Spinal Cord Compression in Patients

With Advanced Metastatic Cancer

Janet L. Abrahm, MD
Harvard Medical School

Steven Z. Pantilat, MD
Education Guides Editor

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Spinal Cord Compression

All I care about is walking and living my life.

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Ms Hs Story

Ms H is a 56-year old interventional radiology

technician living alone
She had breast cancer diagnosed 20 years
earlier, initially treated by left mastectomy
followed by chemotherapy and chest wall
radiotherapy

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Ms Hs Story

Developed bony metastases to rib and hip 4

years later
Bisphosphonates were initiated, and left rib
resection done
Salpingo-oophorectomy done with regression
of the left hip metastasis
Ms H did well for 10 years

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Ms Hs Story

She developed a T7 vertebral metastasis

developed 7 years ago and was treated with
44 Gy to the T6 to T8 vertebral area
A recurrent lesion required T7 vertebral
corpectomy with structural rib autograft and
T4 to T10 instrumented fusion 3 years ago

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Ms Hs Story

Ms H presented this time with worsening

thoracic pain and progressive difficulty
walking
The T7 vertebral tumor now involved the T6 to
T7 ventral epidural space with significant cord
impingement
Her posterior spinal fixation loosened with
progressive deformity of the spine

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Ms Hs Story

Ms Hs surgeon recommended repeat surgery

and stereotactic radiosurgery at a university
hospital, and Ms H agreed
On admission, Ms H had difficulty with gait
and urinary retention and had episodes of
urinary incontinence
Midthoracic pain was incapacitating despite a
fentanyl patch and oral rescue opioids
She was largely confined to bed but able to
ambulate to the bathroom with a walker

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Ms Hs Story

Physical examination found 4 out of 5 strength

in left extensor hallucis longus, tibialis
anterior, and bilaterally in iliopsoas muscles;
sensation was decreased in first toe web, loss
of proprioception bilaterally
Her knee and ankle jerks were hyperactive and
symmetrical, with 3 beats of clonus bilaterally,
and a positive Babinski sign on her left foot
Ms H received dexamethasone 4 mg orally
twice daily, fentanyl transdermal 50 mcg/hr
every 3 days, and hydromorphone 4 mg orally
every 4 hours as needed
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Ms Hs Story

Ms H then underwent a revision posterior

surgery with laminectomies of the T6 through
T8 vertebrae and excision of tumor from the
dorsal aspect of the spine and spinal fusion
from the T3 to L2 vertebrae
Five days later, she had corpectomies of the
T6 to T8 vertebrae with resection of epidural
tumor and anterior column reconstruction
from the T5 to T9 vertebrae using a cage,
rods, and structural rib

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Ms Hs Story

Ms H was transferred to a rehabilitation facility

where she stayed for 3 weeks
Five months later, she required only nonopioid
medications, had good strength and
proprioception, and was walking more than 2
miles daily

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Epidemiology

Ms H is among 12 700 cancer patients in the

United States who develop spinal cord
compression each year
Spinal cord compression can cause pain,
paraparesis or paralysis, incontinence, and
institutionalization

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Cancers That Cause Spinal Cord Compression

Breast, prostate, and lung cancer are the

most common causes of spinal cord
compression
Each accounts for 15%-20% of the cases

Non-Hodgkin lymphoma, myeloma, and

renal cell carcinoma are next most
common
Each accounts for 5%-10% of cases

The remainder of causes are primarily from

colorectal cancer, cancer of unknown
primary, and sarcoma
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Pathophysiology

Malignant cells reach the spinal canal

through
Arterial spread
Venous drainage from organs
Cerebrospinal fluid
Direct extension through the vertebral foramina or
from a metastasis breaking out of a vertebral body

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Assessment of Patients

Back pain is the most common symptom of

spinal cord compression
Noted by 83%-95% of patients prior to diagnosis

Pain can be local, referred, radicular, or all

3
Pain is caused by the expanding tumor in the bone,
bone collapse, or nerve damage

Referred pain is common

Cervical compressions cause midscapular pain
Thoracic compressions cause hip or lumbosacral
pain
Lumbosacral compressions cause thoracic pain
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Assessment of Patients

Thoracic metastases are most common (60%),

followed by lumbosacral (30%) and cervical
(10%)
Cancer type and location of spinal cord
compression
Breast and lung cancers commonly cause thoracic
lesions
Colon and pelvic carcinomas commonly affect the
lumbrosacral spine

In 20% of patients, cancer presents as

spinal cord compression
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Cauda Equina Syndrome

Symptoms include
Diminished sensation over buttocks, posteriorsuperior thighs, and perineal region
Decreased anal sphincter tone in 20%-80% of cases

Urinary retention and overflow

incontinence are pathognomonic of the
syndrome
Absence of postvoid residual rules it out

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Common Signs of Spinal Cord Compression

Radiculopathy
Weakness
Sensory changes
Sphincter incontinence
Autonomic dysfunction (urinary hesitancy,
retention)

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Assessment of Patients

Useful scale for functional assessment of

patients with spinal cord compression is the
Frankel grading system (grades A-E)
A. Complete paraplegia
B. Only sensory function
C. Nonambulation
D. Ambulation
E. No neurological symptoms or signs

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Diagnosis of Spinal Cord Compression

Therapy is typically well-tolerated and should

be considered urgent
Delay in diagnosis results in loss of mobility,
bladder dysfunction, and decreased survival

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Diagnosis of Spinal Cord Compression

Magnetic resonance imaging (MRI) is the

reference standard for detecting epidural
metastatic disease and frank spinal cord
compression
Finding unsuspected lesions is not unusual

Plain spine radiographs are inadequate

Clinicians should order an MRI of the
entire spine in patients with cancer and
back pain
No validated predictive models exist to determine
which patients are at greatest risk for epidural
metastases and spinal cord compression
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Diagnosis of Spinal Cord Compression

MRI of the entire spine should include T1weighted sagittal images with T1- or T2weighted axial images in areas of interest
Patients with prostate cancer with more than
20 bone metastases and who have taken
hormone therapy have a 44% incidence of
spinal epidural disease
MRI of the spine might be considered even before
development of symptoms of spinal cord
compression

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Goals of Treatment

For many patients, reasonable goals are

improvement of pain, quality of life, and
independence
For other patients, the goal is to improve
survival
Understanding the patients goals and
understanding the clinical scenario are
important for an appropriately guided
treatment that balances risks and benefits of
therapy

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Treatment of Spinal Cord Compression

Pain management and symptomatic

measures
Glucocorticoids
Radiation therapy
High precision radiotherapy techniques
Surgery
Chemotherapy and hormonal therapy

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Pain Management and Symptomatic Measures

Pain from spinal cord compression and bony

metastases is somatic and neuropathic
Effective agents for pain include
Opioids
Glucocorticoids for bone pain and neuropathic pain
Neuropathic adjuvants: gabapentin, pregabalin
Bisphosphonates and other bone adjuvants

Symptomatic measures include

Bowel regimen for constipation from opioids or
autonomic dysfunction
Anxiolytics/antidepressants
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Pain Management and Symptomatic Measures

Bisphosphonates decrease bone pain

Zoledronic acid
Pamidronate

Nonsteroidal anti-inflammatory drugs

(NSAIDs)
Best in younger patients and those with no history of
gastrointestinal bleeding and normal renal function

Braces may improve comfort

Avoid physical therapy before radiation or
surgery as it does not improve pain and
may accentuate fracture pain
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Pain Management and Symptomatic Measures

A bowel regimen is critical to prevent

constipation
Medications
For patients who retain sphincter control
Docusate and senna
Polyethylene glycol

For patients who cannot eliminate stool on their own

Polyethylene glycol
Bisacodyl or glycerin suppository

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Pain Management and Symptomatic Measures

Patients with paraparesis or paralysis

frequently experience anxiety and depression
that may require pharmacological treatment
Patients whose self-image or self-esteem are
predicated upon physical activity and
independence may feel out of control,
helpless, and hopeless
Refer patients and families to social workers,
psychologists, psychiatrists, or spiritual
leaders

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Glucocorticoid Therapy

Glucocorticoids reduce injury from traumatic

spinal cord injury
Promote posttreatment ambulation
Beneficial in asymptomatic ambulatory
patients receiving radiation therapy
Optimal dose not determined
Higher doses generally believed to be more
efficacious but also associated with adverse
effects

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Glucocorticoid Therapy

Patients with sensory or motor deficits

Dexamethasone 100 mg intravenous bolus followed
by 6 mg orally 4 times daily for 3 days followed by
a 10 day taper if no neurologic deterioration

Pain relief: 82% overall

Preserves ambulation in patients receiving
radiation therapy (P = .05)
Dexamethasone group: 22 of 27 patients had
preserved ambulation
No dexamethasone group: 19 of 30 patients had
preserved ambulation

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Glucocorticoid Therapy

Guideline recommendations
High dose dexamethasone was a Grade A
recommendation
Optimal dose not known
Dexamethasone 6-10 mg oral or intravenous bolus
with taper during or immediately after radiation
therapy

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Glucocorticoid Therapy Complications

Even at low doses, 5% of 21 patients

receiving < 3 weeks of therapy had
tremulousness, insomnia, delirium, and
hyperglycemia
Toxicity increased with total dose > 400 mg and
treatment > 3 weeks

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Glucocorticoid Therapy Complications

Complications
Anxiety, insomnia, delirium
Oral candidiasis: consider fluconazole 100 mg orally
daily
Glucose intolerance
Pneumocystis jiroveci: if a prolonged course of
dexamethasone is planned, consider prophylaxis
with trimethoprim and sulfamethoxazole

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Radiation Therapy: Outcomes

Directed at vertebral metastatic sites that are

painful or associated with significant epidural
involvement or thecal sac indentation
60%-90% of patients achieve pain relief with
radiation therapy and dexamethasone
60%-100% of patients who are ambulatory
before radiation therapy maintain the ability to
walk
Patients with lung cancer are least likely to remain
ambulatory

40% of paraparetic patients become

ambulatory after radiation therapy
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Radiation Therapy: Outcomes

13%-15% of paralyzed patients have

restoration of full ambulation and sphincter
function
Persistence of paralysis varies by type of
cancer
50% with lung cancer remain paralyzed vs 40% with
prostate cancer vs only 10% with breast cancer

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Radiation Therapy: Technical Aspects

Radiation therapy ports extend 1 or 2 vertebral bodies
above and below the site of compression
Myelosuppression can occur if multiple spinal sites
are treated
Designed to minimize risk of myelopathy
Standard and shorter course have similar efficacy on
posttreatment motor function
Standard therapy: 30 Gy in 10 fractions (usually over 2 weeks)
Shorter therapy: 8 Gy x 2, 1 week apart, or 8 Gy once, or 4 Gy x
5

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Risks and Benefits of Short Course Radiotherapy

Less bone recalcification

More in-field recurrences
Shorter survival
No late radiation-induced toxicity
Shorter courses may be particularly
appropriate for patients with shorter life
expectancy

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Radiation Therapy: Recurrence

Recurrence is common after standard

radiation therapy
10% of patients develop recurrences in the short
term (median 4.5 months)
50% of 2-year survivors have recurrences
Almost all 3-year survivors develop recurrences

Patients who initially received a short

course of therapy can receive a repeat
course
Prognosis after recurrence: median
survival 4.2 months
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High-Precision Radiotherapy Techniques

Can deliver radiation more precisely to tumor,

sparing normal spinal and paraspinal tissues
Intensity modulated radiotherapy (IMRT)
Tomotherapy
Stereotactic radiosurgery (Cyberknife, Novalis
Shaped Beam Surgery)

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High-Precision Radiotherapy Techniques

Stereotactic radiosurgery
Patients receive 1 large dose (eg, 6-8 Gy) to a
localized tumor with a precisely shaped radiation
beam
Patients must be able to physically and emotionally
tolerate staying still for the 90 minutes of treatment
Few studies compare stereotactic radiosurgery to
standard radiation therapy
One retrospective study found similar ambulation,
performance status, and pain control for patients treated
for recurrent disease

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Choosing the Right Radiotherapy

Consultation with radiation oncology,

oncology, neurosurgery, and palliative care
can be helpful in determining which type of
radiotherapy is best for a particular patient
In patients with limited survival, single dose,
standard radiation may be best
For patients with longer survival, longer course
radiation is associated with prolonged survival

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Surgery

No consensus on merits of radiotherapy alone

vs surgical therapy followed by radiation for
selected patients with spinal cord compression
An evidence-based review recommended
Radiation alone for ambulatory patients without spinal
instability, bony compression, or paraplegia
Surgery for patients with progressive neurological
deficits, vertebral column instability, radioresistant
tumors, or intractable pain unrelieved by radiation
therapy

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Surgery

Physicans must weigh the patients health,

ability to tolerate surgery, and goals of
therapy
A life expectancy of more than 3 months is
required for spinal surgery
A scoring system developed by Tokuhashi can be
used to predict survival

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Tokuhashi Scoring System

Based on 6 parameters
General condition (0-2)
Number of extra-spinal metastases (0-2)
3 or more = 0; 1-2 = 1; 0 = 2

Number of vertebral body metastases (0-2)

3 or more = 0; 2 = 1; 1 = 2

Metastases to major internal organs (0-2)

Non-removable = 0; removable = 1; none = 2

Primary site of cancer (0-5)

Lung, osteosarcoma, stomach, bladder, esopahagus, pancreas = 0;
liver, gallbladder, unidentified = 4; kidney, uterus = 3; rectum = 4;
thyroid, breast, prostate, carcinoid = 5; others = 2

Palsy or myelopathy (0-2)

Complete = 0; incomplete = 1; none = 2

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Tokuhashi Scoring System

Each parameter is given a score

Total score ranges from 0 to 15
A score of 8 or less has a prognosis of less than 6
months

Ms H has a score of 15
General condition: 2
Extraspinal metastases: 2
Vertebral body metastases: 2
Metastases to major internal organs: 2
Primary site of cancer: 5
Palsy or myelopathy: 2

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Surgery

Before surgery, patients should have a

Karnofsky Performance Score of greater than
40%
Several trials have confirmed the accuracy of
this scoring system including patients with
metastatic breast or renal cell cancers

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Surgery: Outcomes From Observational Studies

80%-94% of patients obtained pain relief

68%-75% of nonambulatory patients became
ambulatory
50% of severely paraparetic patients became
completely ambulatory

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Surgery Plus Radiation vs Radiation Alone

There is 1 prospective, randomized trial

comparing surgery followed by radiotherapy
with radiotherapy alone in patients with
Compression limited to a single area
Cancer origin other than central nervous system
No prior history of cord compression or preexisting
neurological disease
At least 1 neurological symptom

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Surgery Plus Radiation vs Radiation Alone

Posttreatment ambulation was 84% for

combination treatment vs 57% for radiation
therapy alone
94% of patients who were ambulatory before
combination treatment remained ambulatory,
whereas only 76% of patients who were
randomized to radiation alone did so
Maintenance of continence, functional scores,
and survival were also significantly greater in
the group randomized to combination therapy
Combination therapy was more effective in
patients under age 65 years
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Surgical Complications

Rates of surgical complication range from 23%

to 50%
Surgical complications
Wound breakdown
Failure of spinal stabilization
Infection
Excessive blood loss
Respiratory failure
Intra-abdominal vascular or visceral injury
Cerebrospinal fluid leak

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Surgery: Bottom Line

Although radiation remains the therapy offered

to most patients, surgery is increasingly being
offered to patients who fulfill the strict criteria
of the study by Patchell et al
Nonhematologic tumor
Single site of epidural compression
Cancer other than central nervous system or spinal
origin
No prior spinal cord compression or neurological
disease
At least 1 neurological symptom
If paraplegic, paraplegic for < 48 hours
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Chemotherapy and Hormonal Therapy

Chemotherapy and hormonal therapies have

been used in patients with spinal cord
compression from Hodgkin and non-Hodgkin
lymphomas, germ cell tumors, breast or
prostate carcinomas, or neuroblastomas
In individual case reports, the compression
completely resolved in 5 of the 7 patients
reported
No large case series or randomized controlled
trials have been reported

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Prognosis

Most important predictors of ambulation after

treatment, place of care, and bladder function
Pretreatment ambulatory status
Time from development of motor deficits to
radiotherapy

Overall, 75%-100% of ambulatory patients

remain ambulatory
50% of those who survive 1 year remain ambulatory

Some patients regain ambulation after

radiation therapy
14%-35% of paraparetic patients
15% of paralyzed patients regain function
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1 Month After Spinal Cord Compression

Patient status at 1 month after treatment of

spinal cord compression varied by level of
function at presentation
Function at
Presentation

Home Hospital Hospice

Normal
Bladder
Function

Fully ambulatory

64%

27%

9%

69%

Needing assistance

37%
31%

48%
36%

15%
33%

61%

Could not walk

33%

Mood was normal in most patients, few had moderate or severe

anxiety or depression, and most reported that their lives still contained
quality and meaning.
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Prognosis

Median survival after spinal cord

compression depends on the patients tumor
type, ambulatory status, and number and site
of metastases
Longest survival for patients with
Single metastasis
Radiosensitive tumor
Myeloma, lymphoma, breast, or prostate cancer

Shortest survival for patients with

Multiple metastases
Visceral or brain metastases
Lung or gastrointestinal tumors
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Prognosis

Prognosis depends on type of cancer causing

spinal cord compression
Cancer Type

Median
Survival

1-Year
Survival

Myeloma

6.4 months

39%

Lymphoma

6.7 months

38%

4 months

27%

1.5 months

22%

Prostate cancer
Lung cancer

Median and 1-year survival with spinal cord compression is poor and
varies by type of cancer. Median survival is 9 months for patients
ambulatory after treatment vs 1-2 months for patients nonambulatory
after treatment.
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Prognosis

First Score predicts survival of patients with

spinal cord compression receiving radiation
therapy alone
Lower survival associated with
Tumors other than breast, prostate, myeloma, or
lymphoma
Other bone or visceral metastases
Nonambulatory before therapy
< 15 months since tumor diagnosis
Motor deficits < 14 days before therapy

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Rehabilitation

Useful after radiation or surgery for patients

who are ambulatory and those who are not
Assist with transfers, bowel and bladder function,
nutrition, and mobility

Associated with
Increased satisfaction with life
Less depression
Persistent decreases in pain

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Inpatient Rehabilitation

Posttreatment average length of stay in

rehabilitation facility was 27 days
84% of patients were discharged to home
Mobility, ambulation, self-care, and transfer
abilities persisted for at least 3 months
following discharge

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Palliative Care

Oncologists and palliative care clinicians

should help patients and families explore and
cope with changes in self-image,
independence, roles in the family and
community, and living arrangements

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Palliative Care

Questions to help the clinician understand

the patient better include
Help me understand what a typical day at home was
like before the pain started.
What are the things you need to get done?
What do you really enjoy doing?
Have you ever needed help to take care of yourself
before or has it happened to anyone close to you?
How did you deal with that?
Did you see a counselor?
Did your clergyman or religious community support you?

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Palliative Care

Questions to help the clinician understand the

patient better include
Do you know anyone who had to use a cane or
wheelchair to get around?
How did you feel about that?
How do you think it might make you feel?

If you werent able to walk on your own, what would it

take for you to be able to stay at home?
Who is there to help during the day and overnight?

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Palliative Care

For patients with limited prognoses, clinicians

should also help the patient and family identify
health care proxies and delineate preferences
regarding cardiopulmonary resuscitation
Questions to help in doing this are
Whom do you regularly consult about important
issues?
Is there one person who really understands what is
important to you and how you make your choices
about treatments?
If at sometime in the future you werent able to tell us
directly what you wanted, should we talk with them?

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Palliative Care

Given their short term median survival,

palliative care is especially important for
patients with spinal cord compression due to
lung or gastrointestinal cancers or any
patient who is nonambulatory after surgery or
radiation therapy
Efforts should change from disease-oriented
therapies to creating legacies and bringing
closure to personal relationships

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Palliative Care

Oncology teams can reassure patients and

their families that they will not be abandoned
Oncologists can remain the patients
physician in hospice programs
For patients whose needs exceed those that
the hospice programs can provide, palliative
care teams can help oncology teams provide
care and comfort during the final months

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Conclusion

Diagnosis of epidural spinal cord

compression is an emergency
Survival and quality of life are directly related
to the patients pretreatment ambulatory
status
Emergency MRI of the entire spine and
immediate initiation of specific therapy may
preserve function
All patients benefit from identification of
goals, counseling, and symptomatic
treatment
Care at the Close of Life: Evidence and Experience
Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Conclusion

The majority of patients are offered only

radiation therapy, but surgery plus radiation is
beneficial for patients who meet Patchell
criteria
Patients with a very limited prognosis may be
appropriate candidates for single-dose
radiation therapy or radiosurgery to decrease
pain, preserve ambulation and ability to
transfer, and maintain bowel and bladder
function
All patients can benefit from consultation with
a palliative care team
Care at the Close of Life: Evidence and Experience
Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

This Education Guide slide set

has been created as a part of
Care at the Close of Life: Evidence and Experience

Janet L. Abrahm, MD
Harvard Medical School
Steven Z. Pantilat, MD
Education Guides Editor
Stephen J. McPhee, MD; Margaret A. Winker, MD; Michael W. Rabow, MD; Steven Z. Pantilat, MD; Amy J. Markowitz, JD
Care at the Close of Life: Evidence and Experience Editors
Care at the Close of Life: Evidence and Experience
Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

Spinal Cord Compression

Abrahm JL. Spinal cord compression in patients

with advanced metastatic cancer. In: McPhee SJ,
Winker MA, Rabow MW, Pantilat SZ, Markowitz AJ,
eds. Care at the Close of Life: Evidence and
Experience. New York, NY: McGraw-Hill; 2010:115127.
http://www.jamaevidence.com/content/6603659

Care at the Close of Life: Evidence and Experience

Copyright American Medical Association. All rights reserved. | JAMA | The McGraw-Hill Companies, Inc.

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