Current considerations in the management of neoplastic spinal cord compression

Nearly 20% of patients with neoplastic involvement of the vertebral column develop spinal cord compression, and in 8% this is the initial manifestation of cancer. Important determinants of functional prognosis are: 1) tumor biology, 2) pretreatment neurologic status, and 3) tumor location within the spinal canal and the therapy employed. Future efforts should be invested in manipulation of the last two determinants. Delay in neurologic deterioration may be achieved by pharmacologic manipulation of the deleterious pathophysiologic processes operating in the compressed spinal cord, as recently demonstrated in experimental animal models. Use of modern neuro-imaging techniques (metrizamide myelography combined with computed tomography, and/or magnetic resonance imaging) will accurately define tumor extent and location. Radiotherapy is indicated in highly or moderately radiosensitive tumors. Surgery is reserved for the following situations: diagnosis in doubt, previous radiation exposure, radioresistant tumors, neurologic deterioration during irradiation, and the presence of spinal instability or bone compression of the neural structures. The location of the compressing tumor will dictate the surgical approach--a vertebral body resection in an anterior or anterolateral tumor and a laminectomy in a posterior or posterolateral deposit. Modern instrumentation techniques for spinal column stabilization or vertebral body replacement will allow immediate painless ambulation and a better quality of life for these patients.