Degenerative cervical myelopathy (DCM) is the leading cause of spinal cord dysfunction in adults worldwide. DCM encompasses various acquired (age-related) and congenital pathologies related to ...degeneration of the cervical spinal column, including hypertrophy and/or calcification of the ligaments, intervertebral discs and osseous tissues. These pathologies narrow the spinal canal, leading to chronic spinal cord compression and disability. Owing to the ageing population, rates of DCM are increasing. Expeditious diagnosis and treatment of DCM are needed to avoid permanent disability. Over the past 10 years, advances in basic science and in translational and clinical research have improved our understanding of the pathophysiology of DCM and helped delineate evidence-based practices for diagnosis and treatment. Surgical decompression is recommended for moderate and severe DCM; the best strategy for mild myelopathy remains unclear. Next-generation quantitative microstructural MRI and neurophysiological recordings promise to enable quantification of spinal cord tissue damage and help predict clinical outcomes. Here, we provide a comprehensive, evidence-based review of DCM, including its definition, epidemiology, pathophysiology, clinical presentation, diagnosis and differential diagnosis, and non-operative and operative management. With this Review, we aim to equip physicians across broad disciplines with the knowledge necessary to make a timely diagnosis of DCM, recognize the clinical features that influence management and identify when urgent surgical intervention is warranted.
Malignant spinal cord compression (MSCC) is one of the most devastating complications of cancer. Patients often present with a history of progressive pain, paralysis, sensory loss, progressive spinal ...deformity, and loss of sphincter control. It is an emergency that requires rapid decision making on the part of several specialists, given the risk of permanent spinal cord injury or death. The goals of treatment in spinal metastases are pain control and improvement of neurological function in order to achieve better quality of life (QoL). The standard of care in most cases is rapid initiation of corticosteroids in combination with either surgical decompression in case of an operable candidate, followed by radiation therapy (RT) or RT alone. Surgery is associated with improved outcomes, but is not appropriate for many patients presenting with advanced symptoms of MSCC, such as paralysis, or those with a poor performance status, or cachexic state, as well as altered mental conditions, co-morbidities, surgical risks, and limited life expectancy. On the other hand, aggressive surgical treatment and post-operative RT is advocated for those with more favorable prognosis, or who are expected to have higher neurological recovery potential. Many candidates may require for combined anterior and posterior approaches to effectively deal with the compressive pathology and stabilize the spine. Most patients are presently treated by primary RT, given with the aim of improving function and symptom management. However, there is still debate regarding the most appropriate RT schedule. Rehabilitation can serve to relieve symptoms, QoL, enhance functional independence, and prevent further complications. Ambulatory status has been found to be an important prognostic factor for patients with MSCC.
The evolution of imaging techniques, along with highly effective radiation options has changed the way metastatic epidural tumors are treated. While high-grade epidural spinal cord compression (ESCC) ...frequently serves as an indication for surgical decompression, no consensus exists in the literature about the precise definition of this term. The advancement of the treatment paradigms in patients with metastatic tumors for the spine requires a clear grading scheme of ESCC. The degree of ESCC often serves as a major determinant in the decision to operate or irradiate. The purpose of this study was to determine the reliability and validity of a 6-point, MR imaging-based grading system for ESCC.
To determine the reliability of the grading scale, a survey was distributed to 7 spine surgeons who participate in the Spine Oncology Study Group. The MR images of 25 cervical or thoracic spinal tumors were distributed consisting of 1 sagittal image and 3 axial images at the identical level including T1-weighted, T2-weighted, and Gd-enhanced T1-weighted images. The survey was administered 3 times at 2-week intervals. The inter- and intrarater reliability was assessed.
The inter- and intrarater reliability ranged from good to excellent when surgeons were asked to rate the degree of spinal cord compression using T2-weighted axial images. The T2-weighted images were superior indicators of ESCC compared with T1-weighted images with and without Gd.
The ESCC scale provides a valid and reliable instrument that may be used to describe the degree of ESCC based on T2-weighted MR images. This scale accounts for recent advances in the treatment of spinal metastases and may be used to provide an ESCC classification scheme for multicenter clinical trial and outcome studies.
Systematic literature review from 1970 to 2007.
This study reports the results of a systematic review comparing surgical decompression ± radiation to radiation therapy alone among patients with ...metastatic spinal cord compression.
Currently, the optimal treatment of metastatic spine lesions is not well defined and is inconsistent. Radiation and surgical excision are both accepted and effective. There appears to be a favorable trend for improved neurological outcome with surgical excision and stabilization as part of the management.
A review of the English literature from 1970 to 2007 was performed in the Medline database using general MeSH terms. Relevant outcome studies for the treatment of metastatic spinal cord compression were selected through criteria defined a priori. The primary outcome was ambulatory capacity. A random effects model was built to compare results between treatment groups, based on calculated proportions from each study.
Of the 1595 articles screened, 33 studies (2495 patients) were selected based on our inclusion and exclusion criteria. Sixty-four percent of the patients who underwent surgical decompression, tumor excision, and stabilization had neurological improvement from nonambulatory to ambulatory status. Twenty-nine percent of the radiation therapy group regained the ability to ambulate after treatment (P < 0.001). Paraplegic patients had a 4-fold greater recovery rate to functional ambulation with surgical intervention than with radiation therapy alone (42% vs. 10%, P < 0.001). Pain relief was noted in 88% of the patients in the surgical studies and in 74% of the patients in studies of radiation therapy (P < 0.001). The overall surgical complication rate was 29%.
This systematic review suggests that surgical excision of tumor and instrumented stabilization may improve clinical outcomes compared with radiation therapy alone, with regard to neurological function and pain. However, most data in the current literature are from observational studies, where variations in patient population and treatments cannot be controlled. This compromised our ability to compare the results of both treatments directly.
To report efficacy and safety of percutaneous electrochemotherapy (ECT) in patients with radiotherapy-resistant metastatic epidural spinal cord compression (MESCC).
This retrospective study analyzed ...all consecutive patients treated with bleomycin-based ECT between February-2020 and September-2022 in a single tertiary referral cancer center. Changes in pain were evaluated with the Numerical Rating Score (NRS), in neurological deficit with the Neurological Deficit Scale, and changes in epidural spinal cord compression were evaluated with the epidural spinal cord compression scale (ESCCS) using an MRI.
Forty consecutive solid tumour patients with previously radiated MESCC and no effective systemic treatment options were eligible. With a median follow-up of 5.1 months 1–19.1, toxicities were temporary acute radicular pain (25%), prolonged radicular hypoesthesia (10%), and paraplegia (7.5%). At 1 month, pain was significantly improved over baseline (median NRS: 1.0 0–8 versus 7.0 1.0–10, P < .001) and neurological benefits were considered as marked (28%), moderate (28%), stable (38%), or worse (8%). Three-month follow-up (21 patients) confirmed improved over baseline (median NRS: 2.0 0–8 versus 6.0 1.0–10, P < .001) and neurological benefits were considered as marked (38%), moderate (19%), stable (33.5%), and worse (9.5%). One-month post-treatment MRI (35 patients) demonstrated complete response in 46% of patients by ESCCS, partial response in 31%, stable disease in 23%, and no patients with progressive disease. Three-month post-treatment MRI (21 patients) demonstrated complete response in 28.5%, partial response in 38%, stable disease in 24%, and progressive disease in 9.5%.
This study provides the first evidence that ECT can rescue radiotherapy-resistant MESCC.
•Radiotherapy-resistant metastatic spinal cord compression is an unmet medical need.•Electrochemotherapy (ECT) improves neurological in this advanced cancer setting.•ECT also results in significant pain decrease at 1-month and 3-months.•At MRI, 77% of patients had an objective response at 1 month and 66.5% at 3 months.•Complications were overall minor, with the exception of paraplegia in 7.5% of patients.
The aim of this study was to develop a scoring system for prediction of survival prognosis after surgery in patients with symptomatic metastatic spinal cord compression (MSCC) from non-small cell ...lung cancer (NSCLC).
We retrospectively analyzed nine preoperative characteristics for survival in a series of 64 patients with NSCLC who were operated with posterior decompression and spine stabilization for MSCC. Characteristics significantly associated with survival on multivariate analysis were included in the scoring system. The scoring point for each significant characteristic was derived from the hazard ratios on Cox proportional hazards model. The total score for each patient was obtained by adding the scoring points of all significant characteristics.
Eastern Cooperative Oncology Group (ECOG) performance status, number of involved vertebrae, visceral metastases, and time developing motor deficits had significant impact on survival on multivariate analysis and were included in the scoring system. According to the prognostic scores, which ranged from 4 to 10 points, three prognostic groups were designed: 4-5 points (n = 22), 6-7 points (n = 23), and 8-10 points (n = 19). The corresponding 6-month survival rates were 95, 47 and 11%, respectively (P < 0.0001). In addition, the functional outcome was worse in the group of patients with 8-10 points compared with other two prognostic groups.
The new scoring system will enable physicians to identify patient with MSCC from NSCLC who may be a candidate for decompression and spine stabilization, more radical surgery, or supportive care alone. Patients with scores of 4-5, who have the most favorable survival prognosis and functional outcome, can be treated with more radical surgery in order to realize better local control of disease and prevent the occurrence of local disease. Patients with scores of 6-7 points should be surgical candidates, because survival prognosis and functional outcome are acceptable after surgery, while patients with scores of 8-10 points, who have the shortest survival time and poorest functional outcome after surgery, appear to be best treated with radiotherapy or best supportive care.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Malignant spinal canal compression, a major complication of metastatic cancer, is managed with radiotherapy to maintain mobility and relieve pain, although there is no standard ...radiotherapy regimen. OBJECTIVE: To evaluate whether single-fraction radiotherapy is noninferior to 5 fractions of radiotherapy. DESIGN, SETTING, AND PARTICIPANTS: Multicenter noninferiority randomized clinical trial conducted in 42 UK and 5 Australian radiotherapy centers. Eligible patients (n = 686) had metastatic cancer with spinal cord or cauda equina compression, life expectancy greater than 8 weeks, and no previous radiotherapy to the same area. Patients were recruited between February 2008 and April 2016, with final follow-up in September 2017. INTERVENTIONS: Patients were randomized to receive external beam single-fraction 8-Gy radiotherapy (n = 345) or 20 Gy of radiotherapy in 5 fractions over 5 consecutive days (n = 341). MAIN OUTCOMES AND MEASURES: The primary end point was ambulatory status at week 8, based on a 4-point scale and classified as grade 1 (ambulatory without the use of aids and grade 5 of 5 muscle power) or grade 2 (ambulatory using aids or grade 4 of 5 muscle power). The noninferiority margin for the difference in ambulatory status was −11%. Secondary end points included ambulatory status at weeks 1, 4, and 12 and overall survival. RESULTS: Among 686 randomized patients (median interquartile range age, 70 64-77 years; 503 (73%) men; 44% had prostate cancer, 19% had lung cancer, and 12% had breast cancer), 342 (49.8%) were analyzed for the primary end point (255 patients died before the 8-week assessment). Ambulatory status grade 1 or 2 at week 8 was achieved by 115 of 166 (69.3%) patients in the single-fraction group vs 128 of 176 (72.7%) in the multifraction group (difference, −3.5% 1-sided 95% CI, −11.5% to ∞; P value for noninferiority = .06). The difference in ambulatory status grade 1 or 2 in the single-fraction vs multifraction group was −0.4% (63.9% vs 64.3%; 1-sided 95% CI, −6.9 to ∞; P value for noninferiority = .004) at week 1, −0.7% (66.8% vs 67.6%; 1-sided 95% CI, −8.1 to ∞; P value for noninferiority = .01) at week 4, and 4.1% (71.8% vs 67.7%; 1-sided 95% CI, −4.6 to ∞; P value for noninferiority = .002) at week 12. Overall survival rates at 12 weeks were 50% in the single-fraction group vs 55% in the multifraction group (stratified hazard ratio, 1.02 95% CI, 0.74-1.41). Of the 11 other secondary end points that were analyzed, the between-group differences were not statistically significant or did not meet noninferiority criterion. CONCLUSIONS AND RELEVANCE: Among patients with malignant metastatic solid tumors and spinal canal compression, a single radiotherapy dose, compared with a multifraction dose delivered over 5 days, did not meet the criterion for noninferiority for the primary outcome (ambulatory at 8 weeks). However, the extent to which the lower bound of the CI overlapped with the noninferiority margin should be considered when interpreting the clinical importance of this finding. TRIAL REGISTRATION: ISRCTN Identifiers: ISRCTN97555949 and ISRCTN97108008
Multiple myeloma (MM) is a neoplastic proliferation of plasma cells characterized by the production of monoclonal immunoglobulin. Acute spinal compression is a medical emergency that manifests as ...paresthesia or weakness of the lower extremities, back pain, bladder and bowel dysfunction, or sensory deficits. Magnetic resonance imaging (MRI) or computed tomography (CT) of the entire spine should be performed immediately to make a early diagnosis. Acute SCC is a medical emergency, timely diagnosis and treatment are important to prevent irreversible neurological damage. All patients need a loading dose of corticosteroid as the first line treatment. Radiotherapy may be the main treatment if cord compression is caused by plasmacytoma, with surgery only being necessary if the spinal column is unstable or if the compression is caused by bone fragments from fracture of a vertebral body. Anti-plasma cell therapy and targeted therapy can be used for patients with minimal neurological dysfunction. Bisphosphonates may decrease the risk of SCC and the recurrence of SCC caused by vertebral fractur.
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•Spinal cord compression is a devastating complication of multiple myeloma.•The patient should be managed as soon as possible to prevent permanent loss of neurological function.•MRI is the first choice for the assessment of spinal cord compression in multiple myeloma.•Corticosteroids, surgery, radiotherapy, anti-plasma cell therapies, bisphosphonates are According to the spine stability.
Spinal cord compression (SCC) is a devastating complication of multiple myeloma and has the potential to cause loss of neurological function. The common symptoms of SCC are back pain, motor weakness, and sensory change. Once diagnosed, the patient should be managed as soon as possible to prevent permanent loss of neurological function. Currently, there have been a number of studies describing the mechanism and management experience of SCC in patients with myeloma. The clinical features, diagnostic strategies, and the roles of different therapeutic options are herein reviewed.
Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, including tumors, infections, and degenerative changes. In this article, we review the range of degenerative ...spinal disorders resulting in progressive cervical spinal cord compression and propose the adoption of a new term, degenerative cervical myelopathy (DCM). DCM comprises both osteoarthritic changes to the spine, including spondylosis, disk herniation, and facet arthropathy (collectively referred to as cervical spondylotic myelopathy), and ligamentous aberrations such as ossification of the posterior longitudinal ligament and hypertrophy of the ligamentum flavum. This review summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood–spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies.
ABBREVIATIONS:CSM, cervical spondylotic myelopathyDCM, degenerative cervical myelopathyJOA, Japanese Orthopaedic AssociationmJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligamentSCI, spinal cord injury
Abstract Background context There have been no previous studies looking at the outcome of surgical decompression (+/−stabilization) for various grades of epidural spinal cord compression (ESCC) due ...to spinal metastases. Purpose The aim of this study was to determine the outcome of surgical treatment in patients with ESCC using the Bilsky six-point scale. Study design/Setting This was a retrospective cohort review of prospectively collected data. Patient sample A consecutive series of 101 patients managed over the period of 3 years for ESCC due to spinal metastases in a tertiary spine surgery referral unit were included. Methods Data on age, gender, revised Tokuhashi score, preoperative Frankel grade, tumor histology, magnetic resonance imaging scan–based Bilsky cord compression grade, postoperative Frankel grade at last follow-up, complications, and survivorship were collected. Outcome measures Frankel grading system for function was used to evaluate the patient's preoperative and postoperative neurologic status. Patient survival and postoperative complications were also collected. Results Average patient age was 64.7 years (13–88 years): 62 males and 39 females. Mean follow-up was 7.3 months (3–23.3 months). Most primary tumors were in prostate, breast, renal, lung, and the blood dyscrasias. Within the lower grade of compression (Group 1; Bilsky Grades 0,1a, 1b, and 1c; n=40), 29 patients (72.5%) had no improvement in Frankel grade, seven patients (17.5%) improved, whereas four patients (10%) deteriorated neurologically after surgery. Within the higher compression grade (Group 2; Bilsky Grades 2 and 3; n=61), 37 patients (60%) did not experience neurologic change, 20 (33%) improved, whereas neurology worsened in four patients (7%). When compared with Group 2 patients, Group 1 patients had better preoperative Frankel scores but a greater number of patients in Group 2 improved their Frankel scores significantly postoperatively. The mean revised Tokuhashi score for Groups 1 and 2 was 10 and 9.1, respectively (p=.1). The complication rate for Groups 1 and 2 was 25% and 42.6%, respectively (p=.052). Survival analysis showed no difference between the groups (Group 1: median 376 days 12–1052; Group 2: median 326 days 12–979; p=.62). Conclusions Surgery can achieve improvements in neurology even in higher grades of cord compression. There is a trend toward more complications and worse survival with spinal surgery in patients with higher grades of compression.
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