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Systematic Review of the Diagnosis and Management of Malignant Extradural Spinal Cord Compression: The Cancer Care Ontario Practice Guidelines Initiative‘s Neuro-Oncology Disease Site Group

From the Departments of Radiation Oncology and Medicine, Sunnybrook and Women's College Health Science Centre, University of Toronto; Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto; and Program in Evidence-Based Care, Cancer Care Ontario, McMaster University, Hamilton, Ontario, Canada

Address reprint requests to D. Andrew Loblaw, MD, Rm T2-104, 2075 Bayview Ave, Toronto, Ontario, Canada, M4N 3M5; e-mail: andrew.loblaw{at}sw.ca

PURPOSE: This systematic review describes the diagnosis and management of adult patients with a suspected or confirmed diagnosis of extradural malignant spinal cord compression (MSCC).

METHODS: MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to January 2004 using the following terms: spinal cord compression, nerve compression syndromes, spinal cord neoplasms, clinical trial, meta-analysis, and systematic review.

RESULTS: Symptoms for MSCC include sensory changes, autonomic dysfunction, and back pain; however, back pain was not predictive of MSCC. The sensitivity and specificity for magnetic resonance imaging (MRI) range from 0.44 to 0.93 and 0.90 to 0.98, respectively, in the diagnosis of MSCC. The sensitivity and specificity for myelography range from 0.71 to 0.97 and 0.88 to 1.00, respectively. A randomized study detected higher ambulation rates in patients with MSCC who received high-dose dexamethasone before radiotherapy (RT) compared with patients who did not receive corticosteroids before RT (81% v 63% at 3 months, respectively; P = .046). There is no direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted if patient is progressing on or shortly after RT, and whether patients with spinal instability should be treated with surgery.

CONCLUSION: Patients with symptoms of MSCC should be managed to minimize treatment delay. MRI is the preferred imaging technique. Treatment for patients with MSCC should consider pretreatment ambulatory status, comorbidities, technical surgical factors, the presence of bony compression and spinal instability, potential surgical complications, potential RT reactions, and patient preferences.

Supported by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Authors' disclosures of potential conflicts of interest are found at the end of this article.

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