Metastatic Spinal Cord Compression: A Randomized Trial of Direct Decompressive Surgical Resection Plus Radiotherapy vs. Radiotherapy Alone

Reviewer: S. Jack Wei, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 20, 2003

Presenter: William F. Regine, MD
Presenter's Affiliation: University of Maryland
Type of Session: Plenary


    5-14% of cancer patients will develop spinal cord compression. It is the second most common neurologic complication from cancer after brain metastases and has a very strong negative effect on patient quality-of-life. The respective roles of radiation therapy (RT) and surgery for spinal cord compression (SCC) are not well defined. The current study compares surgery with RT to RT alone for patients with single-site SCC.

Materials and Methods

  • Patients were eligible if they had MRI, biopsy confirmed SCC of a single-site (although multiple contigious vertbral bodies could be involved), and were paraplegic for less than 48 hours.
  • Patient were immediately started on high-dose steroids (100 mg IV then 24 mg q6h)
  • Patients were randomized to: 1) RT (30 Gy in 10 fractions) 2) Surgery (with removable of the maximal amounts of tumor possible with goals of decompression and stabilization of the spine) followed by RT (30 Gy in 10 fractions).
  • Both RT or surgery were started within 24 hours of presentation with RT starting no more than 14 days after surgery in the surgery arm.


  • 101 patients were randomized.
  • The study was stopped at interim analysis due to superior results in the surgery arm.
  • The arms were well balanced with regards to ambulatory status, age, gender, primary tumor type, continence status, spinal level, position of the spinal lesion, and rates of unstable spines.
  • Median time for ambulation was 126 days for the surgery arm and 35 days for the RT alone arm (p=0.006, RR=0.55)
  • For the 32 patients who entered the study non-ambulatory, 56% regained the ability to walk in the surgery arm versus 19% in the RT arm (p=0.03)
  • Time for retaining continence was superior in the surgery plus RT vs. RT alone arm.
  • Overall survival was 129 days vs. 100 days (surgery vs. RT alone, p=0.08)
  • Narcotic and steroid use was lower for the surgery arm (p=0.002)
  • 20% of patients in the RT alone arm received surgery as salvage for refractory disease: 30% had an improvement in neurologic symptoms and 40% experienced surgical complications (compared to 12% of patients receiving immediate surgery).

Author's Conclusions

  • Immediate surgery results in longer time walking and decreased narcotic and steroid use when compared to RT alone for the management of single-site SCC
  • Patients receiving surgery clearly had an improved quality of life; The median survival for patients receiving surgery was 129 days and the median time walking was 126 dayscampared to a median survival of 100 days for RT alone with a median time walking of only 35 days.
  • Immediate surgery is superior to surgery as salvage treatment for single-site SCC.

Clinical/Scientific Implications

    The results of this study strongly support the use of immediate surgery over RT alone as treatment for single-site SCC. The results of this study are better than other historical studies; this is likely due to the requirement of extensive tumor resection in this study compared to laminectomy in previous trials. In patients who can tolerate the surgery and have single-site SCC, surgery followed by RT should be the treatment of choice over RT alone.

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