Assessment and treatment of patients with malignant spinal cord compression

Spinal cord compression is a complication of malignancy that affects the quality of life of 12,700 new patients each year and disrupts the lives of the families striving to care for them. Compression can be prevented by early diagnosis, which requires a high index of suspicion on the part of patients, their families, and their clinicians. Disability arising from delays is associated with shortened patient survival. Magnetic resonance imaging is the gold standard for diagnosis and is needed in any cancer patient presenting with new back pain, whether or not plain films or bone scans show metastases. Symptomatic therapy addresses pain, constipation, spinal instability, and the psychological and social consequences of the associated disability. High-dose corticosteroids are recommended unless they are contraindicated or the patient is ambulatory and asymptomatic while receiving radiation therapy. Evidence-based guidelines recommend radiation therapy for most patients. Short courses of irradiation and reirradiation may be associated with less toxicity than previously thought. Initial surgery is recommended for patients without a previous cancer diagnosis or with a remote cancer, unstable spine or bony cord compression, or inability to receive further irradiation. New surgical data suggest that patients with irradiation-resistant tumors and a single site of compression may have improved function with initial surgery and reconstruction followed by irradiation,compared with irradiation alone.