Interventions for the treatment of metastatic extradural spinal cord compression in adults.
BACKGROUND
Metastatic epidural spinal cord compression (MESCC) is often treated with radiotherapy and corticosteroids. Recent reports suggest benefit from decompressive surgery.


OBJECTIVE
To determine effectiveness and adverse effects of radiotherapy, surgery and corticosteroids in MESCC.


METHODS
CENTRAL, MEDLINE, EMBASE, CINAHL, LILACS and CANCERLIT were searched; last search ran July 2008


METHODS
We selected randomized controlled trials (RCTs) of radiotherapy, surgery and corticosteroids in adults with MESCC.


METHODS
Three review authors independently assessed quality of included studies and extracted data. We calculated risk ratios (RR) and numbers needed to treat to benefit (NNT) with 95% confidence intervals (CI) and assessed heterogeneity.


RESULTS
We identified six trials (n = 544). One trial (n = 276) compared radiotherapy 30 Gray in eight fractions with 16 Gray in two fractions and showed no difference. Overall ambulatory rates were 71% versus 68%, (RR 1.02, CI 0.90 to 1.15); 91% versus 89% of ambulant patients maintained ambulation (RR 1.02, CI 0.93 to 1.12); 28% versus 29% of non-ambulant patients regained ambulation (RR 0.98, CI 0.51 to 1.88). In one trial (n = 101) decompressive surgery had significantly better outcomes than radiotherapy in selected patients. Overall ambulatory rates were 84% versus 57% (RR 0.67, CI 0.53 to 0.86, NNT 3.70 CI 2.38 to 7.69); 94% versus 74% maintained ambulation (RR 0.79, CI 0.64 to 0.98, NNT 5.00 CI 2.78 to 33.33); 63% versus 19% regained ambulation (RR 0.30, CI 0.10 to 0.89; NNT 2.27 CI 1.35 to 7.69). Median survival was 126 days versus 100 days. Laminectomy offered no advantage (n = 29, 1 trial). Three trials provided insufficient evidence about the role of corticosteroids (n = 105, Overall ambulation RR 0.91, CI 0.68 to 1.23). Serious adverse effects were significantly higher in high dose corticosteroid arms (n = 77, two RCTs, RR 0.12, CI 0.02 to 0.97).


CONCLUSIONS
Patients with stable spines retaining the ability to walk may be treated with radiotherapy. One trial indicates that short course radiotherapy suffices in patients with unfavourable histologies or predicted survival of less than six months. There is some evidence of benefit from decompressive surgery in ambulant patients with poor prognostic factors for radiotherapy; and in non-ambulant patients with a single area of compression, paraplegia < 48 hours, non-radiosensitive tumours and a predicted survival of more than three months. High dose corticosteroids carry a significant risk of serious adverse effects.
George
Reena
R
Palliative Care Unit, Christian Medical College, Vellore, Tamil Nadu, India, 632004. reenamg@cmvellore.ac.in
Jeba
Jenifer
J
Ramkumar
Govindraj
G
Chacko
Ari G
AG
Leng
Mhoira
M
Tharyan
Prathap
P
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D019299:Decompression, Surgical; D006801:Humans; D007796:Laminectomy; D011878:Radiotherapy; D016032:Randomized Controlled Trials as Topic; D013117:Spinal Cord Compression / Q000209:etiology / Q000628:therapy*; D013125:Spinal Neoplasms / Q000556:secondary / Q000628:therapy*; D016138:Walking
D000305:Adrenal Cortex Hormones