Spinal Cord Compression

Kathy Pope, Catherine Mandel, and Damien Tange

Contents1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

2 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

3 Epidemiology and Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

4 Clinical Features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

5 Radiological Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65.1 Referral to Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65.2 Patient Care and Optimization of Image Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.3 Radiological Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

6 Goals of Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

7 Management Overview and Decision Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

8 Neurosurgical Intervention Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

9 Neurosurgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.1 Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.2 Stabilization Alone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.3 Laminectomy with Posterior Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159.4 Vertebrectomy with Stabilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

K. Pope (*)Department of Radiation Oncology & Cancer Imaging,Peter MacCallum Cancer Centre, Melbourne, VIC,Australiae-mail: Kathy.pope@petermac.org

C. MandelSwinburne Neuroimaging, Swinburne University ofTechnology, Melbourne, VIC, Australiae-mail: cmandel@swin.edu.au

D. TangeDepartment of Cancer Surgery, Peter MacCallum CancerCentre, Melbourne, VIC, Australiae-mail: Damien.Tange@petermac.org

# Springer International Publishing AG, part of Springer Nature 2018R. D. MacLeod, L. Block (eds.), Textbook of Palliative Care,https://doi.org/10.1007/978-3-319-31738-0_72-1

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10 Surgical Recovery and Length of Hospital Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

11 Interventional Radiological Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1511.1 Vertebroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1511.2 Tumor Embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1611.3 Image-Guided Tumor Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

12 Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1612.1 Radiotherapy Simulation (Set-Up Position and Planning) . . . . . . . . . . . . . . . . . . . . . . . 1612.2 Types of Radiotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1712.3 Dose Fractionation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1712.4 Efficacy and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1812.5 Early and Late Toxicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2012.6 Re-treatment for Recurrent Spinal Cord Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

13 Systemic Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

14 Supportive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

15 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

AbstractSpinal cord compression, one of the mostdreaded complications of malignancy, is usu-ally caused by metastatic bone diseasecompressing the spinal cord and/or nerveroots. If not recognized and treated promptly,it can have potentially catastrophic outcomes.As patients live longer due to newer treat-ments, the incidence of malignant spinal cordcompression may increase, and the types ofpresentation or behavior of tumors maychange. Spinal cord compression must be con-sidered in all patients who have a cancer diag-nosis presenting with back or neck pain and/orneurological symptoms or signs. In this chap-ter, the terminology used in the diagnosis andtreatment of spinal cord compression will bedefined and the epidemiology and pathophys-iology described. Given that spinal cord com-pression is a true emergency, it must bediagnosed and managed promptly by a multi-disciplinary team. Early detection and effectivetreatment can make the difference betweenindependent living and being bed bound. Thischapter will explore the many factors thatshould be considered in determining the mostappropriate care plan and highlight how theultimate goals of care and care plan need tobe continually reassessed to ensure the best

outcome for the patient. Surgical interventionand radiotherapy treatment decisions are com-plex and will be explained in detail, within thecontext of these above considerations. Techni-cal aspects and illustrations to clarify treatmentoptions will be provided. Predicted outcomeswill be discussed; however it is important tonote that the best outcomes occur when thedegree of premorbid neurological deficit isminimal and the diagnosis and treatment initi-ated within 24–48 h of presentation.

1 Introduction

Spinal cord compression is one of the mostdreaded complications of malignancy usuallycaused by metastatic bone disease compressingthe spinal cord and/or nerve roots, with potentiallycatastrophic outcomes. It affects up to 14% ofpatients with cancer and is a true emergency,which must be diagnosed and managed promptlyby a multidisciplinary team, taking into accountmany factors to instigate the most appropriate careplan for that individual patient. Best outcomesoccur when the degree of premorbid neurologicaldeficit is minimal and the diagnosis and treatmentinitiated within 24–48 h of presentation.

2 K. Pope et al.

2 Definitions

Within this chapter, it is necessary to define thecommon interpretation of the terms used. Theterm “spinal cord compression” in degenerativeterms is just that; compression of the spinal cordalone by a structure such as bone or disc. Inmalignant parlance, it has a much broader defini-tion, and it usually refers to compression of thespinal cord or cauda equina either directly from amalignancy or compression by a pathologicalfracture caused by a malignancy and its associatedclinical findings. Malignant spinal cord compres-sion also commonly involves the compression ofnerve roots in the intervertebral foramina and is anintegral part of the clinical picture in the symptompattern (Fig. 1) (Cole and Patchell 2008).

It is best to maintain strict clinical and radio-logical definitions. “Malignant spinal cord com-pression” should only include compression of thespinal cord and conus, whereas “malignant caudaequina compression” is the compression of thelumbar nerve roots in the lumbar vertebral canal.

“Malignant nerve root compression” is theinvolvement of the nerve roots, including withinthe intervertebral foramina. It is important to dis-tinguish between the use of the term compressionin relation to clinical syndromes. Compression isthe mechanical compression of the spinal cord ornerve roots as defined radiologically. Thereforecauda equina compression is a radiological defi-nition and should not be confused with “caudaequina syndrome,” which is the clinical pictureof nerve root signs, perianal sensory loss, anddouble incontinence. It is important to rememberthat a patient can have radiological compressionwithout symptoms. This is termed “subclinicalcord compression.”

“Impending cord compression” is a loose termthat should be avoided. It is used frequently toindicate a radiological finding that may progressto definite cord compression, either from tumorgrowth or bone fracture. Instead the term “at riskof spinal cord compression” should be used.“Unstable fracture” in relation to malignancy indi-cates a vertebra that has developed a fracture and

Fig. 1 Example of a tumor within a vertebral body, anterior to the spinal cord which is growing posteriorly into thevertebral canal to compress the spinal cord and/or nerve roots

Spinal Cord Compression 3

may possibly collapse further from loss of sup-portive elements. A “potentially unstable verte-bra” is one that has lost a significant amount ofits supportive elements and may go on to fracture.

3 Epidemiology andPathophysiology

Estimates of the incidence of spinal cord compres-sion from malignancy are variously quoted asbetween 5% and 14% of people with cancer(National Institute for Health and Clinical Excel-lence (NICE) 2008). In patients with bone metas-tases, approximately 60% will have metastaseswithin the spine, and up to 10% of these patientswill develop spinal cord compression (Spratt et al.2017). With new treatments, patients with cancerare living longer, and it is likely that the incidenceof spinal cord compression may increase. Ofpatients presenting with spinal cord compression,77% have a known pre-existing malignancy. Theremaining 23% have spinal cord compression astheir first presentation of their malignancy(Levack et al. 2002).

Lung, breast, and prostate cancers are thecommonest malignancies causing spinal cordcompression and together account for over 50%of cases. Non-Hodgkin’s lymphoma, renal cellcancer, and multiple myeloma each account for5–10%, and most of the remainder of cases ofmalignant spinal cord compression are due to

colorectal cancers, sarcomas, and melanomas(Cole and Patchell 2008). In 7% of patients, thesite of primary tumor may remain unidentified(Fig. 2) (Levack et al. 2002).

The thoracic spine is most commonly affectedwith up to 70% of lesions. About 30% of lesionsare within the lumbosacral spine and under 10%within the cervical spine (Helwig-Larsen andSorensen 1994) (Fig. 3). Seventeen percent ofpatients have two or more levels of spinal cordcompression (Levack et al. 2002).

Spinal cord and cauda equina compression canresult from several different mechanisms. Directgrowth of tumor (either from a vertebra or fromparaspinal tissues) into the vertebral canal orintervertebral foramina is one mechanism. A patho-logical fracture with displacement of bone frag-ments is another. Often it is a combination of both.Malignant cells within the subarachnoid space mayalso result in neurological deficits caused by tumordeposits growing on the nerves or surface of thespinal cord within the vertebral canal. From a clin-ical perspective, it is helpful to consider any tumorin the subdural and subarachnoid space or within thespinal cord itself (compromising the spinal cord) asa cause of a patient’s symptoms and signs and aslesions where a patient may benefit from treatment.Leptomeningeal disease is most commonly seen inpatients with small cell lung cancer, melanoma,lymphoma, and tumors of the central nervous sys-tem, most commonly medulloblastoma.

Lung 15-20%

Breast 15-20%

Prostate 15-20%

Non-Hodgkin's lympoma 5-10%

Renal cell carcinoma 5-10%

Multiple Myeloma 5-10%

Other malignancies* 15-20%

Unknown primary 7%

Fig. 2 Approximate proportion of primary tumors causing malignant spinal cord compression. *Other malignanciesinclude colorectal carcinomas, sarcomas, melanomas, etc.

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4 Clinical Features

Malignant spinal cord compression is one of themost dreaded complications of metastatic cancer.Its natural history, if untreated, is usually one ofrelentless and progressive pain, paralysis, sensoryloss, and sphincter dysfunction (Loblaw andPerry 2005). These symptoms and signs can varysignificantly between patients (Fig. 4), and therefore

a detailed history and full neurological examinationneed to be performed and documented.

Back pain, the most common presenting prob-lem in patients with spinal cord compression, maybe sharp, shooting, deep, or burning. The pain canbe localized to the back or may radiate in a band-like dermatomal distribution, if tumor compressesthe nerve roots in or near the intervertebral foram-ina. Mechanical back pain is important to recog-nize, as it can be associated with spinal instability.An acute exacerbation of chronic back pain maybe caused by a recent compression fracture.

In addition to pain, other common symptoms ofspinal cord compression include motor dysfunction(weakness with associated reduction in mobilityand/or sphincter disturbance with incontinence),sensory changes (paresthesia and loss of sensation),and autonomic dysfunction (urinary hesitancy andretention). At presentation patients tend to be moreparaparetic than paralyzed and tend to be less awareof the sensory changes. Sphincter disturbance isusually a poor prognostic sign with regard to pres-ervation or improvement of ambulatory status.

Patients with cauda equina syndrome usuallypresent differently, with change in or loss of sensa-tion over the buttock region, posterior-superiorthighs, and perineal region. This is described as a“saddle distribution.” Reduced anal tone and uri-nary retention, with overflow incontinence, aretypically present.

A study (Husband 1998) of patients with malig-nant spinal cord compression found that more thanhalf of the patients had lost further neurologicalfunction between the onset of symptoms and startof treatment. Themajority of delayswere attributedto lack of symptom recognition by the patient anddiagnostic delay by the primary health provider orat the general hospital.

To prevent further deterioration andmaximize the chances of neurologicalrecovery, any new back pain or abnormalneurology that develops in a patient witha known malignancy needs to be investi-gated immediately, as the diagnosis ofspinal cord compression warrants strongconsideration.

Fig. 3 Approximate distribution of the location of malig-nant spinal cord compression presentations. Percentagesare given in red. 17% of patients have two or more levelsof cord compression. (Illustration by Martha Headworth,printed with permission # 2016 Mayfield Clinic)

Spinal Cord Compression 5

Several studies have shown that patients withthe slowest development of motor deficits beforetreatment had the best functional outcome com-pared with patients with faster development ofmotor deficits and that a greater interval fromcancer diagnosis to the spinal cord compressionindependently predicted improved survival(Rades et al. 2002). Each of these factors probablyreflects the presence of less aggressive tumors.Subclinical spinal cord compression (radiologicalevidence of cord compression in the absence ofneurological deficits or pain) is also important torecognize as it represents a window for treatmentwith potentially the best clinical outcomes.

5 Radiological Diagnosis

5.1 Referral to Radiology

A low index of suspicion in a patient with aknown malignancy is important. In a patientwith the new onset of a neurological deficit,

including bowel and bladder dysfunction or limbweakness, where malignant spinal cord compres-sion or cauda equina syndrome is suspected,same-day magnetic resonance imaging (MRI) isimportant if the patient is deemed fit for treatmentand this will be carried out in the same time frame.If a patient is not fit for treatment or would refuseany treatments offered, there is a little benefit inputting the patient through anMRI scan. TheMRIscan can take up to an hour and can be an unpleas-ant experience for a patient, especially one who isin pain. Therefore if an MRI scan will not altermanagement, consider not referring the patient.

As a suspected spinal cord or cauda equinacompression in a patient who is fit for treatmentis a medical emergency, a personal phone call tothe radiologist to expedite the radiological inves-tigation is helpful. Discussion of the patient’sunderlying malignancy, symptoms, and signsassists the radiologist in determining the mostappropriate imaging techniques and dedicatedsequences, including extra sequences throughthe area of the spine that could be responsible for

Clinical symptom Incidence in patients withspinal cord compression

Features

Back pain

Motor deficits & difficultyambulating

Sensory deficts

Autonomic dysfunction

83-95% Localised or radicular

Unilateral or bilateral

Often worse at night

Can be mechanical (worse with

movement)

Often described as ‘heaviness

or clumsiness’ by patient

Weakness on examination

Can involve upper or lower

motor neuron signs depending

on level involved

Change/loss of sensation

typically begins distally and

ascends as the disease

advances

Bowel or bladder symptoms

tend to occur late

Rarely a presenting symtom

35-75%

50-70%

50-60%

Fig. 4 Summary of the different clinical presentations of patients with malignant spinal cord compression (Cole andPatchell 2008)

6 K. Pope et al.

the neurological abnormality, to answer the clini-cal question and to look for other causes of thepatient’s presentation. It is critical to good radio-logical investigation that the patient is examinedthoroughly. While imaging should include thewhole spine, a radiologist who is aware of theneurological findings may detect smaller lesionson the extra, dedicated sequences that would notnecessarily be seen on standard sequences.

The referral (or request) should include infor-mation about:

• Nature of the known malignancy• Neurological findings• Allergies• Renal function• Contraindications to MRI (detailed below)

5.2 Patient Care and Optimizationof Image Quality

These patients are often in pain and usually anx-ious. The MRI scanner table is hard and uncom-fortable. An examination of the whole spine cantake 1 h, and it is imperative that the patient doesnot move during the examination. Some MRIsequences can take over 8 min, and anymovementduring this time can result in nondiagnosticimages. It is helpful for patients to understandwhat to expect: radiographers are good atexplaining the technical side of MRI to patientsbut do not have the training or knowledge of theclinical situation to be able to provide a moreholistic explanation. For patient comfort and bet-ter diagnostic results, it is helpful for patients to beprescribed an appropriate dose of a suitable anal-gesic prior to the scan, such as morphine. Thisshould be administered when the radiographerscall the ward to arrange transport of the patientto MRI.

5.3 Radiological Techniques

Magnetic resonance imaging (MRI) is the imag-ing technique of choice (Baur et al. 2002; Jung et

al. 2003) (Figs. 5, 6, and 7). Its advantagesinclude:

• The ability to obtain images in any plane: usu-ally at least two perpendicular planes and oftenthree planes

• Good contrast between the relevant tissuesincluding the spinal cord, nerve roots, cerebro-spinal fluid, vertebrae, surrounding tissues, andtumor

• Good spatial resolution when the appropriatesequences are obtained and the patient is ableto stay very still

There are, however, some disadvantages ofMRI. These include:

• A long time required to acquire the imaging• Patient discomfort if not adequately managed

in advance• Lack of access to MRI, especially for patients

in rural locations or in departments where theMRI scanner is heavily booked (there are fewopportunities to add in an extra patient withpotential spinal cord compression, not leastbecause of the long scanning time requiredfor a full spine MRI)

• Difficulty monitoring patients when in theMRI scanner

MRI has a number of absolute contraindica-tions. These include:

• Pacemakers: There are now some pacemakersthat are MRI-compatible, but the majority arepotentially lethal and without firm evidence ofMRI compatibility; a pacemaker is an absolutecontraindication.

• Defibrillators and other implanted stimulators• Aneurysm clips: The clips currently used by

neurosurgeons are MRI-compatible, but manyolder clips are not. Placing a patient with anincompatible aneurysm clip in the MRI scan-ner can result in the clip twisting and tearing offthe artery with fatal consequences. Unlessthere is definite proof that the clip type is

Spinal Cord Compression 7

safe, a patient with an aneurysm clip cannot beplaced in the MRI scanner.

• Metal in the eye: Those who weld and grindmetal can get metal fragments in the eye. Ifthese have not been removed, then it is not safeto place the patient in the MRI scanner as themetal fragment may move, causing blindness.

• Some heart valves and intravascular stents areabsolute contraindications. Definite proof ofthe nature of MRI-compatible devices isrequired prior to a patient being allowed inthe MRI scanner.

Relative contraindications include:

• Being confused and/or unable to followinstructions. Communication problems canpose a risk with safety screening and an inabil-ity to understand the need to stay still for suf-ficient time to get diagnostic-quality images.

• Claustrophobia can result in a patient beingunable to stay still in the MRI scanner or tostay in the scanner at all. Premedication with ananxiolytic can be helpful. The same effect may

also be achieved by adequate analgesia withopiates.

• Recent operations with metal implants or clips.These items are problematic with recent oper-ations (due to potential movement) and areconsidered safe after 6 weeks. Although it issafe to perform MRI after this period, as theprosthesis is fixed and stable, local tissueheating can occur. Patients are asked to let theradiographer know if they start to feel an areaof heat. Metal in tattoo pigments can cause asimilar effect.

• There is long checklist of other potential con-traindications about which the radiographerand radiologist will need to be aware. Theradiographer will complete this before anMRI scan can be performed. If the patientcannot speak English (or the language spokenin the country where he or she is being treated),an interpreter will be needed to complete thesafety checklist.

If a patient is unable to undergo an MRI scan,then a CTscan and CTmyelogram are appropriate

Fig. 5 A 50-year-old female with metastatic breast cancerto the bone only presented with neck pain/tenderness,increased upper limb reflexes, and urinary incontinence.Tenderness over the T5 level with associated bilateralradiating pain was also noted. An axial T2-weighted MRimage (on left) through the C6 vertebra and a sagittal T2-weighted MR image of the cervical spine and upper

thoracic spine (on right, with blue line demonstrating thelevel of the corresponding axial image). Confluent tumor atC5 and C6 levels replaces the vertebral bodies, with exten-sion posteriorly into the vertebral canal, resulting in spinalcord compression. The signal return from the spinal cord iswithin normal limits

8 K. Pope et al.

imaging techniques. CT myelography is preferredas this more clearly demonstrates the effect ofvertebral metastases on the spinal cord and intra-thecal nerve roots. This is particularly helpful inthe cervical and thoracic spine where a combina-tion of artifacts from surrounding structures andlittle CSF surrounding the spinal cord can make ittechnically challenging to interpret a standard CTscan of the spine. Imaging patients with caudaequina syndrome can often be achieved with aCT scan alone. Myelography without a CT scanis no longer the standard of care. The lack ofspatial and contrast resolution compromises clin-ical decision-making. On occasion a CT scan mayassist a spine surgeon in planning treatment due tothe better delineation of bony structures whencompared with MRI. In this instance, the CTscan should be restricted to the region beingtreated.

The radiology report should always include adescription of the extent and location of metasta-ses, the effect (if any) on the spinal cord and nerveroots, any deformities of the spine, and any dis-ease noted in adjacent tissues.

6 Goals of Treatment

The management options and decisions involvedare complex for the team treating patients withmalignant spinal cord compression. Perhaps themost fundamental question that must first beanswered is as follows: What are the goals oftreatment? The next question that follows is: Arethese goals actually achievable? For example, theultimate goal might be to regain the ability towalk, but the achievable goal may be to retainbed mobility and improve the patient’s pain levelsto enable easier transfers (from bed to chair).These treatment goals should be revisited at eachdecision point during a patient’s management,ensuring that futile treatment is not recommended,and the “bigger picture” is kept in mind. Patients,their carers, and treating teams need to be openand honest about treatment goals.

To answer these questions relating to treatmentgoals, the key factors to consider are mobility,continence, analgesia, estimated prognosis of thepatient, and patient preferences. Active treatmentsshould be explored if ambulatory or sphincterfunction can be potentially preserved or recov-ered, or pain levels improved. These treatmentsinclude surgical interventions and/or radiother-apy. Best supportive care is imperative for allpatients. The overarching treatment aim is alwaysto improve the patient’s quality of life.

7 Management Overview andDecision Process

Prompt diagnosis and instigation of appropriatetreatment strongly affect the patient’s ultimateoutcome. The strongest prognostic factor for over-all survival and the ability to ambulate after treat-ment is pretreatment neurological status andspecifically motor function (Talcott et al. 1999).

Fig. 6 AT2-weighted sagittal image of the thoracic spineof the same patient demonstrating a lesion in the T5 verte-bral body extending into the anterior extradural space andabutting the ventral surface of the spinal cord (red arrow),without signal change within the cord. Numerous metasta-ses involving the entire vertebral columnwere found on thewhole spine images

Spinal Cord Compression 9

Therefore in a patient with known cancer, newback pain or abnormal neurological symptoms orsigns should be investigated immediately. If thediagnosis of spinal cord compression is not con-sistent with the patient’s known cancer biology,consideration should be given to arranging abiopsy. This will assist in excluding differentialdiagnoses, such as osteomyelitis.

Once the diagnosis of malignant spinal cordcompression is confirmed, the treatment decisionsneed to be made quickly by the multidisciplinaryteam, comprising of the neurosurgeon, oncolo-gists (both radiation and medical), palliative carephysician, and community teams including theprimary care provider. Urgent neurosurgical opin-ion should be considered for patients with symp-tomatic spinal cord compression, as evidencesuggests that in selected patients, outcomes arebetter with decompressive surgery prior to radio-therapy (Patchell et al. 2005). Several nationaltreatment guidelines and protocols suggest thattreatment with surgery or radiotherapy ideallyshould be commenced within 24 h of radiologicaldiagnosis for best functional outcome (National

Institute for Health and Care Excellence (NICE)2014; eviQ Cancer Treatments Online (CancerInstitute NSW) 2012), together with other studiesconfirming better outcomes if surgery isperformed within 48 h of initial presentation ofsymptoms (Quraishi et al. 2013).

This initial multidisciplinary decision processmay be performed utilizing a “virtual consulta-tion” via telephone or the Internet, especially ifthe neurosurgical and oncology specialists aregeographically distant from the patient. The treat-ment options can be divided into four categories(surgery, radiotherapy, systemic and supportivecare) and will be detailed further in the next sec-tions. Most patients require a combination of thesetreatments; however the decisions regardingsequencing can be complex.

There are many factors that the multidisciplinaryteam considers in developing a suitable treatmentplan for each patient with malignant spinal cordcompression. These can be divided into patient,tumor, and treatment factors (Fig. 8).

All of these factors are then synthesizedtogether to choose the most appropriate treatment

Fig. 7 This 93-year-old patient had metastaticangiosarcoma and presented with mid-lower thoracicradicular pain, radiating in a left T9–T10 dermatomaldistribution. An axial T2-weighted MR image of thepatient through the T9 level. There is nerve root compres-sion from a left-sided paravertebral mass extending into the

vertebral canal through the intervertebral foramen. Thespinal cord is displaced to the right. Signal return withinthe spinal cord is normal (Orange arrow: tumor in theintervertebral foramen. Green arrow: tumor in the vertebralcanal)

10 K. Pope et al.

recommendation. For instance, for a patient withsurgically appropriate disease, who has neverreceived radiotherapy to the spine, with minimalburden of disease, and an excellent expected long-term prognosis, both surgical management andadjuvant radiotherapy would be recommended,in addition to exploring aggressive systemic treat-ment with the best supportive care. For a patientwith a poor performance status, previously treatedspinal cord compression, who has a short progno-sis and has exhausted systemic options, furthersurgery and/or radiotherapy may not be able toprovide any potential benefit, and instead bestsupportive care alone is probably the best option.These factors will be explored further in the fol-lowing section with respect to each treatmentintervention, but it is important to further elabo-rate on a few general factors.

Given that the overall aim is to improve thepatient’s quality of life, it is extremely importantto consider the premorbid level of function of thepatient and what improvements are achievable. At

best, interventions are able to reverse neurologicalabnormalities back to the patient’s baseline leveland eradicate pain. In practice this can be difficultto achieve, and therefore an honest and accurateestimation of “possible” versus “likely” benefitneeds to be discussed with the patient and carers.Pain can be temporarily improved with steroidmedication and analgesia, together with pressurecare, insertion of indwelling urinary catheters, andother important supportive care measures. Formore durable analgesia benefit, surgery and/orradiotherapy are the best options.

Estimated overall disease prognosis can bevery difficult to predict accurately, despite manytools being developed (Krishnan et al. 2013), andprobably deserves its own separate chapter.Essentially, if a patient has had a long disease-free interval (from diagnosis or last episode ofdisease progression to the development of spinalcord compression), has promising systemicoptions, or has oligo-metastatic disease, thenthey are likely to have a longer prognosis. Patients

Functional impact of symptoms (mobility & continence)

Pain levels

Patient preferences

Time elapsed since developing symptoms/signs

Any improvement with dexamethasone

Estimated prognosis

Bone only +/- visceral metastasesTrue ‘oligo-metastatic’ disease

••• Underlying cancer biology/progression

Predicted outcome from active treatments (i.e. potentially reverse or preserve function,or improve pain)

Estimated length of time to achieve potential benefit from treatments

Technical surgical factors

Radio-responsiveness of tumour

Response to systemic treatment options

Previous treatments (neurosurgical interventions and radiotherapy in particular)

Toxicities expected from treatments

Structural impact of disease (e.g. presence of bony compression and spinal instability)Levels within the spine involved

Physical location of patient (distance to travel to hospital for surgery &/or radiotherapy

delivery))

Performance status (often measured as EGOG status) (Oken M 1982) prior to onset of

syptoms/signs

PATIENTFACTORS

TUMOURFACTORS

TREATMENTFACTORS

Fig. 8 Factors to be considered by the multidisciplinary team in formulating a care plan for patients with malignant spinalcord compression

Spinal Cord Compression 11

with particular tumor biologies (e.g., metastaticprostate cancer or receptor-positive breast cancerwith bone-only disease) may also have betterprognoses. The oncologist and palliative carephysician who know the patient most closely arebest placed to make this prognosis estimation.

For surgery and/or radiotherapy to achievepotential overall benefit, the predicted prognosismust be long enough to allow these treatments tobe delivered, the toxicities managed, the patient torecover, and the best possible treatment outcomesrealized. In the case of combined surgery and radio-therapy, a good rule of thumb is that if overallprognosis is less than 3 months, the patient maynot live long enough to recover from the operationand anesthetic, proceed to radiotherapy (often fivedaily treatments over 1 week), heal from sideeffects, and await the 4–6 weeks it usually takesfor maximal analgesia response and the initial con-solidation of the structural benefit from radiother-apy. This has to be balanced by the patient’s wishesand acceptance of potentially spending a prolongedperiod of time either in hospital or away from theirusual place of residence, to receive these treatments.

Essentially the long-term benefits of an inva-sive, timely, or costly procedure might not mani-fest in patients with a short life expectancy.Furthermore, an overly aggressive treatmentapproach might cause more harm than benefit inpatients who are frail and neurologically debili-tated, or who are dying (Spratt et al. 2017). Anumber of algorithms have been developed toassist management teams in deciding appropriatetreatment. The recent Lancet oncology review bySpratt et al. summarizes one such approach inpatients with spinal metastases (Figs. 9 and 10)(Spratt et al. 2017). Spinal cord compression isdetailed in the far-right portion (red box) of theMNOP (mechanical, neurological, oncological,preferred treatment) algorithm (Fig. 10).

8 Neurosurgical InterventionOverview

Surgical treatment in the management of malig-nant spinal cord or cauda equina compressionremains controversial and difficult. It is not

always an available option. The commonest treat-ment options are decompression, stabilization, orboth. The best-known studies showed that decom-pression alone produced a similar or worse out-come when compared with radiotherapy alone formalignant spinal cord compression, due to thedestabilizing influence of the operation (Georgeet al. 2015). For this reason, the majority ofpatients who now have surgery for spinal cordcompression will have decompression combinedwith a form of stabilization. The preferred optionis to make the decision and enact it, prior to theonset of major symptoms and signs. Prolongedparaplegia in a patient from malignant compres-sion will generally not resolve with surgery.

The typical goals of surgery are:

1. Prevention of neurological deterioration2. Restoration of neurological function3. Treatment of pain from compression4. Fracture stabilization for pain control and

prevention of progressive deformity

The decision to operate needs to be based onthe assessment of the value to the patient from theprocedure. The questions that need to be askedare:

What does the patient want?

Patients will usually have an opinion in regardto what they are prepared to go through. This willdepend on their expectations of the outcome. Thepotential outcomes must not be overstated. Sur-gery is going to be associated with a period ofconvalescence and likely rehabilitation, and thepatient may not want to go through this.

Is surgery technically possible and what are therisks?

A surgical opinion with review of the radiol-ogy prior to discussion with the patient is invalu-able, as many patients are not technically suitablefor surgical intervention or the procedure will betoo large considering the patient’s condition.

12 K. Pope et al.

Is the patient fit for any operation planned?

Surgery is precluded if the patient cannot havea prolonged anesthetic, is unable to stop any bloodthinner medications, or is neutropenic orthrombocytopenic.

Is there a significant benefit to the patient from thesurgery?

If the patient cannot walk prior to the surgeryand has a predicted survival of less than 3 months,they are unlikely to walk again. If a patient hassevere pain and has an unstable crush fracture,then stabilization should reduce the pain substan-tially which will significantly decrease medicationrequirements and hopefully supportive care mea-sures, thereby improving quality of life.

What is the patient’s life expectancy?

The only surgery that should be entertained inpatients with short life expectancy is for the treat-ment of pain. If there is a long life expectancy,then it is appropriate to consider treatment early,as prevention of fractures and subsequent pain,kyphosis, and neurological deficit is ideal.

Rate of growth of the tumor and alternative treat-ment options?

In the palliative treatment of metastatic cancerinvolving the spine, it must be remembered thatsurgery is a temporary option, as the tumor willrecur. If the lesion is radioresistant and there areno medical options, then even with surgical treat-ment, there is likely to be residual disease, and

Fig. 9 Algorithm 1: initial assessment algorithm forpatients with spinal metastases. KPS Karnofsky Perfor-mance status, EBRT external beam radiotherapy, MNOPmechanical, neurological, oncological, preferred

treatment. *For selected patients with effective systemictherapy treatment options, systemic therapy without theuse of radiotherapy might be most appropriate

Spinal Cord Compression 13

hence regrowth will occur at the known existingdisease progression rate.

Should radiotherapy/radiosurgery be usedperioperatively?

Conventional radiotherapy will affect tissuehealing. If the patient has already had radiotherapyand subsequent surgery is planned, postoperativewound breakdown and infection will bemuchmorelikely. If stereotactic surgery to the tumor bed isplanned, insertion of metal hardware may cause

Fig. 10 MNOP algorithm for management of spinalmetastases. Spinal cord compression is detailed in the far-right portion (red box). MNOP mechanical, neurological,

oncological, preferred treatment, EBRT external beamradiotherapy, SRS stereotactic radiosurgery

Fig. 11 (a) Patient lying supine on radiotherapy CT sim-ulation couch for planning purposes. Blue vacuum bag isunder patient. (b) Close-up photograph of treatment

reference points (to be tattooed). This will assist withrepositioning patient in the same position for radiotherapytreatment

14 K. Pope et al.

scatter of the radiation and affect the ability to planthe radiotherapy accurately. Preoperative radiosur-gery, if time permits, may be a better and simpleroption. If postoperative radiotherapy is planned, aperiod of at least 2 weeks is usually required forsurgical healing, prior to fractionated radiotherapy.

9 Neurosurgical Procedures

9.1 Laminectomy

This involves the removal of a lamina from the backof the spine, thereby exposing the vertebral canaland allowing access to the spinal cord and any tumoraround it. This is only suitable for patients who donot have any instability and predominately posteriorand lateral extradural compression.

9.2 Stabilization Alone

This is usually a posterior procedure in the thoracicand lumbar spine. It involves the insertion of screwsinto the pedicles of the vertebral bodies and thelinking of the screws to a rod that will cross anunstable segment of fracture. It can be imagined asan internal fixture or scaffolding. These are nowusually constructed from titanium and, if done with-out other procedures, will be performed by a min-imally invasive or percutaneous technique.Stabilization can be used in combination with exter-nal beam or stereotactic radiotherapy where tumorcontrol would be adequate with radiation alone, butthere is a risk of vertebral collapse.

9.3 Laminectomy with PosteriorStabilization

This is a combination of the above two proceduresand allows for a more extensive bone removal andhence a wider decompression. In this combinedprocedure, the decompression may extend toinvolve the pedicles and part of the vertebra,which may then cause instability that needs to betreated with the stabilization. It may be acompletely open procedure or combined with aminimally invasive technique.

9.4 Vertebrectomy withStabilization

If the vertebra needs to be removed, this usuallyinvolves an anterior approach, but some surgeonswill do certain levels from a posterior approach. Thecomplexity and size of the operation increases fromless complex in the cervical spine to much morecomplex in the lumbar spine. At most levels in thecervical spine, vertebrectomy with stabilization isrelatively uncomplicated. Anterior surgery at verte-bral levels C1 and C2 is not indicated in the palli-ative setting because of its complexity and risks.Similarly anterior surgery at vertebral levels T3–T5is best avoided in the palliative setting. These levelsare best treated frombehind. If there is a high degreeof instability either from the tumor or the operation,then an anterior decompression will be combinedwith posterior stabilization. Anterior surgical pro-cedures in the lumbar and thoracic spine are lesslikely to be entertained in the palliative settingbecause of the risks.

10 Surgical Recovery and Lengthof Hospital Stay

Recovery from an operation will depend on thescale of the procedure undertaken and the preop-erative state of the patient. An elective straightfor-ward minimally invasive procedure over fivethoracic vertebral levels with no preoperative def-icit will typically involve a hospital stay ofbetween 3 and 5 days in this patient group. Acervical vertebrectomy with anterior stabilizationalone will be closer to 2 days.

11 Interventional RadiologicalProcedures

11.1 Vertebroplasty

Vertebroplasty is the fluoroscopically guided, per-cutaneous injection of bone cement into a verte-bral body. Vertebroplasty will not relieve spinalcord compression; however, it can be helpful inrelieving mechanical pain and stabilizing a verte-bra at risk of fracture, particularly if the disease is

Spinal Cord Compression 15

within the vertebral body. As vertebroplasty isminimally invasive, it does not require a pro-longed healing time before other treatments canbe started.

11.2 Tumor Embolization

Very vascular tumors, such as renal carcinoma,may be rendered easier to treat surgically ifembolized by a neuroradiologist and therebymade less vascular, prior to operation. Emboliza-tion can be performed using particles, coils, glue,or ethylene vinyl alcohol and may also contributeto reduction in a pain and neurological symptoms.

11.3 Image-Guided Tumor Ablation

There are a variety of radiological ablative tech-niques available, such as radiofrequency ablation,microwave ablation, thermal ablation, andcryoablation. These are typically used to treatpainful metastases or as further treatment toareas previously irradiated. They are not used totreat acute spinal cord compression.

12 Radiotherapy

Radiotherapy is the mainstay of treatment forspinal cord compression and is given in combina-tion with surgery, when appropriate. The mainaims of radiotherapy are to reduce tumor bulkand pressure on the spinal cord and/or nerveroots, consolidate the mechanical benefit fromsurgery, and hopefully provide durable tumor con-trol. Therefore, in a similar way to surgery, theoverall goals with radiotherapy are to:

1. Prevent further neurological deterioration.2. Restore neurological function.3. Reduce pain.

It is important to note that even in the situationwhere any neurological improvement is unlikely,radiotherapy can still potentially palliate symp-toms of pain and improve quality of life. The

maximal benefits from radiotherapy usuallytakes 4–6 weeks to occur, so this needs to beconsidered in making decisions.

There are two main types of radiotherapy: con-ventional external beam radiotherapy and stereo-tactic radiotherapy, which will be discussed inmore detail below. Radiotherapy can be given asa single dose or fractionated into several smallerdoses. Prior to starting radiotherapy, all patientsshould be considered for a full spine MRI, andcommenced on corticosteroids (up to 16 mg dexa-methasone a day in divided doses) as soon as thediagnosis is suspected. There is little evidence thathigher doses are more effective (George et al.2015; Loblaw and Mitera 2012), but seriousadverse events are frequently higher with high-dose steroids, as expected. If the patient is receiv-ing concurrent cytotoxic chemotherapy or immu-notherapy, the potential increased risk of sideeffects with the radiotherapy needs to be consid-ered and discussed with the patient and medicaloncologist. Early radiotherapy-associated toxic-ities (e.g., esophagitis or erythematous skin reac-tion) tend to peak approximately 7–10 days afterradiotherapy is completed and are specific to thearea treated. They should be monitored and man-aged until resolution occurs. Late radiation reac-tions are rare in this setting.

12.1 Radiotherapy Simulation (Set-Up Position and Planning)

For radiotherapy to be effective, it needs to deliverthe prescribed dose to the correct location withinthe body, with an accuracy of millimeters. This isachieved by ensuring the patient has adequateanalgesia prior to simulation and each treatmentand is able to lie in a comfortable and reproducibleposition. Often a patient-specific molded vacuumbag is used to help keep the patient immobilized ina comfortable position, together with small tattoomarks that are used to line the patient up in thecorrect position via laser beams on the treatmentmachine (Fig. 11a, b). A CT simulation image isusually acquired prior to starting treatment, andthe radiotherapy is planned from this. In an

16 K. Pope et al.

emergency this process is simplified and oftencondensed to a single step.

12.2 Types of Radiotherapy

Conventional external beam radiotherapy is themost common technique used to treat spinal cordcompression. It is a noninvasive method of deliv-ering radiation to the tumor and surroundingstructures (often the vertebral body above andbelow the level of concern) and is usually deliv-ered using one to three radiotherapy beams (Fig.12), depending on the location of the spinal cordor cauda equina compression. The radiationbeams are shaped as they come out of the linearaccelerator before they reach the patient to ensurethey are directed at the tumor.

Stereotactic radiotherapy is another noninva-sive technique but is more conformal using manysmaller beams entering the body from a number ofdifferent angles. This means the radiotherapy dosedistribution more closely matches the tumor andvertebral body (Fig. 13), avoiding nearby struc-tures (particular organs at risk) compared withconventional external beam radiotherapy (Facultyof Radiation Oncology, The Royal Australian andNew Zealand College of Radiologists 2017). Ste-reotactic radiotherapy is able to deliver a higherbiological dose because it is better able to avoidnormal healthy tissues and therefore requirestighter margins, a stricter set-up, and the patientto be very compliant and immobile during treat-ment planning and delivery. This higher biologi-cal dose may be particularly beneficial for tumorhistologies (e.g., sarcoma, renal cell carcinoma,and melanoma) that have traditionally beenregarded as relatively radioresistant.

While conventional external beam radiother-apy is widely available and easily delivered, ste-reotactic radiotherapy is more complex and maynot be available in all situations. Stereotacticradiotherapy is unlikely to be used in an emer-gency situation because of the additional timerequired for planning and treatment verification.There are however two main advantages withstereotactic radiotherapy. Firstly, in a non-emergency situation for a patient with good

prognosis disease, who has limited spinal metas-tases, the radiation oncologist may want toincrease the radiotherapy dose to hopefullyimprove local control in the longer term (Loblawand Mitera 2012). This may be given preopera-tively (prior to insertion of surgical hardware) sothat the radiotherapy dosimetry and treatment ver-ification are more accurate. The second benefit ofstereotactic radiotherapy is for patients who havehad previous external beam radiotherapy to thesame spinal level and have a good performancestatus and a malignancy with a good prognosis. Inthis situation there may be an opportunity to offerre-treatment with stereotactic radiotherapy, withthe advantage of sparing the spinal cord (avoiddose being deposited there) and a reduction in thetreatment volume (therefore avoiding other nor-mal tissues receiving additional dose). These arecomplex decisions and treatments requiring multi-disciplinary discussion. Currently in the UnitedStates, the RTOG 0631 trial is comparing stereo-tactic radiotherapy with conventional externalbeam radiotherapy and includes patients with alimited (one to three) number of spine metastases,with or without minimal extradural compression(RTOG Foundation Inc 2016).

12.3 Dose Fractionation

The radiation oncologist chooses the “best-fit”radiotherapy dose and fractionation schedule,depending on the factors that were listed earlierin Fig. 8. The total dose and the number of radio-therapy treatment fractions (#s) vary widely(George et al. 2015). Various doses are acceptablefor conventional external beam radiotherapy,including a single 8 Gy #, 16 Gy in 2 � 8 Gy#sdelivered 1 week apart, 20 Gy in five daily #sdelivered over a week, or 30 Gy in 8#s deliveredover 2 weeks (4 days break in the middle of splitcourse). Consideration should also be given toweekend treatment, especially early on in a frac-tionated course, or with the single doses. Higherdoses may be considered for patients who are ofexcellent performance status, have limited dis-ease, and have a long disease natural history.Stereotactic spine radiotherapy dose schedules

Spinal Cord Compression 17

also vary widely and include single 8–24 Gy frac-tions and multi-fraction dose schedules of27–30 Gy in 3–5#s (Huo et al. 2017).

12.4 Efficacy and Outcomes

Radiotherapy is the most widely used treatment inthe management of malignant spinal cord com-pression. A Cochrane Review (George et al. 2015)included six randomized trials (n= 544) of whichPatchell et al. (2005) was the only trial to comparesurgery with radiotherapy (RT) versus

radiotherapy alone. This trial reported the follow-ing outcomes:

• Overall ability to walk after treatment was 84%(surgery + RT, RR 0.67, CI 0.53–0.86) vs. 57%(RT alone) (Patchell et al. 2005).

• Ability to walk was maintained by 94% (sur-gery + RT) vs. 74% (RT alone) ( p = 0.024),with the median length of time able to walkbeing 153 days (surgery + RT) vs. 54 days (RTalone) ( p = 0.024).

• Regaining ability to walk after treatment wasachieved by 62% (surgery + RT) vs. 19% (RT

Fig. 12 Dosimetry of a conventional external beam radio-therapy plan for a patient with a single bone metastasis atT9 level. A single posterior beam is delivered, to a totaldose of 20 Gy in five daily fractions. The green line is 95%

of the prescribed dose. There is exit dose through the liverand stomach, potentially causing some mild temporarynausea

18 K. Pope et al.

alone) ( p = 0.01), with non-ambulant surgicalpatients walking for a median of 59 days vs.0 days (RT alone) ( p = 0.04)

• Median survival was 126 days (surgery + RT)vs. 100 days (RT alone) ( p = 0.033).

• Serious adverse effects (perforated gastriculcer, psychosis, and death due to infection)were reported in 17% of patients receivinghigh-dose corticosteroid (96–100 mg dexa-methasone) vs. 0% in moderate-to-low-dose(10–16 mg dexamethasone) patients (Georgeet al. 2015).

This Patchell study excluded patients withpoor prognosis (<3 months survival), multiplelevels of spinal cord compression, and radiosen-sitive tumors (lymphomas, leukemia, multiplemyeloma, and germ-cell tumors). It is importantto note that patients with pathological fracturesand spinal instability were included in the ran-domization, a situation which radiotherapy alonewould not be expected to reverse and may havecontributed to the poorer ambulatory outcomes inthe radiotherapy-alone arm. A requirement of thetrial was neurosurgical anterior decompressionwithin 24 h of diagnosis, which may not be

Fig. 13 Dosimetry of a stereotactic radiotherapy plan fora patient with a single bone metastasis at T7 level. Ninebeams are delivered, to create a total dose of 30 Gy in fourdaily fractions. The yellow line is 100% of the prescribed

dose and can be seen wrapping around (and thereforesparing) the spinal cord. There is minimal exit dose as thedose is highly conformal, therefore less toxicity to nearbyorgans

Spinal Cord Compression 19

achievable in many settings. Again it is importantto note that even in patients with poor-prognosisdisease, not suitable for surgery, or where neuro-logical deficit reversal is unlikely, radiotherapyalone may still improve pain control and henceoverall quality of life.

In terms of radiotherapy dose fractionation, theevidence suggests that single-fraction radiother-apy 8 Gy is just as effective as multiple fractionsin patients with poor prognosis (<6 months sur-vival) and no indication for primary surgery (diag-nostic doubt, vertebral instability, bonyimpingement as the cause of spinal cord compres-sion, or previous radiotherapy of the same area).No significant differences in overall survival,ambulation, duration of ambulation, painresponse, and bladder control were reported inthe two randomized controlled trials (Maranzanoand Bellaviat 2005; Maranzano and Trippa 2009)comparing dose schedules (single versus multiplefractions) in these poor-prognosis patients.

For patients with a good prognosis, the use ofsurgery and radiotherapy should be consideredwhere appropriate. Local tumor recurrence(within the radiotherapy field) may be more com-mon, and consequently re-treatment rates higher,with a single dose, compared with higher-doseshort-course radiotherapy schedules. Hence inpatients who are expected to live longer, higherdoses of radiotherapy are often prescribed, despiteminimal evidence comparing radiotherapy sched-ules in patients with spinal cord compression anda good prognosis (George et al. 2015).

12.5 Early and Late Toxicities

Early radiotherapy toxicities are usually tempo-rary, occurring midway during the radiotherapycourse, peaking within 7–10 days of finishing, andusually resolving within approximately 4 weeksof radiotherapy course completion. These sideeffects will vary depending on the level of thespinal cord compression being treated (otherorgans/tissues within the RT field) and the dosedelivered and may include:

• Esophagitis

• Nausea and vomiting (if the stomach in theradiotherapy field)

• Diarrhea (if bowel in the radiotherapy field)• Alopecia (within the radiotherapy field only)• Pneumonitis (if a significant volume of the

lung is within the radiotherapy field)• Skin reaction (includes itch, erythema, dry des-

quamation, but rarely moist desquamation atthese lower doses) where the radiotherapyenters or exits the body

• Fatigue which is independent of the radiother-apy site and instead related presumably tocytokine release

Late radiotherapy toxicities are rare at theselow palliative doses but may be permanent, usu-ally occurring months to years after radiotherapy.Chronic progressive myelopathy is the main lateside effect that must be considered. The estimatedrisk of myelopathy is low (<1%) for the conven-tional external beam radiotherapy dose schedulesdescribed above but may increase with dose-esca-lated stereotactic radiotherapy schedules (if spinalcord dose is not appropriately avoided) or in re-treatment settings (Kirkpatrick et al. 2010).

12.6 Re-treatment for RecurrentSpinal Cord Compression

Patients should be followed up clinically and/orradiographically to determine whether a localrelapse develops. As with the first spinal cordcompression diagnosis, prognosis, the probabilityof neurological recovery, and time to neurologicalrecovery are highly dependent on pretreatmentneurological status (Loblaw and Perry 2005).Patients should be considered for surgical decompression with or without radiotherapy first,because salvage rates seem to be better despitehigher complication rates (Patchell et al. 2005). Ifa patient is not medically and surgically operable,radiotherapy with or without steroids should begiven. Consideration needs to be given to thecumulative dosage of the combined radiotherapycourses, and therefore technique of radiotherapyshould be chosen to keep the cumulative dose of

20 K. Pope et al.

radiotherapy as low as possible to reduce the riskof myelopathy. Newer radiotherapy techniquessuch as stereotactic radiotherapy can be used tominimize cord dose (Loblaw and Mitera 2012;Ryu et al. 2010).

13 Systemic Treatments

A detailed explanation of all systemic agents thatmay be beneficial in patients with malignant spi-nal cord compression is beyond the scope of thischapter. Systemic agents include cytotoxic che-motherapy, immunotherapy, biological targets,hormonal therapy, and bisphosphonates. Each ofthese may have a role in different tumor subtypes,depending on the background performance statusof the patient, burden of disease, previous sys-temic therapies received, and likelihood of benefitversus expected toxicities. However, these sys-temic agents are usually not suitable as primarytreatment in the emergency setting for acutemalignant spinal cord compression. Instead radio-therapy, surgery, or a combination of both isrequired.

For certain tumor biologies, the inclusion ofsystemic agents is of greater importance. In thecase of multiple myeloma, although surgery andradiotherapy remain the primary approaches totreat malignant spinal cord compression, systemictherapy such as chemotherapy agents with ste-roids and either proteasome inhibitors or immu-nomodulatory drugs, with or without high-dosechemotherapy and stem cell transplantation,works rapidly and can be used instead of radiationin selected patients if there is minimal neurologi-cal deficit (Sen and Yavas 2016).

14 Supportive Care

Supportive care of all patients presenting with spi-nal cord compression is of utmost importance. Thisincludes commencing corticosteroids, appropriateanalgesia and aperients, exclusion/management ofhypercalcemia, consideration of insertion of anindwelling urinary catheter, attention to pressurecare, thromboprophylaxis, and referral to allied

health and palliative care services if not already inplace. The option of “best supportive care”withoutthe active intervention of surgery and/or radiother-apy should always be considered and discussedwith the patient and family if appropriate. Anxietyand depression are common in patients with cancer,and a referral to a psychosocial practitioner shouldbe considered (eviQ Cancer Treatments Online(Cancer Institute NSW) 2012).

15 Conclusion

Spinal cord compression needs to be considered inall patients who have a malignancy and presentwith new or escalating back pain and/or abnormalneurology. Spinal cord compression is an emer-gency that must be diagnosed quickly, ideallywith an MRI of the whole spine, urgent multi-disciplinary input, and management instigatedpromptly. The best outcomes occur when thedegree of premorbid neurological deficit is mini-mal and the diagnosis and treatment initiatedwithin 24–48 h of presentation. Decompressivesurgery with stabilization, followed by radiother-apy, in appropriately selected patients should beconsidered for best outcomes. Short courses orsingle fractions of radiotherapy (without surgery)are appropriate for patients with a predicted sur-vival of less than 3 months, particularly if they areambulant and have radiosensitive disease. Radio-therapy given to patients with very poor prognosismay still improve pain levels and quality of life,despite minimal improvement in neurologicalfunction.

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