Speed is of the essence in the management of spinal cord compression since the degree of recovery is dependent on the pre-treatment status. Fewer than 10% of patients with established paraplegia from metastatic disease walk again.

If spinal cord compression is suspected, dexamethasone 16-20 mg should be given immediately. This relieves peritumoural oedema. Awaiting radiological confirmation of spinal cord compression before starting steroids is almost never warranted. If neurological improvement occurs, the steroid dose may be reduced to the lowest that will maintain that improvement. If immediate surgery is not contemplated, neurological status should be assessed at least daily so that deterioration may be detected early and surgical intervention considered.

For patients able to walk or whose paresis responds to steroids, radiotherapy is as successful as surgery and is therefore the treatment of choice. Radiation is usually delivered via a single posterior field, which should extend one or two vertebrae above and below the compressing lesion. Typical doses include 8 Gy in a single fraction, 20 Gy in 4-5 fractions, or 30 Gy in 10 fractions. Some prefer longer fractionation regimes for patients with hormone-responsive tumours (breast, prostate) that are newly diagnosed as metastatic.

Radiation-induced oedema may exacerbate symptoms: be prepared to increase the dose of steroids again during radiotherapy. Indications for surgery include:

♦ Acute-onset paraplegia

♦ Fracture dislocation

♦ Failure to respond to steroids

♦ Tumours known to be radio-resistant or when spinal cord compression progresses during, or recurs after, irradiation

♦ No histological proof of malignancy

Patients with spinal instability, retropulsed bone fragments, or complete collapse of a vertebra with myelopathy do not benefit from radiotherapy alone. Since complete surgical clearance of tumour is not likely to be attempted or achieved, post-operative radiotherapy is usually necessary.

Patients with established paraplegia are extremely unlikely to recover after either surgery or radiotherapy. No treatment may therefore be appropriate, unless persistent pain is itself an indication for active intervention.

The overall condition and prognosis should also determine how active management should be. For example, complex spinal surgery, involving weeks or months of hospitalization, is inappropriate for someone whose underlying disease carries a very poor prognosis.

Chemotherapy has no role in the management of acute spinal cord compression.

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