A randomized trial of direct decompressive surgical resection in the treatment of spinal cord compression caused by metastasis

Category: CNS Tumors

Authors: R. Patchell, P. A. Tibbs, W. F. Regine, R. Payne, S. Saris, R. J. Kryscio, B. Young; University of Kentucky, Lexington, KY; University of Maryland, Baltimore, MD; Memorial Sloan-Kettering Cancer Center, New York, NY; Rhode Island Hospital, Providence, RI

Abstract: To determine the efficacy of radical surgical resection of metastatic tumor causing spinal cord compression, we randomly assigned patients with cord compressions to either surgery followed by radiotherapy (surgery group) or radiotherapy alone (radiation group). The intent of surgery in all cases was to remove as much tumor as possible, provide immediate decompression, and stabilize the spine. Both groups were treated with the same corticosteroid protocol and both received total radiation doses of 30 Gy. After an interim analysis at the midpoint, the study was stopped because the criterion of a predetermined early stopping rule was met. One hundred-one patients formed the valid study group (50 in the surgery group and 51 in the radiation group). Patients treated with surgery retained the ability to walk significantly longer than those treated with radiotherapy alone (median, 126 days vs. 35 days, p = 0.006). Surgically treated patients also maintained continence and functional Frankel and American Spinal Injury Association scores significantly longer than patients in the radiation group. Length of survival was not significantly different between the two groups, although there was a trend towards longer survival time in the surgery group (median, 129 days vs. 100 days, p = 0.08). Thirty-two patients (16 in each group) entered the study unable to walk; patients in the surgery group regained the ability to walk in a significantly greater proportion than patients in the radiation group (9/16 {56%} vs. 3/16 {19%}, p = 0.03). The median length of hospitalization during which the cord compression was diagnosed and treated was 10 days for both treatment groups (p = 0.86). We conclude that patients with spinal cord compressions treated with radical direct decompressive surgery plus postoperative radiotherapy regain the ability to walk more often and maintain it longer than patients treated with radiation alone. Surgery permits most patients to remain ambulatory and continent for the remainder of their lives while patients treated with radiation alone spend approximately two thirds of their remaining time unable to walk and incontinent.