Treatment of Metastatic Spinal Epidural Disease: A Review of the Literature

Abstract and Introduction

Object: Spinal cord compression is one of the most dreaded complications of metastatic cancer. It can lead to a number of sequelae, including pain, spinal instability, neurological deficits, and a reduction in the patient's quality of life. Except in selected circumstances, treatment is palliative. Treatment options include surgery, radiation, and chemotherapy. The goal of this study was to summarize the existing data on the outcomes of various treatment methods for metastatic spinal epidural disease and to make appropriate recommendations for their use.
Methods: The authors used a search strategy that included an electronic database search, a manual search of journals, analysis of bibliographies in relevant review papers, and consultation with the senior author. There is good evidence, including Class I data, that steroid drugs constitute a beneficial adjunctive therapy in patients with myelopathy from epidural compression. Historically, conventional radiation therapy has been viewed as the first-line treatment because it has been shown to be as effective as a decompressive laminectomy, with a lower incidence of complications (Class II data). Nevertheless, in the last 20 years there has been remarkable progress in surgical techniques and technology. Currently, the goals of surgery are to achieve a circumferential decompression of the spinal cord, and to reconstruct and immediately stabilize the spinal column. Results in a large body of literature support the belief that surgery is better at retaining or regaining neurological function than radiation and that surgery is highly effective in relieving pain. Most of the data on the treatment of metastatic spinal disease are Class II or III, but the preliminary results of a well-designed, randomized controlled trial in which surgery is compared with standard radiation therapy represents the first Class I data.
Conclusions: As the number of treatment options for metastatic spinal disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

In approximately 50 to 70% of patients with cancer there is evidence of metastatic disease at the time of death.^[36] The spinal column is the most common osseous site, and may be involved in up to 40% of patients with cancer.^[11,89] Not all spinal metastases will lead to neurological dysfunction, however. Epidural spinal cord compression from metastases occurs in 5 to 10% of cancer patients and in up to 40% of patients with preexisting nonspinal bone metastases.^{[6,8,15,26,38,89]} Of those with spinal disease, 10 to 20% will experience symptomatic spinal cord compression, resulting in more than 25,000 cases per year; this number is expected to grow.^[28,50,72]

The thoracic spine is the most common site of disease (70%), followed by the lumbar (20%) and cervical spine (10%).^[15,28,29] Metastatic spinal disease can arise from one of three locations: the vertebral column (85%), the paravertebral region (10-15%), and, rarely, the epidural or subarachnoid/intramedullary space itself (< 5%).^[15,28,29] The posterior half of the VB is usually involved first, with the anterior body, lamina, and pedicles invaded later.^[1] Intradural (including intramedullary) metastases from nonneural primary tumors are extremely rare, but have been reported.^[41,73] Multiple lesions at noncontiguous levels occur in 10 to 40% of cases.^{[15,19,28,29]}

Approximately 50% of spinal metastases arise from one of three primary sites: breast, lung, or prostate.^[15] These are followed by renal, gastrointestinal, thyroid, sarcoma, and the lymphoreticular malignancies lymphoma and multiple myeloma. Metastases from prostate, breast, melanoma, and lung lesions commonly cause spinal tumors in 90.5, 74.3, 54.5, and 44.9% of patients, respectively.^[89] The incidence of neurological deficits caused by epidural spinal cord compression varies, however, with the site of primary disease as follows: 22% of patients with breast cancer, 15% with lung cancer, and 10% with prostate cancer.^[28] In the past, neurological dysfunction and spine pain would have been the first manifestation of their cancer in up to 70% of patients.^{[13,14,79,82]} In these cases, the lung was the primary source of malignancy more than 50% of the time.^[28,79]

Treatment for spinal metastases is frequently palliative. Only in selected cases, usually with renal cell carcinoma, can cure be the goal if the spine is the only known site of disease.^[12] Treatment can be broadly categorized as chemotherapy, radiation, and surgery. In this article we summarize the existing data on these treatment modalities and provide appropriate recommendations on their indications.

Neurosurg Focus. 2003;15(5) © 2003 American Association of Neurological Surgeons

Cite this: Treatment of Metastatic Spinal Epidural Disease: A Review of the Literature - Medscape - Nov 01, 2003.