Epidural compression from metastatic tumor with resultant paralysis

Metastasis to nervous system: spinal epidural and intramedullary metastases

Spinal cord epidural metastasis (SEM) is a common complication of systemic cancer with an increasing incidence. Prostate, breast and lung cancer are the most common offenders. Metastasis usually arises in the posterior aspect of vertebral body with later invasion of epidural space. Pathophysiologically, vascular insufficiency is more important than direct spinal cord compression. The most common complaint is pain, and two thirds of patients with SEM have motor signs at initial diagnosis. Currently magnetic resonance imaging is the most sensitive diagnostic tool. The optimal management of SEM is still arguable, but recent advances in surgical management of SEM and higher complication rate of surgery following radiotherapy should persuade clinicians to consider de novo surgery where possible. Radiotherapy has an important role, particularly in treatment of radiosensitive tumors and in patients who are not candidates for surgery. Novel approaches such as stereotactic radiosurgery are promising; however, response to chemotherapy depends on inherent properties of primary tumor. Recurrent SEM is a substantial problem for which surgery or repeat radiotherapy may be options. Intramedullary metastasis is rare but should be considered in patients with systemic malignancy and asymmetrical presentation of myelopathic symptoms. The prognosis is usually poor and preferred modality of treatment is radiotherapy.

Comparison of 1 x 8 Gy and 10 x 3 Gy for functional outcome in patients with metastatic spinal cord compression

PURPOSE

Since life expectancy is markedly reduced in patients with metastatic spinal cord compression (MSCC), a short and effective radiation schedule is desired. This study investigates a reduction of the overall treatment time to only one day by comparing 1 x 8 Gy to the multi-fractionated 10 x 3 Gy for functional outcome.

METHODS AND MATERIALS

Data of 204 patients, treated for MSCC with either 1 x 8 Gy (n = 96) or 10 x 3 Gy (n = 108), were analyzed retrospectively. Motor function and ambulatory status were evaluated before and up to 24 weeks after RT. A multivariate analysis (nominal regression) was performed including radiation schedule, performance status, age, irradiated vertebra, and relevant prognostic factors (histology, ambulatory status, time of developing motor deficits). Improvement of motor deficits was selected as basic category and compared with no change and deterioration.

RESULTS

Univariate analysis showed no significant difference between the schedules for post-treatment motor function and ambulatory rates. Multivariate analysis demonstrated a significant effect on functional outcome for the prognostic factors, but not for the radiation schedule (p = 0.853 for no change, p = 0.237 for deterioration).

CONCLUSIONS

Our data suggest the two fractionation schedules to be comparably effective for functional outcome. Thus, 1 x 8 Gy should be considered for patients with a poor survival prognosis.

Evaluation of five radiation schedules and prognostic factors for metastatic spinal cord compression

PURPOSE

To study five radiotherapy (RT) schedules and potential prognostic factors for functional outcome in metastatic spinal cord compression (MSCC).

PATIENTS AND METHODS

One thousand three hundred four patients who were irradiated from January 1992 to December 2003 were included in this retrospective review. The schedules of 1 x 8 Gy in 1 day (n = 261), 5 x 4 Gy in 1 week (n = 279), 10 x 3 Gy in 2 weeks (n = 274), 15 x 2.5 Gy in 3 weeks (n = 233), and 20 x 2 Gy in 4 weeks (n = 257) were compared for motor function, ambulatory status, and in-field recurrences. The following potential prognostic factors were investigated: age, sex, performance status, histology, number of involved vertebra, interval from cancer diagnosis to MSCC, pretreatment ambulatory status, and time of developing motor deficits before RT. A multivariate analysis was performed with the ordered logit model.

RESULTS

Motor function improved in 26% (1 x 8 Gy), 28% (5 x 4 Gy), 27% (10 x 3 Gy), 31% (15 x 2.5 Gy), and 28% (20 x 2 Gy); and posttreatment ambulatory rates were 69%, 68%, 63%, 66%, and 74% (P = .578), respectively. On multivariate analysis, age, performance status, primary tumor, involved vertebra, interval from cancer diagnosis to MSCC, pretreatment ambulatory status, and time of developing motor deficits were significantly associated with functional outcome, whereas the RT schedule was not. Acute toxicity was mild, and late toxicity was not observed. In-field recurrence rates at 2 years were 24% (1 x 8 Gy), 26% (5 x 4 Gy), 14% (10 x 3 Gy), 9% (15 x 2.5 Gy), and 7% (20 x 2 Gy) (P < .001). Neither the difference between 1 x 8 Gy and 5 x 4 Gy (P = .44) nor between 10 x 3 Gy, 15 x 2.5 Gy, and 20 x 2 Gy (P = .71) was significant.

CONCLUSION

The five RT schedules provided similar functional outcome. The three more protracted schedules seemed to result in fewer in-field recurrences. To minimize treatment time, the following two schedules are recommended: 1 x 8 Gy for patients with poor predicted survival and 10 x 3 Gy for other patients. Results should be confirmed in a prospective randomized trial.

Effectiveness and toxicity of single-fraction radiotherapy with 1×8Gy for metastatic spinal cord compression

Toxicity and functional outcome were evaluated in 199 MSCC-patients irradiated with 1 x 8 Gy. Motor function improved in 54/199 patients (27%). Patients who regained walking ability were 20/78 (26%). Long-term-survivors (> or =12 months) who needed re-irradiation for in-field-recurrence were 19/65 (29%). Acute toxicity was mild, late toxicity not observed. A randomised trial comparing single-fraction RT to multi-fraction RT is mandatory.

Epidural metastatic spinal cord compression: functional outcome and survival after inpatient rehabilitation

STUDY DESIGN

Retrospective descriptive study.

OBJECTIVES

(1). To obtain an overall appraisal of patients with epidural metastatic spinal cord compression (SCC) admitted to nine Dutch spinal cord units (SCUs) between 01-01-1990 and 01-01-2000. (2). To identify factors that predict survival >1 year after in-patient rehabilitation of patients with epidural metastatic SCC.

SETTING

Dutch SCUs. Rehabilitation Center Amsterdam, Amsterdam. Rehabilitation Center Heliomare, Wijk aan Zee. Rehabilitation Center De Hoogstraat, Utrecht. Rehabilitation Center Rijndam, Rotterdam. Rehabilitation Center Sophia Stichting, Den Haag. Rehabilitation Center Beatrixoord, Haren. Rehabilitation Center Het Roessingh, Enschede. Rehabilitation Center Sint Maartenskliniek, Nijmegen. Rehabilitation Center SRL Hoensbroeck, Hoensbroek.

METHODS

(1). Clinical records were reviewed and demographic, clinical and functional data were collected according to a protocol. The date of admittance to the SCU, rehabilitation goals, date of discharge and date of death were recorded. (2). The odds ratio (OR) was calculated for all determinants on admittance to the SCU in order to find indicators that predict survival >1 year after discharge from the SCU. An OR >or=2 was considered to be clinically significant.

RESULTS

In total, 131 patients with epidural metastatic SCC were admitted. In all, 117 clinical records were retrieved and 97 clinical records provided complete data. The average age on admittance was 58 years. Among the patients 53% were male. The average Barthel score on admittance was 7.2/20 points. The average length of stay in the SCU was 104 days (3-336). Overall, 66% of the patients were discharged. The average Barthel score on discharge was 12.0 points. The average survival after discharge was 808 (0-3669) days. During their stay on the SCU, seven patients died. At 1 year after discharge, 52% of the patients were still alive. These patients suffered less complications, had been admitted less often to a hospital during rehabilitation, had made better functional progress and had been discharged home more often. A survival >1 year after discharge is related to ASIA D (OR 4.3), MRC 4 and 5 (OR 5.4), tumour in remission (OR 3.8) and independence or partial independence on the Barthel items: dressing (OR 4.3) and making transfers (OR 5.0).

CONCLUSIONS

Patients with epidural metastatic SCC may benefit from in-patient rehabilitation.

A prospective evaluation of two radiotherapy schedules with 10 versus 20 fractions for the treatment of metastatic spinal cord compression

BACKGROUND

The optimal treatment of patients with metastatic spinal cord compression (MSCC) is still being debated. The current observational multicenter study, performed prospectively by the authors, evaluated two radiotherapy (RT) schedules and prognostic factors with respect to functional outcome

METHODS

In the current study, 214 patients with MSCC were irradiated between April 2000 and September 2003 with 30 gray (Gy) per 10 fractions per 2 weeks (n = 110) or with 40 Gy per 20 fractions per 4 weeks (n = 104). Motor function and ambulatory status were evaluated before RT and until 6 months after RT. The following potential prognostic factors were investigated: RT schedule, performance status, age, number of irradiated vertebrae, type of primary tumor, pretreatment ambulatory status, and length of time developing motor deficits before RT.

RESULTS

Both groups were balanced for patient characteristics and potential prognostic factors. Motor function improved in 43% of patients after 30 Gy and in 41% of patients after 40 Gy (P = 0.799). Posttreatment ambulatory rates were 60% and 64% (P = 0.708), respectively. A multivariate analysis demonstrated that a slower progression of motor deficits before RT (P < 0.001), a favorable histology of the primary tumor (P < 0.001), and being ambulatory before RT (P = 0.035) were associated with a better functional outcome. RT schedule (P = 0.269) and other variables had no significant impact. Acute toxicity was mild, and late toxicity was not observed during the period of follow-up. Follow-up was 12 (6-28) months in patients surviving >/= 6 months.

CONCLUSIONS

Thirty gray per 10 fractions was preferable to 40 Gy per 20 fractions, because it was associated with similar outcome, less treatment time, and lower costs. The type of tumor, pretreatment ambulatory status, and length of time developing motor deficits before RT were relevant prognostic factors and should be considered in future studies.

Prognostic factors for survival in metastatic spinal cord compression: a retrospective study in a rehabilitation setting

OBJECTIVE

Metastatic spinal cord compression (MSCC) occurs in 5-10% of all patients with cancer, and it is associated with short survival durations. Patients with MSCC may also have functional loss and require rehabilitation before discharge from the hospital. The purposes of this retrospective study were to identify clinical and social variables that had a significant impact on survival of patients with MSCC who underwent inpatient rehabilitation.

DESIGN

A total of 60 consecutive patients with MSCC who were admitted to the inpatient rehabilitation unit at our tertiary care cancer center between 1996 and 1998 were included. Age, discharge destination, primary tumor site, metastasis, comorbidity, hemoglobin and albumin levels, treatment rendered for MSCC, opioids used, and psychological symptoms were examined as variables, and the Kaplan-Meier survival analysis was used.

RESULTS

Our study showed that most of the variables we examined had no significant influence on survival time (median, 4.1 mo), with the exception of gastrointestinal cancer; patients with gastrointestinal cancer had a poorer prognosis (median survival durations, 0.6 mo; P < 0.0001). We also found a 1-mo gap between the time of diagnosis and the time of transfer to the rehabilitation unit.

CONCLUSION

This study suggests that rehabilitation programs for patients with MSCC should be of short duration and that early referral (i.e., when the patient is diagnosed of MSCC) to the rehabilitation service should be encouraged.

Role of radiotherapy in the treatment of motor dysfunction due to metastatic spinal cord compression: comparison of three different fractionation schedules

PURPOSE

The optimum fractionation schedule for radiotherapy (RT) of metastatic spinal cord compression (MSCC) is still debated in the literature. Several reports have compared different fractionation schedules for pain relief. To our knowledge, this retrospective analysis is the first to compare three different schedules for functional outcome.

METHODS AND MATERIALS

For posttreatment functional and ambulatory outcome, three schedules, 30 Gy in 10 fractions (n = 93), 37.5 Gy in 15 fractions (n = 80), and 40 Gy in 20 fractions (n = 74), were compared. Motor function was evaluated by a 6-point scale before and at the end of RT and 3, 6, and 12 months later. A multivariate analysis was performed for functional outcome, including fractionation schedule and the three relevant prognostic factors (primary tumor type, time of developing motor deficits before RT, and ambulatory status).

RESULTS

No significant difference was observed for posttreatment motor function or ambulatory rates among the three schedules. According to the multivariate analysis, the radiation schedule had no significant impact on functional outcome (p = 0.223) in contrast to the three prognostic factors (p <0.001, p <0.001, and p = 0.012).

CONCLUSION

The three fractionation schedules were comparable for functional outcome. The least time-consuming schedule (30 Gy in 10 fractions) should be considered for patients with a markedly reduced life expectancy.

Always on a Friday? Time pattern of referral for spinal cord compression

For patients with spinal cord compression, radiotherapy should be initiated as soon as possible to optimize the chances for restoration of neurological function. The speed of referral in the region of our radiotherapy institution with nine general hospitals was analysed based on a tumour and treatment-related registry. From January 1987 to December 1997, 443 patients were treated. All patients were seen and treated on the day of referral. Significantly more referrals took place on Friday, 30%, compared with 12% on Monday, 17% on Tuesday, 15% on Wednesday, 20% on Thursday, 5% on Saturday and 1% on Sunday (p < 0.002). This difference was the same for patients whether they were formerly treated in our institution (n = 242) or not (n = 201). No significant difference was found between different categories of patients (p = 0.28). These data are discussed with the referring physicians to encourage speed of diagnosis and referral.

Prognostic factors in metastatic spinal cord compression: a prospective study using multivariate analysis of variables influencing survival and gait function in 153 patients

PURPOSE

Based on a very large patient cohort followed prospectively for at least a year or until death, we analyzed the prognostic significance of various clinical and radiological variables on posttreatment ambulatory function and survival.

METHODS AND MATERIALS

During a 312-year period we prospectively included 153 consecutive patients with a diagnosis of spinal cord compression due to metastatic disease. The patients were followed with regular neurological examinations by the same neurologist for a minimum period of 11 months or until death. The prognostic significance of five variables on gait function and survival time after treatment was analyzed.

RESULTS

The type of the primary tumor had a direct influence on the interval between the diagnosis of the primary malignancy and the occurrence of spinal cord compression (p < 0. 0005), and on the ambulatory function at time of diagnosis (p = 0. 016). There was a clear correlation between the degree of myelographic blockage and gait function (p = 0.000) and between gait function and sensory disturbances (p = 0.000). The final gait was dependent on the gait function at time of diagnosis (p < 0.0005). Survival time after diagnosis depended directly on the time from primary tumor diagnosis until spinal cord compression (p = 0.002), on the ambulatory function at the time of diagnosis (p = 0.018), and on the ambulatory function after treatment.

CONCLUSIONS

The pretreatment ambulatory function is the main determinant for posttreatment gait function. Survival time is rather short, especially in nonambulatory patients, and can only be improved by restoration of gait function in nonambulatory patients by immediate treatment.

Neoplastic vs. traumatic spinal cord injury: an inpatient rehabilitation comparison

OBJECTIVE

To compare demographics, injury characteristics, and functional outcomes of patients with neoplastic spinal cord compression with those with traumatic spinal cord injuries.

DESIGN

A prospective 5-yr comparison was undertaken comparing 34 patients with neoplastic spinal cord compression with 159 patients with traumatic spinal cord injury.

RESULTS

Patients with neoplastic spinal cord compression were significantly older, more often female, and unemployed than patients with traumatic spinal cord injury. Neoplastic spinal cord compression presented more often with paraplegia involving the thoracic spine, and injuries were more often incomplete compared with traumatic spinal cord injury. Patients with neoplastic spinal cord compression had a significantly shorter rehabilitation length of stay compared with those with traumatic spinal cord injury. The neoplastic group had significantly lower FIM change scores. Both groups had similar FIM efficiencies and discharge to home rates.

CONCLUSIONS

Patients with neoplastic spinal cord compression have different demographic and injury characteristics but can achieve comparable rates of functional gains as their traumatic spinal cord injury counterparts. Although patients with traumatic injuries achieve greater functional improvement, patients with neoplasms have a shorter rehabilitation length of stay and comparable FIM efficiencies and home discharge rates.

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation

OBJECTIVE

To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation.

DESIGN

A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification.

SETTING

Tertiary university medical centers.

PATIENTS

Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria.

MAIN OUTCOME MEASURES

Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home.

RESULTS

Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges.

CONCLUSIONS

Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.

The efficacy of treatment for malignant epidural spinal cord compression

The aims of this study were to document the efficacy of treatment and to identify factors that were predictive of the outcome in malignant epidural spinal; cord compression. The medical records of patients treated at the Prince Henry and Prince of Wales Hospitals in the period 1980-1989 with a diagnosis of malignant epidural spinal cord compression were reviewed. A total of 94 patients were eligible for the study and were treated by radiotherapy alone (37), surgery alone (19) and surgery followed by radiotherapy (38). Efficacy was determined by measuring complete resolution of symptoms and signs at 1 month after presentation, and also by using an overall functional improvement score (FIS). Complete resolution of individual pre-treatment symptoms that were measured 1 month after treatment occurred as follows: pain (30/88), sensory disturbance (12/61), weakness (8/17), bladder dysfunction (10/42), and bowel dysfunction (10/36). Complete resolution of motor deficit occurred in 7/82 and of sensory deficit in 9/73. The ability to walk was regained in 19/51 previously non-ambulatory patients, and bladder function improved sufficiently to remove an indwelling catheter in 9/32 previously catheterized patients. As judged by FIS, 67 patients improved, 15 patients remained stable and 12 patients deteriorated. Of the treatments given, a combination of surgery followed by radiotherapy was associated with the greatest functional improvement (P = 0.001). The coexistence of 'liver failure' was the only patient-related factor identified which was associated with outcome (P = 0.041). The treatment of malignant spinal cord compression appears to be worthwhile; however, the outcome of treatment is not easy to predict from pretreatment factors. A 'functional improvement score' may be useful in assessing treatment efficacy.

Clinical outcome in metastatic spinal cord compression. A prospective study of 153 patients

BACKGROUND

Despite many reports on metastatic spinal cord compression, only very few prospective studies of the clinical outcome of spinal cord compression have been carried out.

METHODS

153 consecutive patients with a known malignant solid tumor and a myelographically verified diagnosis of spinal cord compression were followed with regular neurological examination.

RESULTS

At time of diagnosis 79 patients were walking, while the remaining were bedridden. In total 21 of the 74 initially non-walking patients began walking after therapy. There was a need for urinary catheter in 57 (37%) patients at the time of diagnosis. During follow-up, 10 of 57 patients (18%) dispensed with the catheter. A total of 116 patients experienced radicular pain at the time of diagnosis, while in 95 of 116 patients (83%) the pain disappeared after therapy.

CONCLUSION

the present study confirms, that early diagnosis, i.e., while the patients are still ambulatory, is most important, but the prognosis for recovery of ambulatory function is not as pessimistic as earlier described. In addition the results indicate that supplementary systemic therapy, when available, may have a positive influence on recovery.

Symptoms and signs in metastatic spinal cord compression: a study of progression from first symptom until diagnosis in 153 patients

The symptoms in metastatic compression of the spinal cord or cauda equine are described after a systematic recording of the sequence of symptoms in 153 patients. Radicular pain was predominant in patients with metastases located in the lumbar area, while the severity of motor symptoms was positively correlated with thoracic metastases. The most common initial symptom was radicular pain, followed, with decreasing frequency, by motor weakness, sensory complaints and bladder dysfunction. The progression of motor weakness influenced the probability of establishing the diagnosis of spinal cord compression by stepwise marked increased probability when patients lost gait function or progressed into total paralysis.

Factors related to the outcome of inpatient rehabilitation in patients with neoplastic epidural spinal cord compression

In this study we have tried to develop a method to predict the survival and the functional outcome following neoplastic spinal cord injury (SCI), which can be helpful when selecting patients for an intensive inpatient rehabilitation programme. We reviewed the clinical records of all patients with neoplastic epidural spinal cord compression, admitted to any Dutch spinal cord unit (SCU) between 1-1-1985 and 1-1-1990 (n = 74). According to the outcome on 1-1-1991 the average stay at the SCU was 111 days, whereas the average survival after discharge was 423 days. Seven patients died during their stay. Of all of the factors analysed, six showed a positive relationship with prolonged survival (> one year after discharge) and improved functional level: tumour biology (lymphoma, myeloma, breast and kidney tumours); SCI as the presenting symptom of the malignancy; slow (> 1 week) progression rate of neurological symptoms; tumours treated with a combination of surgery and radiotherapy; (partial) bowel control at admission; and (partial) independence regarding transfer activities at admission. A sum score (range 0-6) of these indicators is introduced. A patient with a sum score of 0-1 has zero probability of living longer than one year after discharge and 0.19 of functional improvement during stay at the SCU. A score of 5-6 yields probabilities of 0.77 and 0.92 respectively. We conclude that the sum score can be helpful when selecting patients for an intensive inpatient rehabilitation programme or modifying such a programme. Validation for application in a general hospital is needed.

Urodynamics in the early stages of spinal cord compression from prostate adenocarcinoma

Acute urinary retention developed in 2 patients with a history of prostate cancer. Urodynamic evaluation revealed autonomic dysfunction, which contrasted with a prior urodynamic study, indicating a possible spinal lesion. Radiographic evaluation led to early diagnosis and treatment of spinal cord compression from metastatic prostate adenocarcinoma. We discuss the diagnostic role of urodynamics in such cases.