title: Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial.
abstract: BACKGROUND
  The standard treatment for spinal cord compression caused by metastatic cancer is corticosteroids and radiotherapy. The role of surgery has not been established. We assessed the efficacy of direct decompressive surgery.
  
  
  METHODS
  In this randomised, multi-institutional, non-blinded trial, we randomly assigned patients with spinal cord compression caused by metastatic cancer to either surgery followed by radiotherapy (n=50) or radiotherapy alone (n=51). Radiotherapy for both treatment groups was given in ten 3 Gy fractions. The primary endpoint was the ability to walk. Secondary endpoints were urinary continence, muscle strength and functional status, the need for corticosteroids and opioid analgesics, and survival time. All analyses were by intention to treat.
  
  
  RESULTS
  After an interim analysis the study was stopped because the criterion of a predetermined early stopping rule was met. Thus, 123 patients were assessed for eligibility before the study closed and 101 were randomised. Significantly more patients in the surgery group (42/50, 84%) than in the radiotherapy group (29/51, 57%) were able to walk after treatment (odds ratio 6.2 [95% CI 2.0-19.8] p=0.001). Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs 13 days, p=0.003). 32 patients entered the study unable to walk; significantly more patients in the surgery group regained the ability to walk than patients in the radiation group (10/16 [62%] vs 3/16 [19%], p=0.01). The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.
  
  
  CONCLUSIONS
  Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone for patients with spinal cord compression caused by metastatic cancer.
authors.affiliation: Department of Surgery (Neurosurgery), University of Kentucky Medical Center, Lexington, KY 40536, USA. rpatchell@aol.com
authors.forename: Roy A
authors.initials: RA
authors.lastname: Patchell
authors.forename: Phillip A
authors.initials: PA
authors.lastname: Tibbs
authors.forename: William F
authors.initials: WF
authors.lastname: Regine
authors.forename: Richard
authors.initials: R
authors.lastname: Payne
authors.forename: Stephen
authors.initials: S
authors.lastname: Saris
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Kryscio
authors.forename: Mohammed
authors.initials: M
authors.lastname: Mohiuddin
authors.forename: Byron
authors.initials: B
authors.lastname: Young
mesh_terms: D003131:Combined Modality Therapy; D019299:Decompression, Surgical; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013117:Spinal Cord Compression / Q000209:etiology*; D013125:Spinal Neoplasms / Q000150:complications / Q000532:radiotherapy / Q000556:secondary* / Q000601:surgery*; D013131:Spine / Q000601:surgery; D016896:Treatment Outcome; D016138:Walking