Treatment Desired Outcomes

© Because patients with spinal metastases are generally incurable, the primary goal of treatment of spinal cord compression is palliation. The most important prognostic factor for patients presenting with spinal cord compression is the degree of underlying neurologic dysfunction. Only around 10% of patients who present with paralysis are

able to ambulate following treatment. Therefore, the goals of treatment are recovery of normal neurologic function, local tumor control, pain control, and stabilization of the spine. Therapeutic options depend primarily on the following factors:

• Underlying malignancy

• Prior therapies

• Stability of the spine at presentation

• Overall patient prognosis

Nonpharmacologic Therapy

Radiation therapy is generally considered to be the treatment of choice for most patients. Exceptions to this include patients with prior radiation to the treatment site and patients with inherently radio-resistant tumors (i.e., melanoma, renal cell carcinoma). The radiation field should include two vertebral bodies above and below the involved area.

Surgery for spinal cord compression typically involves either laminectomy for posterior lesions or decompression with fixation. Surgery is the treatment of choice for the following patients: (a) patients with unstable spine requiring stabilization; (b) immediately impending sphincter dysfunction requiring rapid spinal decompression; (c) patients who do not respond to or have received their maximum dose of radiother-

apy; (d) direct compression of the spinal cord due to spinal bony fragments. Recent evidence suggests that surgery followed by radiation therapy may be superior to radiotherapy alone in terms of increased ambulation time after treatment, maintenance

of continence, and rates of nonambulatory patients becoming ambulatory. Surgery is also useful for establishing a tissue diagnosis in cases of unknown malignancy. Overall, the risks and benefits of surgery must be weighed against the expected prognosis of the patient in light of the significant rehabilitation required after surgery.

Pharmacologic Therapy

Corticosteroids play a vital role in the management of spinal cord compression. Dexa-methasone is most frequently used to reduce edema, inhibit inflammation, and delay onset of neurologic complications. Dexamethasone has been shown to improve am-bulation in combination with radiation as compared to radiation alone. Significant controversy exists regarding the optimal dosing of dexamethasone. Oral loading doses of 10 to 100 mg followed by 4 to 24 mg orally four times daily have been used. Higher doses may be used in cases of rapidly progressing symptoms, but adverse effects including GI bleeding and psychosis are more severe. Steroids should be continued during radiation therapy then tapered appropriately.

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