Radiotherapy is the most widely used treatment in the management of malignant spinal cord compression. The Cochrane review by George et alr of 6 randomised trials (n=544) of which Patchell et alr was the only trial to compare surgery vs RT reported the following outcomes:
- Overall ability to walk after treatment was 84% (RT+Surgery, RR 0.67, CI 0.53-0.86) vs 57% (RT alone).r
- Ability to walk was maintained by 94% (RT+Surgery) vs 74% (RT alone).
- Regaining ability to walk after treatment was achieved by 63% (Surgery + RT) vs 19% (RT alone).
- Median length of time able to walk was 122 days (Surgery + RT) vs 13 days (RT alone) (p=0.003).
- Median survival was 126 days vs 100 days.
- Serious adverse effects (perforated gastric ulcer, psychoses and death due to infection) were reported by 17% of patients receiving high dose corticosteroid (96-100mg dexamethasone) vs 0% in moderate to low dose (10-16mg dexamethasone) patients.r
The Patchell studyr excluded patients with multiple levels of spinal cord compression and chemotherapy and radiotherapy sensitive disease. It is important to note that patients with pathological fractures and spinal instability were included in the randomisation, a situation which radiotherapy alone would not be expected to reverse and may have contributed to the poorer ambulatory outcomes in the radiotherapy alone arm. A requirement of the trial was neurosurgical anterior decompression within 24 hours of diagnosis, which may not be achievable in many settings.
Palliative spinal cord radiotherapy for cord compromise may not reverse neurological deficits, but may still be appropriate to improve pain control.
Single fraction radiotherapy of 8Gy has been shown to be just as effective as multiple fractions in patients with a poor prognosis. For patients with a good prognosis (the use of surgery and radiotherapy should be considered.r
Maranzano et alr have reported on 2 RCTs comparing dose schedules for poor prognosis patients (single versus multiple fractions):
- No significant differences in overall survival, ambulation, duration of ambulation, pain response and bladder control were reported.
- However, there is a greater incidence of in-field failures with single fraction regimens.