention in an attempt to improve the quality of life of these patients. To assess the effects of and indications for surgery, the clinical histories of 53 patients with this malignant disease who had undergone decompressive laminectomy have been reviewed retrospectively. The importance of the presence of complete or partial spinal cord compression in correlation with the presence of complete or partial myelographic block is dealt with. The results concerning pain, gait disturbances and sphincter disorders are studied with respect to the clinical and myelographic picture for the purpose of establishing the indications for decompressive laminectomy. Pain is not an indication for operative decompression, and complete paraplegia always never improves, thus being a contraindication. But in incomplete spinal cord involvement a decompression operation may be followed by an improvement of neurological deficit and quality of life.

Decompression of epidural metastases from germ cell tumors with chemotherapy

Epidural cord compression from germ cell tumor metastases is not common. Treatment usually requires high dose corticosteroids with radiation therapy and/or surgical decompression. Three patients with epidural germ cell tumor metastases were treated with cisplatin-based chemotherapy and all three had complete neurologic recovery. Systemic chemotherapy should be considered as initial therapy with corticosteroids for epidural cord compression from metastatic germ cell tumor.

Metastatic epidural spinal cord compression. Results of treatment and survival

All medical records of patients treated for metastatic compression of the spinal cord or cauda equina in the eastern part of Denmark from 1979 through 1985 were reviewed. With regard to treatment response and survival, 345 patients could be evaluated. Carcinoma of the lung (19%), prostate (18%), breast (13%), and kidney (10%) were the most frequent primary malignancies causing spinal compression. The outcome of treatment depended primarily on the patients' condition at the time of diagnosis: 79% of the patients who were able to walk before the treatment remained ambulatory, whereas only 21% of the nonambulatory paraplegic patients and 6% of the paralytic patients regained walking ability. Patients treated with laminectomy followed by radiotherapy seemed to respond better than patients treated with radiotherapy or laminectomy alone, but when the patients' pretreatment motor function was taken into account no significant difference was found between the three forms of treatment. In the subgroup of nonambulatory patients, however, a significantly better restoration of gait was observed in patients treated with the combination of laminectomy and radiotherapy than in patients treated with radiotherapy alone. A longer survival in the group treated with the combination of laminectomy and radiotherapy may reflect that these patients were in a lower stage of disease and thus had a better potential of regaining motor function. The results call for prospective randomized studies.

Percutaneous interbody osteosynthesis in the treatment of thoracolumbar traumatic or tumoural lesions. A review of 51 cases

The authors describe a technique of percutaneous interbody osteosynthesis applicable to the dorsal and lumbar spine. 51 patients were so treated for different aetiologies: traumatic conditions (35 cases) and tumoural lesions (16 cases). The material used consisted of special instruments that are positioned in double obliquity by a percutaneous posterolateral approach. A posterior approach limited to the pathological focus was used jointly whenever a graft or a decompression was necessary (19 cases). Several types of anaesthesia were used (local, local-regional, general, neuroleptanalgesia). The patients benefited by the advantages that usually accompany percutaneous techniques. The advantages and limitations of the method are discussed.

Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression

We reviewed all medical records concerning patients suffering from spinal cord or cauda equina compression (SCC) secondary to cancer, in the eastern part of Denmark, from 1979 through 1985. During the period the incidence of SCC in cancer patients went up from 4.4% to 6%. However, this increase was not significant. The series comprised 398 cases, with carcinoma of the prostate (19%), lung (18%), breast (14%) and kidney (10%) accounting for 61%. The symptoms were evaluated in accordance with the patients rating of pain, motor deficits, sphincter control and paraesthesia, whereas the clinical manifestations were classified on the basis of motor deficit and bladder dysfunction. During the period preceding the diagnosis of SCC, 83% of the patients suffered from back pain, 67% from deteriorating gait and 48% had retention of the urine. In 35% of the patients there was no sphincter disturbance and 10% had normal sensory function. The outcome of treatment was estimated by changes in motor deficits and sphincter function, and depended primarily on the patients condition at the time of the diagnosis. Of the patients who were able to walk before treatment, 79% remained ambulatory, whereas only 18% of the non-ambulatory patients regained walking ability. Patients treated by decompressive laminectomy followed by radiotherapy apparently had a better response than patients treated with surgery or irradiation alone, but when the patients pre-treatment motor function was taken into account, no significant difference was observed. The study may call for a properly randomized trial with careful stratification of tumour biology, performance status and neurological deficits.

Epidural compression from metastatic tumor with resultant paralysis

To determine the value of the usually given 'urgent' palliative radiotherapy in paraplegic patients with epidural compression from metastatic tumor, 20 consecutive cases treated between 1981 and 1986 were retrospectively analyzed. Bronchogenic and prostatic carcinoma were the more common extraspinal sources of metastasis. Epidural metastasis involved the thoracic spine in most cases. The onset of neurological symptomatology was frequently within two weeks prior to hospitalization. The majority of the subjects received at least 3000 cGy given in 10 to 15 fractions. Symptomatic (pain relief) response rate was 78 (7/9) percent. The observed period of survival averaged 2.5 months after treatment. This study reaffirmed the little chance for recovery of lost limb(s0 motor function. None of the patients (most of whom were paraplegic from two to 90 days pre-irradiation) became ambulatory including the two in whom irradiation was administered within 24 hours from the onset of paraplegia.

Role of radiotherapy in metastatic spinal cord compression: preliminary results from a prospective trial

A non-randomized prospective trial in which radiotherapy (RT) alone played the major role in the treatment of metastatic spinal cord compression (MSCC) is reported. Diagnosis was formulated on myelography and/or myelography plus computed thomography (CT). Of 51 cases treated, 48 are evaluable. The therapy consisted of radiation alone (42 cases) or decompressive laminectomy followed by radiotherapy (6 cases). Surgery was performed when the site of the primary tumor was unknown. The group of patients who received radiotherapy alone (42 of 48 evaluable cases) are analysed in this report. Medium to high doses of steroids were administered to all patients depending on the gravity of the case. Patients with chemo- or hormone-responsive primary tumors also received chemotherapy and/or hormone therapy. Pain relief, assessed by comparing use of narcotics and minor analgesics before and after treatment, was achieved in 54% cases (confidence limits, CL = 38-69%). In 36% (CL = 22-51%) of patients back pain diminished to the point when only milder analgesics were necessary (partial remission). Motor performance, based on patients' ability to walk, improved in 48% cases (CL = 31-65%). The 19 patients who were ambulatory before RT, did not deteriorate after treatment. Sphincter function, evaluated by patient's need for indwelling catheter, improved in 3 of 7 automatic dysfunction cases. It was found that early diagnosis was more important than primary tumor type for predicting a good was found that early diagnosis was more important than primary tumor type for predicting a good prognosis. In fact, all ambulating patients responded to treatment independent of the radiosensitivity of the tumor histology.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal cord compression in small cell lung cancer: a retrospective study of 610 patients

The records of 610 consecutive patients with small cell lung cancer, treated on a common protocol in a multicentre trial, were reviewed and 24 (4%) cases of spinal cord compression identified. Five hundred patients had isotope bone scans performed at presentation, and in 131 (26%) there was abnormal isotope uptake in the spinal column; only 7% of these patients developed spinal cord compression. However, of the 24 patients who presented with back pain and had a positive bone scan affecting the spine, 36% developed cord compression. Cerebral metastases occurred at some stage in 19.5% of all patients and in 45% of patients with cord compression. The combination of cerebral metastases and a positive bone scan gave a 25% chance of developing spinal cord compression. There were two distinct forms of clinical presentation. Six patients (group A) presented with cord compression: All had back pain and positive bone scans, five out of six had sphincter disturbance, and median survival from cord compression was 30 weeks. Eighteen patients (group B) developed cord compression while on treatment: 28% had positive initial bone scans, 44% back pain and 61% sphincter disturbance, and median survival from cord compression was 4 weeks. Spinal cord compression is an important cause of morbidity and mortality in small cell lung cancer. We suggest that it may be possible to select patients who should receive radiotherapy to the spine to try to prevent the development of this complication.

One-stage posterolateral decompression and stabilization for primary and metastatic vertebral tumors in the thoracic and lumbar spine

During the past decade, anterior approaches to the spine have been shown to be much more effective than laminectomy for the relief of pain and neurological deficits due to vertebral metastases. Laminectomy has failed because it does not allow adequate decompression of epidural lesions anterior to the thecal sac. In an effort to combine the advantages of the posterior approach with an adequate decompression, a one-stage posterolateral decompression-stabilization procedure was performed on nine patients with thoracolumbar spine tumors. The approach has been used for decompression and stabilization after thoracolumbar burst fractures. Marked lasting improvement was seen in all six patients with preoperative neurological deficits and in four patients with severe back pain and/or radiculopathy. Three nonambulators and two marginal ambulators could walk postoperatively without assistance. Of five patients who were working preoperatively, four returned full-time to their prior occupations. Three patients had serious complications, including one early postoperative death. No patient deteriorated neurologically due to the procedure. Although the series is small, it demonstrates that adequate one-stage decompression-stabilization of spinal epidural lesions is possible via the posterolateral approach and should be considered in certain cases as an alternative to the anterior approach.

Radiotherapy and the management of metastatic bone pain

A pilot study was carried out to investigate the ease with which pain could be quantitatively assessed before and after treatment. The results obtained showed the methods used to be suitable and convenient for quantifying pain both before and after radiotherapy, given as either a single or a multiple fraction regimen. The protocol could be used to produce data for statistical analysis in a long-term, prospective, randomised trial to determine the optimum single dose of radiation necessary for maximum pain relief with minimal side effects.

Central nervous system lesions and advanced ovarian cancer

Over the past 5 years we have seen seven cases of central nervous system tumors in patients with advanced or recurrent ovarian carcinoma. These have ranged in location from the conus medullaris to the brain and have varied in time of occurrence from the time of cancer diagnosis to 63 months following surgery. A diagnosis of metastatic ovarian carcinoma was established in six of the cases, while one patient had a second primary malignancy. All cases had prodromal and localizing neurologic symptoms which led to the suspicion of central nervous system involvement. The critical diagnostic studies were myelography and computed tomography of the brain and spine. We have reviewed our approach to diagnosis and therapy.

Back pain and epidural spinal cord compression

The physician must have a high index of suspicion to detect SCC early in patients with malignancy. Back pain is the first symptom in almost all patients, and the diagnosis should be considered for all older patients with back pain. Asking about back pain should be a routine part of the review of systems, especially for patients with known malignancies. Clinically, it is impossible to tell whether or not a patient who has back pain and cancer has epidural SCC. Patients may be stratified as to the likelihood of SCC using the history and physical examination, but the diagnosis relies on radiographic visualization of the spinal cord. It may be acceptable to closely follow patients with normal neurologic examinations and normal plain films, but even this is controversial and includes only a minority of patients. Myelography remains the test of choice. MRI will play an increasingly important role in the future, but has not yet been systematically evaluated. The best therapeutic approach is not clear, but standard treatment is only about 50% effective in all cases. At present, radiation therapy is the treatment of choice for many patients, in particular those who are ambulatory at diagnosis. Anterior resection with vertebral body reconstruction is an exciting approach and may substantially improve the prognosis for patients who are paraparetic or paraplegic. It is important to attempt to choose for each patient the diagnostic and therapeutic options offering the best chance for comfort and preservation of function. The decision of how or even whether to treat is multifactorial and is more complicated than the determination of simply whether or not compression is present.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative treatment of thoraco-lumbar metastases, using methylmetacrylate and Kempf's rods for vertebral replacement and stabilization. Report of 15 cases

The authors report their experience in the treatment of 15 cases in thoracolumbar metastases with spinal cord compression. A decompressive laminectomy was routinely performed and followed by a transversoarthropediculectomy. Most part of the neoplastic tissue was removed from the epidural space, vertebral body and retroperitoneal or retro-pleural areas. Complete decompression of the nervous elements was always achieved. Stabilization was obtained by replacement of the neoplastic vertebral body with a methylmetacrylate prothesis and eventually by Kempf's compression instrumentation. The surgical treatment was completed in a single stage operation, by a classical posterolateral approach. Orthopaedic, neurologic and oncologic advantages of this treatment are discussed.

The role of vertebral body collapse in the management of malignant spinal cord compression

The management of malignant spinal cord compression has been reviewed recently and attention drawn to the adverse effects of laminectomy. Data from that review suggested that the presence of vertebral body collapse could have an important negative effect on the outcome of laminectomy. However, there was only scant evidence available in the literature to support that conclusion. Eighty consecutive patients with thoracic spinal cord compression due to a single metastasis treated by laminectomy are reported here. It is seen that the presence of vertebral collapse signified: a much reduced chance of regaining the ability to walk; a much greater possibility of further neurological deterioration; and a major increase in the incidence of post-operative spinal instability. The role of laminectomy in the management of such patients needs to be further questioned and alternative therapeutic measures such as radiotherapy, posterior spinal instrumentation or anterior surgery should be strongly considered in the presence of vertebral body collapse.

Early detection and treatment of spinal epidural metastases: the role of myelography

Spinal epidural metastases were detected in 75 of 140 cancer patients with back pain who were evaluated prospectively by clinical criteria, spine roentgenography, and bone scan. Fifty-five of the 75 patients with epidural metastases had no evidence of myelopathy when diagnosed. Of the patients diagnosed and treated while still ambulatory, more than 90% remained so. Myelograms were performed in 127 patients to diagnose the 75 with epidural disease. To try to reduce the number of myelograms needed, we attempted to design radiotherapy ports based on clinical symptoms and the plain spine films alone. A port could not be designed for 64 of the 127 patients, either because of diffuse vertebral metastases or a normal plain roentgenogram. A port could be designed for 63 patients, and all epidural disease would have been encompassed in 50 of the 54 patients who had spinal epidural metastases (93%). Most patients with cancer and back pain require myelography for accurate treatment planning. There are, however, situations in which treatment can be determined based on symptoms and plain films alone, with a low risk of missing epidural cancer.

Circulatory disturbance of the spinal cord with epidural neoplasm in rats

An experimental model of spinal epidural neoplasm was produced in rats by injecting Walker 256 carcinoma cell suspension anterior to the T12-13 vertebral body. With this model, spinal cord blood flow (SCBF) and its response to CO2 inhalation were estimated by the carbon-14-antipyrine autoradiography and the hydrogen clearance methods. In the early stages after tumor implantation, weakness, axonal swelling, and edema of the white matter were observed, while both SCBF and its response to CO2 inhalation remained normal. In the next stage, the tumor invaded the spinal canal and compressed the spinal cord epidurally. The edema of the white matter progressed, while the gray matter was morphologically intact. The SCBF and its response to CO2 inhalation were altered at both the compression area and caudally in the spinal cord. Changes in response to CO2 inhalation appeared earlier than the SCBF decrease. In the last stage, the SCBF decreased rapidly to the critical level, producing irreversible nervous tissue damage. Microangiographic studies revealed extensive obliteration of the spinal epidural venous plexus and patency of the larger nutritional vessels. From the data obtained, the progressive vascular pathophysiology related to spinal epidural neoplasm is as follows: 1) the vertebral venous plexus is compressed and obliterated in the early stages of the disease, and vasogenic edema appears in the spinal cord; 2) as the tumor grows, mechanical compression of the spinal cord is added and the circulatory disturbance increases; and 3) in the last stage, SCBF decreases rapidly to a critical flow level, and the loss of cord function becomes irreversible.

Frequency, diagnosis, and prognosis of spinal cord compression in small cell bronchogenic carcinoma. A review of 817 consecutive patients

A retrospective review of 817 consecutive patients with small cell bronchogenic carcinoma disclosed 29 cases of spinal cord compression (frequency, 3.5%). Twelve patients (group 1) presented with symptom of cord compression, whereas the remaining 17 patients (group 2) developed this complication during therapy. Clinical features differed in the two groups: pain was present in 83% of the patients in group 1 and in 47% of those in group 2. Pain preceded motor dysfunction in 75% and 12% of the two groups, respectively. Radiologic bone destruction of the spine was found in 11 of 12 patients in group 1 and in 3 of 16 patients in group 2. Myelography was performed in 8 patients in group 1 and in 14 patients from group 2. A complete block was found in seven and none of the patients in each of the two groups, respectively. Treatment with irradiation and/or laminectomy rarely resulted in a significant improvement of preexisting neurologic impairment but it frequently prevented the progression of symptoms, leading to preservation of sphincter control and ambulatory function in eight of nine and seven of eight patients, respectively. Careful evaluation is mandatory for patients presenting with back pain and radiographic evidence of bone destruction, as 11 of 26 such patients were found to have spinal cord compression. It is concluded that spinal cord compression presents in two distinct ways. One with early onset, pain, evidence of bone destruction, and complete myelographic block. The second is characterized by motor impairment with no evidence of bone destruction and only partial myelographic block. Treatment rarely ameliorates symptoms but prevents deterioration, making early diagnosis important.

Treatment outcome and complications in patients treated for malignant epidural spinal cord compression (SCC)

Sixty-seven episodes of spinal cord compression (SCC) were retrospectively evaluated regarding presenting features and treatment outcome. They were divided into three motor function groups. Group 1 consisted of 35 ambulatory patients, group 2 of 29 non-ambulatory patients and group 3 of three paraplegic patients. Lower extremity weakness was usually a late presenting feature and was frequently rapidly progressive. We suggest that SCC is an emergency, as successful treatment is unlikely if motor function is poor. All of the group 1 patients completing treatment remained ambulatory, in contrast to group 2 patients, in which only 25% regained the ability to walk, and group 3 patients, none of whom regained the ability to walk. Initial surgery or initial radiotherapy appeared to be equally effective in restoring or maintaining the ability to walk. Survival of patients ambulatory at completion of treatment was superior to that of non-ambulatory patients (p less than 0.03). Analysis of steroid-related complications suggested that frequent, severe and sometimes fatal complications can result from prolonged use with these drugs.

Cauda equina compression secondary to metastatic carcinoma of the uterine corpus: preservation of neurologic function and long-term survival following surgical decompression and radiation therapy

Spinal cord or cauda equina compression secondary to epidural metastasis rarely develops in patients with endometrial carcinoma and the early signs and symptoms of compression can therefore be inadvertently overlooked. A 78-year-old patient who developed bone metastasis with destruction of the fifth lumbar vertebral body and blockage of the cauda equina at L-4, L-5 as the only sites of metastasis is reported. This occurred 2 years after initial treatment of a stage IB, well-differentiated, grade I, adenosquamous carcinoma of the endometrium. The patient remains alive, with good neurological function and free of metastatic disease, 2 1/2 years following vertebrectomy, radiation therapy, and adjuvant Provera (medroxyprogesterone acetate) therapy. This patient represents the only case of metastatic endometrial cancer with cauda equina compression in the literature in whom long-term disease-free follow-up has been noted.

Functional outcome and survival in spinal cord injury secondary to neoplasia

A 12-year retrospective view of patients admitted to the rehabilitation unit for care of spinal cord injury (SCI) secondary to neoplasia was conducted. Twenty-seven such patients were identified. One year survival was 58%, and independent functioning achieved in the rehabilitation unit was well-maintained in the survivors. Survival and functional outcome tended to be best in those with less severe neurologic injuries. The study indicated a better 1-year survival in such injuries than has previously been described. Patients with complete SCI had a relatively poor prognosis, especially for independent function. As control of metastatic cancer improves, patients with spinal cord injury caused by neoplasia will probably become a significant part of the SCI population.

Spinal carcinomatous metastases. Retrospective study of 67 surgically treated cases

A series of 67 surgically treated spinal carcinomatous metastases is reviewed in order to establish the role played by surgery in the management of such a disease. The authors compare the results achieved in two groups of patients treated with a different therapeutic approach: either surgery alone or surgery associated with other therapies (mainly radiotherapy). On this basis, although no ideal treatment for spinal epidural metastases can be established, the authors suggest decompressive laminectomy as a first choice approach in the treatment of patients bearing a scarcely radiosensitive spinal metastasis with a rapidly deteriorating motor function.

Adverse effects of the management of malignant spinal cord compression

As a prelude to further work which attempts to improve the management of metastatic spinal cord compression the efficacy and adverse effects of existing therapy has been assessed. All papers dealing with the management of malignant spinal cord compression since 1960 have been reviewed. Data from this review is presented in a novel manner in order to identify not only the degree of successful return to ambulation achieved but more importantly the extent of the adverse effects which occur during existing management. It is seen that, while in general some 35% of patients treated in any manner retain or return to the ability to walk, some 20% to 25% sustain major neurological deterioration. In addition, those patients treated by laminectomy who do deteriorate may be subject to a significant rate of perioperative mortality and major structural complications related to the surgical wounds. In the light of the adverse factors described, the role of laminectomy as first-line management of malignant cord compression is questioned. Alternative modes of treatment are discussed and a tentative scheme of management described which it is hoped will lead to a better quality of survival of the group as a whole in addition to maintaining, or perhaps, improving the rate of successful return to ambulation.

Value of early attention to spinal compression syndromes

In a consecutive series of 125 patients with spinal compression syndromes, neurological regression was evaluated in relation to the time interval from (a) initial symptoms (patient delay), (b) diagnostic recognition (diagnostic delay), and (c) decision on treatment (therapeutic delay) until the time of definitive treatment. Patients with benign lesions showed a statistically significant negative correlation between the duration of (a) + (b) + (c) and the therapeutic result. In cancer patients there was a tendency for rapid progression of the disease to give a poorer result than in patients in whom the course was more insidious. In all, 77 patients improved after a short therapeutic delay (14 h), while in the remaining 48 the status was unchanged or worse after a long delay (34 h); this is a highly significant difference.

Vertebral body resection in the treatment of cancer involving the spine

Results of radical spinal surgery with vertebral body resection in of 51 patients with primary and metastatic cancer of the spine were analyzed. Seven patients had primary spine tumors, 16 had paravertebral tumors that involved the spine by direct extension, and 28 had blood-borne metastases to the spine. Thirty-five patients (68%) had prior therapy directed to the spine: 4 had undergone previous surgery, 9 had surgery and radiation, and 22 had radiation alone. Forty-five patients (90%) had intractable pain, and 25 patients (48%) were nonambulatory. Myelography revealed high-grade or complete block in 39 patients (76%). Following surgery, 38 of 45 (84%) had pain relief, and 40/58 (78%) were ambulatory at discharge. Of the 25 patients who were unable to walk prior to surgery, 15 (60%) improved to fully ambulatory status. The surgical mortality was low (4%), and complications were few (10%). These results are superior to those reported following treatment by radiation and steroid therapy. In selected patients who have actual or potential neural compression resulting from tumor within the vertebral body, such surgery should be considered as initial therapy.

Distraction rod stabilization in the treatment of metastatic carcinoma

Stabilization of the spinal column with Harrington distraction rods and acrylic fusion was the primary form of treatment in a select group of patients with metastatic carcinoma of the spinal column. Clinical criteria included patients in poor general medical condition with intractable pain originating from metastatic tumor involvement in the ventral components of the thoracic or upper lumbar spinal column and minimal evidence or absence of spinal cord compression. After stabilization, pain relief was almost total and sustained, and neurological status generally remained unchanged from preoperative findings without any evidence of improvement of preexisting abnormalities or occasions of rapid neurological deterioration. This form of spinal stabilization may offer significant relief of debilitating pain, lessen the risk of pathological fracture-dislocation of the thoracic or upper lumbar vertebral column, and reduction in the local compressive effects on the spinal cord caused by ventrally situated metastatic tumor.

Spinal metastases with neurological manifestations. Review of 600 cases

The authors have studied 600 cases of spinal metastasis causing a neurological syndrome. The most significant statistical data are reviewed. The cases are examined according to clinical characteristics, type of primary tumor, site of lesion, and survival. Each of these factors influenced the choice and results of treatment. As a general rule, combined treatment (surgery and radiotherapy) was used. Preliminary surgery was performed as an emergency, designed to halt progression of the neurological syndrome and to prevent its more serious manifestations. The technique and usefulness of surgery are discussed for different situations and the short-term results of treatment are related to the various factors involved.

Radiation therapy for spinal epidural metastases with complete block

Myelography was performed in 535 patients at the Memorial Sloan-Kettering Hospital from January 1979 to December 1979. In 110 cases a complete block was demonstrated and of these, 78 had epidural metastases. A uniform treatment was applied using radiation therapy and high dose steroid. The neurologic outcome for each patient was evaluated, correlating pre-treatment neurologic status, pathologic type, nature of block (level, structural versus tumoral), and result of repeat fluoromyelography. Only 2 patients improved, but 11 became completely paraplegic. The survival was influenced by the ambulatory status after treatment (median survival: 52.7 weeks in the ambulatory group and 4.6 weeks in the paraplegic). Based on this series, rational approach and management of complete block secondary to spinal epidural metastases are discussed.