Introduction: High grade metastatic epidural canal compromise is generally regarded as surgical disease. However many patients are unwilling or unable to undergo open surgical decompression. This study investigates the outcomes of treating patients with significant (Ryu/Rock grade IV and V, Spine Oncology Study Group Grade 2c and 3) metastatic epidural spinal cord compression with spinal radiosurgery (SRS) as first-line therapy in lieu of surgical decompression.
Methods: Utilizing the Spinal Tumor Database at Henry Ford Health System, 32 patients with 35 lesions who had adequate radiological (range 29-2001 days, median 235 days) and clinical follow-up (range 88-2070 days, median 280 days) after SRS were identified. These patients were retrospectively reviewed for clinical and radiological response to radiosurgery.
Results: At this time, 16 patients were still alive (50%). 23/32 (72%) lesions in ambulatory patients pre-SRS had a stable or improved neurological exam. 5/32 progressed neurologically despite radiosurgical treatment. 4 patients initially had neurological improvement then later declined neurologically. Of the 3 patients who were initially non-ambulatory, all 3 regained ambulatory status. Radiologically, 13/21 lesions with grade 4 compression had stable or improved compression. 5 lesions progressed radiologically, 3 initially responded to therapy then progressed later. 3 patients required surgery for neurologic compromise, 2 patients for mechanical instability. 12/14 lesions with grade 5 compression were improved or stable after SRS, whereas the other 2 progressed. 2 patients required decompressive surgery for neurologic deficit, 1 patient had surgery for stabilization
Conclusions: Most patients were treated successfully with radiosurgery avoiding surgery while maintaining or improving neurologic exam. 27% of patients with radiographic grade IV and V needed surgery. Thus, radiosurgery as first-line therapy for high grade metastatic epidural compression appears to be a viable treatment paradigm. Nonetheless, since a small, but significant fraction of patients required surgical intervention, this highlights the need for close clinical and radiological follow-up.
Patient Care: Data suggest that some patients with high grade metastatic epidural canal compromise who are unwilling or unable to undergo open surgical decompression can undergo spinal spinal radiosurgery as first-line therapy in lieu of surgical decompression.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Understand the Ryu/Rock grading system for metastatic epidural spinal cord compression
2) Evaluate whether radiosurgery as first-line therapy for high grade metastatic epidural compression appears to be a viable treatment paradigm
3) Appreciate the need for close clinical and radiological follow-up for patients treated with SRS in lieu of surgical decompression