Evidence Tables (for individual studies)

Study Identification:Bilsky, M.H., Boland, P., Lis, E., Raizer, J.J. (2000) Single stage posterolateral transpedicle approach for spondylectomy, epidural decompression and circumferential fusion of spinal metastases. Spine, 250. 25[17] 2240–49
Design:retrospective case series; evidence level 3
Country / Setting:USA
Population:25 undergoing PTA, out of 104 patients with MSCC
Intervention:posterolateral transpedicular approach for anterior and posterior surgical decompression and spinal fusion.
Outcomes:Pain relief, neurologic symptoms; ASIA scale
Follow-up:
Results:The posterolateral transpedicular approach provides a wide surgical exposure to decompress and instrument the anterior and posterior spine. This technique avoids morbidity associated with anterior approaches and provides immediate stability.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: not reported
Overall survival: not reported
Symptom control: pain relief was immediate and durable. 15 patients with severe back or radicular pain rated their pain as mild after the surgery, and two others improved to moderate pain status. No patient developed recurrent mechanical back pain or loss of fixation.Postoperative pain assessmentPreoperative pain assessment
MildModerateSevere
Mild2315
Moderate3
Severe
Patients who were neurologically intact before the surgery remained neurologically normal; five patients improved a grade to become neurologically intact (ASIA grade D to E). Patients with significant neurologic deficit before the surgery (ASIA grade C) did not fare as well. The two patients who worsened in this group had the acute onset of myelopathy and high grade spinal cord compression.Postoperative scorePreoperative score
ABCDE
A1
B1
C1
D11
E515
Functional status was assessed (ECOG) and all patients who were fully ambulatory before the surgery (0–2) remained so (0–1). Ten patients who were bedridden more than 50% of the time or who were completely disabled (3–4) improved to ambulatory status (0–2) and 4 patients did not improve.
412
Rate of revision surgery/ recovery: not reported
QOL: not reported
Economics: not reported
Complications/safety:
Postoperative scorePreoperative score
01234
011
15332
222
3
Chen, Y. J., Chang, G. C., Chen, H. T., Yang, T. Y., Kuo, B. I., Hsu, H. C., Yang, H. W. & Lee, T. S. (2007) Surgical results of metastatic spinal cord compression secondary to non-small cell lung cancer. Spine, 32: E413–E418.
Design: retrospective case series, evidence grade 3
Country: Taiwan

Aim: To evaluate postoperative outcomes and survival rates of NSCLC patients surgically treated for symptomatic spinal metastasis.

Synopsis: Chen et al. (2007) evaluated postoperative outcomes and survival rates of non-small cell lung cancer patients surgically treated for symptomatic spinal metastasis. The study reported that 68% of patients regained the ability to walk, and overall 74% of patients were able to walk after surgery. Median survival was 8.8 months. 61% of patients survived more than 6 months and 32% survived more than 1 year. For patients surviving more than 6 months, 89% were ambulatory. The authors highlighted that for an aggressive disease such as advanced metastatic lung cancer, “it is worthwhile to aggressively treat patients with symptomatic spinal cord compression”.
Inclusion criteria
Any symptomatic metastatic spinal cord compression (thoracic or lumbar spine) secondary to non-small
cell lung cancer (NSCLC) who underwent palliative surgery with the indication for surgery being neurologic progression due to spinal cord compression.
Exclusion criteria
Population
A retrospective analysis of hospital records and radiographs was conducted: 31 patients with symptomatic metastatic spinal cord compression (thoracic or lumbar spine) secondary to NSCLC underwent palliative
surgery.
Interventions
  • 37 surgical procedures were performed in the 31 patients.
  • The choice of surgical approach was dependent on the preoperative tumour location in the first 3 (10%) patients with the method of combined anterior and posterior procedures (anterior corpectomy, reconstruction with methylmethacrylate, and posterior instrumentation).
  • Surgical method was changed to a posterolateral transpedicular approach (PTA) in the remaining 28 (90%) patients.
  • All patients underwent posterior spinal instrumentation after adequate decompression.
  • Local radiotherapy, systemic chemotherapy, and targeted therapy were provided to patients post-operatively.
  • Posterolateral Transpedicular Surgical Approach: see details supplied in paper.
Outcomes
  • Patient Characteristics
  • Performance Score/Ambulation
  • Survival
  • Analysis of Prognostic Factors for Survival: The factors considered for inclusion in analyses were age (≥65 vs. <65 years), tumor type (adenocarcinoma vs. non- adenocarcinoma), preoperative and postoperative ambulatory status (Frankel A + B+ C, non-ambulatory vs. Frankel D+ E, ambulatory), preoperative Eastern
  • Cooperative Oncology Group performance status (0, 1 vs. 2, 3, 4), and postoperative adjuvant therapy (with vs. without).
  • Postoperative complications
  • Follow-up times ranged from 15 to 30 months.
Results
Patient Characteristics Performance Score/Ambulation
  • Neurologic improvement by at least one Frankel grade was reported in 25 of 31 cases (80%).
  • 5 patients showed no improvement, and one patient showed deterioration from Frankel grade B to A.
  • Overall, 74% of patients (23 of 31) were able to walk after surgery.
  • 17 of 25 (68%) non-ambulatory (Frankel B/C) patients became ambulatory (Frankel D/E) again.
Survival / Analysis of Prognostic Factors for Survival:
  • Patients surviving >6 months, 89% (17 of 19) were ambulatory.
  • One patient developed a symptomatic tumor recurrence at the previous level of decompression.
  • 3 patients developed new symptomatic spinal cord compression due to noncontiguous metastasis (all these patients received decompressive surgeries again).
  • Post-surgery, 11 patients received chemotherapy and 13 patients received gefitinib treatment.
  • Median survival = 8.8 months
  • 61% (19 of 31) of the patients survived for more than 6 months,
  • 32% (10 of 31) survived for more than 1 year.
  • 6 patients are still alive.
  • A log-rank test and Cox proportional hazards model indicated that better preoperative performance status, postoperative ambulatory status, and improvement in ambulatory status after surgery all had statistically significant associations with longer survival.
Postoperative complications
  • wound infection was the most common complication (With 8 complications in total; 5 were surgery-related)
  • No intraoperative mortality, but 2 deaths occurred in the immediate postoperative period.
General comments
Retrospective study provides limited evidence of effectiveness, without a comparative group. The patient numbers are low.
Study Identification:Harris, J.K., Sutcliffe, J.C. & Robinson, E. (1996). The role of emergency surgery in malignant spinal extradural compression: assessment of functional outcome. British Journal of Neurosurgery, 10(1), 27–33
Design:retrospective case series; evidence level 3
Country / Setting:UK; Department of Neurosurgery
Population:81 patients with malignant extradural spinal compression; patients with vertebral collapse secondary to metastasis without extradural tumours were excluded; 49 male, 32 female; median age 65, mean 60.0, range 15–86; 3 patients with two separate episodes at different sites; location: cervical spine 3 (3.6%), thoracic 64 (76.2), thoraco-lumbar 6 (7.1%), lumbar 9 (10.7%), sacral 2 (2.4%); 19 patients were mobile pre-operatively, 43 patients were continent
Intervention:Emergency or elective surgery and decompression
Outcomes:functional outcome: mobility and bladder function
Follow-up:3 months
Results:Even if the patient is incontinent and immobile, emergency spinal decompression leads to better outcome. A greater proportion of patients which have undergone emergency surgery rather than electively (within 24 hours) showed functional improvement (61.5% versus 25%). Overall, 70% of patients were mobile post-operatively.
Long term deformities: not reported
Overall survival: not reported
Symptom control: For patients with functional deficit (incontinence or immobility) emergency surgery was associated with a better outcome (p=0.04) ; 71% of patients with emergency surgery had a good outcome, 32 patients improved functionally; 61% of patients with elective surgery had a good outcome, 7 patients improved functionally 24% of preoperatively mobile patients with emergency procedure were alive at 3 months follow up; all mobile patients remained mobile; 49% of immobile and incontinent patients improved following surgery; 47% of incontinent and immobile patients regained the ability to walk

Post-operative functional outcome (good outcome=functional improvement, or preservation of mobility and continence)
ImprovedUnchangedDeterioratedGood outcome
Emergency surgery3219171.2%
Elective surgery718360.7%
Overall3937467.5%
Comparison of pre-operative functional status with post-operative functional outcome according to the surgical approach (number in brackets indicate procedures performed as an emergency)
PreoperativePost-operative
TotalMobile and continentImmobile and incontinentGood outcomePoor outcomeOther outcome
Laminectomy6612 (4)29 (19)45 (31)18 (10)3 (2)
Laminectomy and fusion124 (3)5 (5)7 (5)4 (2)1 (1)
Anterior corporectomy and fusion211 (1)2 (1)00
Rate of revision surgery/ recovery: not reported
QOL: not reported
Economics: not reported
Complications/safety: not reported
Study Identification:Jansson, K.A., Bauer H.C.F. (2006) Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases, Eur Spine Journal, 200615:196–202
Design:retrospective case series; evidence level 3
Country / Setting:Sweden; Dept. of Orthopaedics
Population:282 consecutive patients with thoracic of lumbar metastasis; 69% men, 31% women; mean age 66 (range 23–93)
Intervention:Posterior decompression and stabilisation; posterior stabilisation with rods (hooks, screws, pedicle screws) augmentation with methyl methacrylate; anterior decompression with reconstruction of the vertebral body (bone cement);
Outcomes:Survival; ambulation, motor function - Frankel grades
Follow-up:3 months postoperative; yearly after that
Results:Important improvement of function can be gained by surgical treatment but complication rate was high as was mortality from disease within the first months of surgery. Between 10–20% of the patients did not benefit form the surgical treatment and some of those will have been worsened by complications and increased pain.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: not reported

Overall survival: a total of 37/282 (13%) died within 30 days. The rate of survival was 0.63 at 3 months, 0.47 at 6 months, 0.30 at 1 year, 0.16 at 2 years and 0.005 at 5 years. The 30 day mortality was not related to the extent of metastatic disease, but the 3 months survival rate was 0.50 for patients with non-skeletal metastases, compared to 0.81 for those with a solitary skeletal metastasis.

Symptom control: 23 patients who had normal motor function preoperatively (Frankel E) retained this function postoperatively. 12/255 with motor deficits worsened postoperatively and 179 improved at least one Frankel grade. Among 144 patients who were non-walkers but retained some motor function (Frankel C) 100 could walk at discharge (D–E). 10/26 patients who had no motor function (A–B) regained sufficient neurological function to walk during follow-up. The ability to walk was retained at 1 and 2 years of follow-up.
Rate of revision surgery/ recovery: a total of 29/282 patients were re-operated during follow-up 17 at the same level (due to local progression of disease at previously decompressed site and /or failure of stabilisation),. Median time to re-operation was 3 (0.4–9) years. 12 patients with epidural compression at a new spinal level were re-operated after only 0.7 (0.3–10) years.
QOL: not reported
Economics: not reported
Complications/safety: a total of 60 complications recorded in 56/282 patients (20%). Systemic complications were often associated with death. 49/282 had local complications and 34 wound infections of which 9 were operated with wound revision.
Klimo, P., Jr., Kestle, J. R. & Schmidt, M. H. (2003) Treatment of metastatic spinal epidural disease: a review of the literature. Neurosurgical Focus, 15: E1.
Inclusion/Exclusion Criteria: not reported in the review

Population
Patients with metastatic spinal epidural disease

Interventions Outcomes
  • “Success” defined as the proportion of patients who were ambulatory after treatment
  • “Rescue” defined as the proportion of non-ambulatory patients who regained ambulatory function, either with assistance or independently
  • Mortality and morbidity are defined as occurrence of death or complication within 30 days of the operation.
  • Morbidity: is the number of complications divided by the number of patients in the study (therefore, overestimates may arise if one patient suffered more than one complication)
Results
Posterior Decompressive Laminectomy Efficacy of laminectomy alone compared with radiation alone and with laminectomy followed by radiation:
  • 8 controlled cohort studies investigated the efficacy of laminectomy alone with radiation alone and with laminectomy followed by radiation.
  • No detailed analysis of the results of these studies was reported apart from a narrative report that “laminectomy was viewed as a procedure with minimal neurological benefit and significant morbidity”, and from this evidence, clinical practice should include radiation as the primary treatment.
Decompressive laminectomy with internal fixation (eg. pedicle screws) and fusion:
  • In a study by Sherman and Waddell (1986) reported that out of 134 patients treated with either a laminectomy (111 patients) or laminectomy with stabilization (23 patients), 75 patients who had had laminectomy with stabilization reported better post treatment ambulatory status (92 compared with 57%), sphincter function, and pain control, and less recurrent neurological dysfunction.
  • This review reports that these finding are supported by further 6 studies. No detail about these studies are reported in the review.
Circumferential Spinal Cord Decompression
Approaches included anterior (transthoracic or retroperitoneal) or posterior, including posterolateral trajectories (laminectomy, transpedicular, costotransversectomy, or lateral extracavitary) and reconstruction and immediate stabilization of the spinal column.
  • There is a substantial body of evidence evaluating Circumferential Spinal Cord Decompression (17 studies reported) but it is low quality and comes from uncontrolled cohort studies or case series studies. However, these studies did provide more detail on outcomes of circumferential decompression compared to laminectomy studies.
  • The results (of individual studies) reported in the review were listed in a table and the range of results are presented wrt outcome.
Success:
From 16 studies the range of success was, 72 to 98% of patients were ambulatory after treatment, with an overall crude mean of 86%

Rescue:
From 15 studies the range of rescue was 0 to 94%, of non-ambulatory patients who regained ambulatory function, either with assistance or independently, with an overall crude mean of 57%

Mortality
Mortality rates were reported for all 17 studies, this ranged from 0% to 31% of patients dying within 30 days of the operation. The crude mean of these rates = 5.7%

Morbidity
Morbidity data was available for 15 studies, this ranged from 7.7 to 65% of patients experiencing a complication within 30 days of the operation. This rate was the number of complications divided by the number of patients in the study (therefore, overestimates may arise if one patient suffered more than one complication). The crude mean rate from these rates = 31.8%

Complications were further described by surgical, hardware or medical, rates were generally low, however, surgical complications due to wound infection etc. had the highest rate of complication, ranging from 1 to 45% of patients, with a crude mean rate of 8.69 % of patients experiencing this complication.

Further details:
This review did provide details about the following included studies:
  1. One case series study described the results of 80 patients who had solitary metastatic spinal lesions. Depending on the anatomical and radiological findings on the extent of the tumor, the researchers used a variety of approaches: an anterior approach was used in 32 patients, a strictly posterior or posterolateral approach was used in eight, and a combined antero-posterior approach was used in 40.
    • Preoperatively, 48 patients (60%) were ambulatory and 55 (69%) experienced a 2severe pain.
    • Postoperatively, 78 (98%) were ambulatory, including 94% of those who were initially non ambulatory.
    • Pain was improved in 95%, with 76% reporting complete relief.
    • Overall survival duration was 30 months, with considerable range among the various tumor types. Patients with breast and renal cell carcinoma had a median survival duration of 36 months compared with 15 and 12 months for gastrointestinal and cancer of unknown primary carcinoma, respectively.
  2. Another case series study reported their results with trans-thoracic vertebrectomy in 72 patients. Pain was improved in 92% of patients, and 93% were able to walk postoperatively.
  3. In a retrospective case series of 25 patients who had undergone single stage posterolateral transpedicular decompression for MSCC, pain relief was reported to have been immediate and durable.
    • 15 patients with severe back or radicular pain rated their pain as mild after the surgery, and two others improved to moderate pain status.
    • No patient developed recurrent mechanical back pain or loss of fixation.
    • Patients who were neurologically intact before the surgery remained neurologically normal; five patients improved a grade to become neurologically intact (ASIA grade D to E). Patients with significant neurologic deficit before the surgery (ASIA grade C) did not fare as well. The two patients who worsened in this group had the acute onset of myelopathy and high grade spinal cord compression.
    • Functional status was assessed (ECOG) and all patients who were fully ambulatory before the surgery (0–2) remained so (0–1). Ten patients who were bedridden more than 50% of the time or who were completely disabled (3–4) improved to ambulatory status (0–2) and 4 patients did not improve
General comments
This review conducted systematic searches and described the search terms.

The quality of the evidence was assessed and the definitions of the different classes of evidence denoting quality and strength of treatment recommendations were also described. Inclusion/exclusion criteria not reported and used.

Outcome measures were pre-specified and some evaluation of pooled estimates were reported. However, no detail of analysis was described and a more narrative summary was presented. In some sections, outcomes are described with only a broad description of the results for several studies included and no detail (about study protocol or results) presented.
Study Identification:Klimo, P., Dailey, A.T., Fessler, R.G. (2004)Posterior surgical approaches and outcomes in metastatic spine disease. Neurosurgery Clinics of North America 15: 425–435
Design:Unsystematic review of RCTs, prospective cohort studies and retrospective case series; evidence level 4
Country / Setting:international
Population:Patients with MSCC enrolled in 55 reported studies
Intervention:Studies reporting on posterior decompressive laminectomy, vertebrectomy, anterior approaches,
Outcomes:
Follow-up:Majority of studies included in the review had long-term follow-up
Results:Laminectomy is no more effective than RT in relieving pain and preserving and regaining neural function. Laminectomy should only be used for disease isolate to the dorsal spine without evidence of concomitant instability
Postoperative decompressive laminectomy with internal fixation provides a better outcome in terms of ambulatory status, sphincter function and pain control. This is a reasonable surgical option in patients who cannot tolerate a more extensive approach or who have multilevel disease.
Various posterolateral approaches allow adequate anterior and posterior decompression and the ability to reconstruct and stabilise with acceptable peri-operative risk
Long term deformities: not reported
Overall survival: not reported
Symptom control:
Direct posterior trajectories:
Laminectomy is no more effective than RT in relieving pain and preserving and regaining neural function. Before surgery 80% of patients were non-ambulatory and 56% has sphincter dysfunction. Overall, mobility increased to 45%imediately after surgery but decreased to 33% and 25% to 2 and 4 month follow-up respectively. Postoperative sphincter dysfunction decreased to 38% but then increased to 46% at 2 months and 51% at 4 months. None of the plegic patients had any improvement.
Posterior decompressive laminectomy with internal fixation provides a better outcome in terms of ambulatory status, sphincter function and pain control. Comparative laminectomy only, patients who underwent internal fixation had better ambulatory status at 6 months (92% vs 57%), sphincter function (63% vs 31%) and pain control (55% vs 32%). Postoperative RT did not improve the results in either group.
Posterolateral trajectories:
Transpedicular approach out of the 18 patients with preoperative neurological deficit 10 showed improvement the single most common reported complication was cerebrospinal fluid leak and 4 patients were reported to have suffered migrations of the methylmethacrylate graft or pins.
Costotransversectomy: adequate anterior decompression was achieved in all reported patients. Patients who were ambulatory remained so after surgery and pain was improved in 75% of patients. No perioperative deaths, neurological injuries or wound complications were reported. However, the authors recommend this method to be used only in patients with extensive bone disease, non-contiguous spinal involvement, visceral metastases or other contraindications for transcavity procedures, as well as in extremely old patients.
Rate of revision surgery/ recovery: not reported
QOL: not reported
Economics: cost of surgery and rehab not reported
Complications/safety: reported above
Klimo P, Thompson C J, Kestle J R, Schmidt M H. (2005) A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro-Oncology 7(1): 64–76

NOTE: the appraisal of this review has been conducted by Centre for Reviews and Dissemination (CRD) and was accessed through DARE database, where additions have been made by the NICE reviewer it has been noted.

For Centre for Reviews and Dissemination Appraisal refer to:
A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. [Abstract number: 12005009537] Database of Abstracts of Reviews of Effects, available http://www​.crd.york.ac.uk/crdweb/ [31 January 2007] Abstract of: A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Klimo P, Thompson C J, Kestle J R, Schmidt M H. Neuro-Oncology (2005) 7(1): 64–76
Design: Retrospective or prospective cohort studies were eligible for inclusion.
Overall evidence level: 3 (Designated by NICE Reviewer)

Aim: To compare the effect of surgery versus conventional radiotherapy on theambulatory status of people with metastatic spinal epidural disease.

Results
Ambulatory success (Refer to CRD Appraisal)
Ambulatory rescue (Refer to CRD Appraisal)
Pain (As described by NICE reviewer)
  • Although this outcome was reported frequently across studies, the assessment was quite crude with no distinction between the type of pain (axial vs. radicular), and improvement was simply a dichotomous variable (i.e., yes/no).
  • Only one paper (Gokaslan et al 1998) reported this outcome in a comprehensive manner. Out of the 72 patients who underwent a thoracotomy for vertebral metastases, 65 presented with pain. Complete resolution was achieved post-treatment in 15 patients (23%), significant improvement in 45 (69%), and no change or worsening in five (8%). Gokaslan et al (1998) also recorded and classified the type of analgesics used by patients both preoperatively and postoperatively. 28 patients were able to decrease their class of analgesic use by at least one category.
  • The review authors recorded the percentage of patients within each study that had any improvement in pain after their primary treatment. Within the surgical studies, the average percentage of patients that experienced an improvement in pain was 90% (71%–100%) compared with 70% (54%–83%) within the radiation studies.
Sphincter function (bladder function) (As described by NICE reviewer)
  • Of the 131 patients within the surgical articles, 65 (50%) were incontinent preoperatively compared with 22 (17%) postoperatively.
  • In the radiation studies, 82 out of 397 patients (21%) were incontinent prior to radiation compared with 61 patients post-radiation (15%).
  • Overall rescue rate (for the sphincter function) with surgery was 66% compared with 26% with radiation.
Survival (As described by NICE reviewer)
  • Survival was difficult to assess within this body of evidence because it was inconsistently reported.
  • The most consistent means of presenting survival data is the 12-month mortality rate, which was readily available in nine surgical articles and two radiation articles.
  • The one-year survival in the surgical studies (n=502) ranged from 12% to 62%, with an average of 41%
  • For the radiation articles (n=397), the rate was 20% to 28%, with an average of 24%
  • The most significant factor that determined post-treatment survival was the primary histology.
  • Although the survival statistics vary among the papers, in general, patients with breast and renal cancer have a more favourable survival prognosis than those with lung cancer and sarcoma.
Complications and local recurrences (As described by NICE reviewer)
  • No significant treatment-related complications were reported in the radiation studies. Within the surgical papers, 63 patients died within 30 days of their operation (6.3%).
  • 233 complications (23%) occurred within the following categories defined previously: medical, 100; neurologic, 19; hardware, 18; and surgical, 96.
  • One radiation article described patients that developed local recurrences. 2.4% patients developed local recurrences.
  • 81 patients described in nine surgical papers also developed local recurrences for an incidence of at least 8%
General comments (NICE Reviewer)
This review conducted a systematic search of the literature for evidence about the effectiveness of surgery compared to radiotherapy. Quality assessment of included studies was not reported (other than describing the types of studies included). Overall the comparative analysis conducted was indirect, included uncontrolled studies and therefore it is greatly influenced by bias. Conclusions that the authors have drawn need to considered/used with caution.
Study Identification:Kwok, Y., Tibbs, P.A., Patchell, R.A. (2006) Clinical Approach to metastatic epidural spinal cord compression. Hematology – Oncology Clinics of North America, 20, 1297–1305
Design:unsystematic review of RCTs, prospective cohort studies and retrospective case series; evidence level 4
Country / Setting:international
Population:patients diagnosed with MSCC enrolled in 29 studies
Intervention:Laminectomy; laminectomy plus postoperative RT; anterior decompression (thoracotomy and retoperitoneal dissection); posterior decompressive and maximal debulking surgery and stabilisation
Outcomes:Ambulatory status; continence; pain relief
Follow-up:Majority of studies included in the review had long-term follow-up
Results:If operable, patients with MSCC should undergo maximal tumour resection and stabilisation followed by postoperative radiotherapy. Although patients have short survival risks of paraplegia can be minimised.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities:

Overall survival: not reported

Symptom control: fewer than 50% of patients treated with RT alone will remain ambulant and even fewer will regain the ability to walk. However, retrospective studies suggest that RT was as effective as posterior laminectomy plus RT and showed no benefit of surgery in terms of pain relief, ambulation or sphincter function. In preliminary uncontrolled studies using direct surgical decompression results have been promising, with ambulatory rates higher than 75%. In several series even about 50% of patients who were non-ambulatory preoperatively regained ambulance.

Rate of revision surgery/ recovery: not reported

QOL: not reported

Economics: cost of surgery and rehab not reported

Complications/safety: not reported
Study Identification:Lewansrowsky, K.U., Hecht, A.C., DeLaney, T.F., Chapman, P.A., Horniceck, F.J., Pedlow, F.X. (2004) Anterior spinal arthrodesis with structural l cortical allografts and instrumentation for spine tumour surgery. Spine, vol. 29, 10:1150–59
Design:retrospective case series; evidence level 3
Country / Setting:USA
Population:30 patients with MSCC; 18 women, 12 men; median age 47 (range 17–76)
Intervention:Anterior vertebral reconstruction with fresh frozen cortical bone allografts, in combination with anterior or posterior instrumentation.
Outcomes:Overall survival, complications/revision rate
Follow-up:
Results:Anterior column reconstruction with structural cortical allografts proved to be a reliable technique in patients with MSCC. Median survival was 14 months. 93% of the allografts were radiographically incorporated as early as 6 months after surgery in spite of adjuvant chemotherapy and RT. Postoperative complications can often be successfully managed. 14 (46%) patients had intraoperative or postoperative complications. 2 patients underwent revision surgery for local recurrence. There were no allograft infections, fractures or collapse.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities:

Overall survival: overall median survival period 14 months (range 7 months-5 years). Patients with chordoma had the best overall median survival time.

Symptom control: not reported

Rate of revision surgery/ recovery:

QOL: not reported

Economics: not reported

Complications/safety: 14 patients (46%) have experienced intraoperative or postoperative complications. These include wound breakdown in 3 cases, stabilisation failure in 2, superficial wound infections in 4, excessive haemorrhage in 6, postoperative respiratory failure in 1, intraoperative vascular/visceral injury in 2 and cerebrospinal fluid leak in 2 patients. Adjuvant RT and chemotherapy did not appear to be related to clinical complications. Four operations were necessary for treatment of complications: 2 for wound revision, 2 for infection. 2 patients underwent revision surgery for local recurrence.
General comments: -
Study Identification:Loblaw, D.A., Perry, J., Chambers, A., Laperriere, N.J. (2005) Systematic Review of the Diagnosis and Management of Malignant Extradural Spinal Cord Compression. Journal of Clinical Oncology 23:2028–2037
Design:Systematic review of RCTs, population based studies, prospective cohort studies, cross-sectional studies, retrospective case series; evidence level 3
Country / Setting:International
Population:MSCC patients
Intervention:Six general types of cervical laminoplasty; Surgery plus RT; RT alone; vertebral body resection; laminectomy
Outcomes:Survival, ambulation, complication rate
Follow-up:Not reported for individual studies
Results:There is not direct evidence that supports or refutes the type of surgery patients should have for the treatment of MSCC, whether surgical salvage should be attempted of patient is progressing on RT and whether patients with spinal instability should be treated with surgery.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities:

Overall survival: not a significant difference in survival between groups (p=0.08) studied in the Patchell RCT.

Recovery rate:

Symptom control – ambulation: Patients undergoing surgery in addition to RT are more likely to retain and maintain ambulatory status longer than patients treated with RT alone (p=0.006)

Rate of revision surgery/ recovery - further interventions (depending on prior surgery): not reported

QOL: not reported

Economics: - cost of surgery and rehab: not reported

Complications/safety: surgery is associated with significant morbidity and mortality: 0–54% 30 day postoperative complication rates and 0–13% postoperative mortality rates reported in the reviewed literature. Overall complications are higher for vertebral body resection (10–54%) vs laminectomy (0–10%). The rate of complications is increased in patients who received RT before surgery 32%, vs. 12 % in patients who received surgery first (p<0.05)
General comments: trials analysed for survival data might have been too small and insufficiently powered to detect difference in survival data.

This review was not really helpful for this question, as the main focus of this review are clinical symptoms, optimal investigations for diagnosis, role of corticosteroids and indications for RT. Surgery is tangential and not particularly well addressed in relation to this PICO
Study Identification:Patchell, R.A., Tibbs, P.A., Regine, W.F., Payne, R. (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial, Lancet, 2005, 366:643–48
Design:RCT; evidence level 1−
Country / Setting:USA, departments of neurosurgery and radiation oncology
Population:101 patients, tissue-proven carcinoma and MSCC, randomised – within strata, by permutated blocks, to surgery (n=50) or RT (n=51)
Intervention:Direct decompressive surgery followed by RT, compared to RT alone
Details about surgical interventions used:
  • The aim of surgery was to provide immediate direct circumferential decompression of the spinal cord. The operation was tailored for each patient depending on the level of the spine involved and the patient’s circumstances.
  • In general, for anteriorly located tumours the approach in the cervical spine was anterior, and in the thoracic and lumbar spine, depending on the tumour location, the approach was through a transversectomy or anterior approach. For laterally-located tumours, a lateral approach was used, and for posteriorly-located tumours, a laminectomy was done and any other posterior elements involved were removed. Stabilisation of tumours in all locations was performed if spinal instability was present; cement (methyl methacrylate), metallic rods, bone grafting, or other fixation devices were used.
Outcomes:Ability to walk, urinary continence, muscle strength and functional status, need for corticosteroids and opioid analgesics, survival time
Follow-up:Median 102 days surgery grp (0–1940); 93 days RT grp. (0–1117 days)
Results:Direct decompressive surgery plus postoperative radiotherapy is superior to treatment with radiotherapy alone. Patients treated with surgery had significantly better outcomes: significantly more patients in the surgery group than in the radiotherapy group were able to walk after treatment and retained the ability to walk significantly longer. Of those patients unable to walk pre-operatively, significantly more patients in the surgery group regained the ability to walk compared to patients in the radiotherapy group. Surgical treatment resulted in significant differences in maintenance of continence, muscle strength (ASIA score), functional ability (Frankel scores) and increased survival time The need for corticosteroids and opioid analgesics was significantly reduced in the surgical group.
Long term deformities: not reported
Overall survival: Increased survival time reported for the surgery grp. 30 day mortality rates were 6% in the surgery group and 14 % in RT grp, (p=0.32)
Symptom control: pain control, continence,, sphincter function, neurological function - ASIA /Frankel grades
The combined post-treatment ambulatory rate in surgery group was 84%(42/50) and 57% (29/51) in RT alone grp. (odds ratio 6:2 [95%CI 2.9–19.8] p=0.01). 32 patients entered in the study were unable to walk; significantly more patients in the surgery group regained the ability to walk compared to patients in the radiotherapy group (10/16, 62% vs. 3/16, 19%, p=0.01).Patients treated with surgery also retained the ability to walk significantly longer than did those with radiotherapy alone (median 122 days vs. 13 days, p=0.003).Of those patients who had the ability to walk at study entry 94% (32/34) in the surgery group preserved the function compared to 74% (26/35) in the RT grp. (p=0.024).
Surgical treatment resulted in significant differences in maintenance of continence, muscle strength (ASIA score), functional ability (Frankel scores). At 30 days patients in the surgery grp. maintained or improved their pre-treatment ASIA score at a significantly higher rate than RT grp. patients (86% vs. 60%, p=0.0064).
Frankel scores at or above study entry were higher in surgery grp (91% vs. 61%, p=0.0008)
Rate of revision surgery/ recovery: further interventions (depending on prior surgery): not reported
QOL: not reported explicitly
Economics: cost of surgery and rehab not reported as such, but the analysis shows that surgery did not result in prolonged hospitalisation, median hospital stay was 10 days in both the surgery (2–51 days) and RT (0–41) group, p=0.86.
Complications/safety: 4 patients reported with surgical complications: wound infection and 1 with failure of fixation that required additional surgery.
Mannion, R. J., Wilby, M., Godward, S., Lyratzopoulos, G. & Laing, R. J. C. (2007) The surgical management of metastatic spinal disease: prospective assessment and long-term follow-up. British Journal of Neurosurgery, 21: 593–598.
Design: prospective cohort study, evidence grade 2−
Country: UK

Aim: To evaluate the long term outcomes of patients with MSCC who received decompression surgery with fixation followed by radiotherapy.
Inclusion criteria
Patients were selected from a wider patient population as suitable for surgery. The patient suitability depended on: severity of paraparesis: MRC grade ≥ 3, pain suggesting instability; primary tumour type; prognosis ≥ 6 months and extent of disease: intra and extra vertebral, presence of other mets.
Exclusion criteria
Patients who did not meet the above criteria
Population
62 patients participated were included
Interventions
  • Primary treatment: Patients underwent surgical decompression surgery (decompress the neural elements) and to confirm tissue diagnosis
  • Secondary treatment: Fixation for an unstable spine.
  • Surgical Types included anterior approach and type of fixation (vertebrectomy and fixation) compared to posterior approach and type of fixation use (laminectomy and fixation, laminectomy only (intradural), vertebrectomy and fixation, occipto-cervical fusion.) Fixation was with pedicle screws or halo jacket.
  • 85% were posterior approach and 15 % were anterior approach
  • Patients were followed for 10 years prospectively.
Outcomes
  • Survival
  • Ambulation (pre and post-operatively reported as ability to walk independently, with or without walking aids.
  • Urinary continence: pre and post-operatively reported as patients with voluntary control over micturition and not requiring a catheter (indwelling or intermittent)
  • Quality of life (29% of patients responded to a pre and post-operative SF-36 questionnaire, reported visual analogue pain scores and Roland Morris back pain scores)
Results
62 patients participated were included, median age 62 years.
Most common tumour type was breast, 26%
Most common vertebral site was the thoracic region, 58%
Most common presenting symptom was axial back pain (at the level of disease), 84% and 53% experiencing paraparesis.

Survival:
  • 56% of patients survived at 1 year; 28% of patients survived at 3 years Median survival = 13 months.
  • 2 patients died within 1 month of surgery, 5 patients died within 3 months (of this 5; one group were elderly and did not tolerate surgery and another group were younger patients with aggressive tumour growth)
  • Majority of patients surviving at 3 months were ambulant and maintained continence.
Morbidity:
6% of patients had wound infection and 6% experienced instability or collapse post operatively. Only 3 % had neurological deterioration.

Ambulation:
  • 68% of patients were ambulant pre-operatively; of the remaining 32% not ambulant – 50% could walk post operatively.
  • 80% of patients were ambulant post-operatively – median follow up 3 months.
Urinary continence:
  • 86% of patients were continent pre-operatively (with an additional 4 patients continent post-op)
  • Overall continence = 92% of patients continent post-operatively– median follow up 3 months.
  • Of the 9 incontinent patients pre-operatively, 6 regained continence post-operatively.
Quality of Life
Components of SF-36 included Physical function; role limitation (how does a patient feel their condition is impacting their role in life); bodily pain.
  • Physical function: A significant difference of improvement was reported between pre-operative function and post operative at 3 months with further improvement at median 1 year follow up.
  • Role limitation: A significant difference of improvement was reported between pre-operative function and post operative at 3 months with further improvement at median 1 year follow up.
  • Bodily Pain: A significant difference of improvement was reported between pre- operative function and post operative at 3 months with further improvement at median 1 year follow up.
  • A median survival analysis was conducted for patients who returned a complete SF-36 data set (n=18), it indicated that survival was longer in this group of patients than in the group as a whole (18 months compared to 13 months).
Visual analogue pain scores and Roland Morris back pain scores indicated a significant difference of improvement (that is, a reduction) reported between pre- operative function and post operative at 3 months with further improvement at median 1 year follow up.
General comments
Limitations include the bias involved with non random patient section for treatment, as well as the lack of a comparative group. Caution with interpretation of the QoL results is required because as the results represent those of a select patient group and are not representative.

No information was provided about the radiotherapy that patients received, that is, how long after surgery did they receive it, what RT regimen they received and what the possible difference in effect would be post op/pre RT VS post op/post RT.
Study Identification:Prasad, D., Schiff, D. (2005) Malignant Spinal Cord Compression. Lancet Oncol 2005; 6:15–24
Design:Systematic Review of RCTs prospective cohort studies and retrospective case series; evidence level 3
Country / Setting:international
Population:patients diagnosed with MSCC
Intervention:Laminectomy; anterior decompression (thoracotomy and retroperitoneal dissection); RT
Outcomes:Ambulatory status; continence; complications; pain relief
Follow-up:Majority of studies included in the review had long-term follow-up
Results:Patients with MSCC treated with radical direct decompressive surgery and post-operative RT remain ambulatory and continent for the rest of their lives. Laminectomy has been only proven to help is the compression is posterior. In anterior spinal cord compression there is loss of spinal ability when the posterior elements are removed, leading to neurological deterioration. Anterior decompression allows for total removal of the pathological vertebral body and tumour mass. Bone grafting is not used because the bed is often to diseased to support the graft and post-operative RT will reduce the chance of graft acceptance.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: 51% of patients with spinal cord compression had vertebral collapse and 25% of patients treated with laminectomy sustained major neurological deterioration associated with surgery.

Overall survival: mean post-operative survival 271 days.

Recovery rate: 92% of patients had a stable spine as a result of surgery

Symptom control: 82% of patients improved after surgery in terms of pain relief and ambulation.

Rate of revision surgery/ recovery: not reported

QOL: not reported

Economics: cost of surgery and rehab not reported

Complications/safety: not reported
General comments: this study is not really helpful in answering the question, as its main focus is on epidemiology and pathophysiology, clinical features and general therapeutic aspects: use of corticosteroids, RT and surgery. Very little in this review is dedicate to the comparison of various surgical approaches.
StudyRatliff, J.K., Cooper, P.R.(2003) Metastatic spine tumours, Southern Medical Journal 97, 246–53
Design:Expert opinion / unsystematic review; evidence level 4
CountryInternational
Population:patients with MSCC
Intervention:surgery
Outcomes:Pain control, neurologic deficit, survival, complications
Follow-up:n/a
Results:Surgical treatment of MSCC remains controversial. Modern surgical techniques provide options for decompression and immediate stabilisation. Laminectomy alone in case of ventral compression is seldom used due to poor outcomes. Anterior, posterior or combined decompression with immediate stabilisation have been shown to provide improved patient outcomes when compared with historical reports of RT, decompressive laminectomy without stabilisation or combined RT and laminectomy. Surgery is often contemplated after failure of radiation and chemotherapy to achieve tumour control. In properly selected patients surgery should be considered as initial therapy, as it provides excellent pain relief, significant chance of recovery of neurologic function, acceptable perioperative morbidity and mortality and prevention of late neurologic deterioration.
Long term deformities: not reported. Transient neurologic deficits ranging from quadriparesis form cord ischemia to foot drop form nerve root retraction are reported in several series.

Overall survival: overall patient survival will depend on primary malignancy, degree of systemic spread and tumour biology. Median survival of at least 1 year after surgery is reported in may series. Considerable diminished survival presents in certain malignancies, such as metastatic colon carcinoma or metastatic melanoma with spinal involvement, where median survival is less than 4 months.

Symptom control: Pain control: isolated pedicle screw stabilisation achieved nearly 90% improvement in VAS pain scores at 1 month after surgery. Similar results are reported in more aggressive anterioposterior combined approaches, with over 90% of patients achieving improvement in pain control after decompression and stabilisation. Multiple series report reduction in pain control medication. Neurologic deficit: postoperative neurologic function depends on preoperative status. Patients with severe deficit of long-standing duration may not achieve improvement even with adequate decompression and fusion. Assessment of operative outcomes varies in different series making comparison difficult. In properly selected patients 70–80% may achieve improvement in neurologic function. Recovery of walking of previously non-ambulatory patients may be achieved in 50% of patients. Addition of decompressive laminectomy to RT did not contribute to improvement. Addition of stabilisation via anterior or posterior approaches achieved improvement in 70% of patients. Patients who deteriorate during RT may manifest poor recovery, with 77% of patients unchanged after surgery.

Rate of revision surgery/ recovery: not reported

QOL: not reported

Economics: not reported

Complications/safety: severe complications include perioperative neurologic deterioration, wound breakdown, significant blood loss and mortality. Major and minor complication may occur in up to 30% of patients. Pulmonary, cardiac and gastrointestinal complications, along with cerebrospinal fluid leakage are common. Instrumentation failures may occur. The use of high dose steroids, RT and chemotherapy increase complication rates. Perioperative mortality should be expected I less than 5%. Wound complications after RT in laminectomy have been reported in 28% of patients, and an increase from 12 to 32% was reported in patients treated with RT before decompression and stabilisation. Surgery performed within 7 days of beginning RT results in a wound complication rate of 46%. Wound infections are uncommon in anterior transthoracic approaches.
Blood loss may be significant in surgical decompression and stabilisation of spinal malignancies. (2–100 ml – range 50–31,000 ml). Perioperative embolisation did not correlate with decreased blood loss, although empirically embolisation appeared to decrease intraoperative blood loss.
General comments: -
Study Identification:Senel, A., Kaya, A.H., Kuroglu, E., Celik, F., (2007) Circumferential stabilisation with ghost screwing after posterior resection of spinal metastases via transpedicular route. Neurosurgical Review, 30:131–137
Design:Case reports; evidence level 4
Country / Setting:Turkey
Population:7 patients with MSCC; 4 women, 3 men, mean age 62.4 (range 55–70 years)
Intervention:posterior transpedicular laminectomy/corpectomy, circumferential stabilisation using ghost screws and acrylic cement.
Outcomes:Neurological function, pain control
Follow-up:Mean 12 months (range 2–24 months)
Results:
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: not reported

Overall survival: 1 patient died 1 month postoperative of pulmonary embolism. Overall survival not reported

Symptom control: patients who were neurological intact were able to self-mobilise rapidly and those with preoperative neurological deficit were mobilised early with support. One of 2 patients who had severe paraparesis at presentation exhibited improvement after surgery and only showed slight paraparesis at the 2month follow-up. The Karnofsky score preoperatively and at last follow-up ranged form 50–70% and 70–100% respectively.

Rate of revision surgery/ recovery: not reported

QOL: not reported

Economics: not reported

Complications/safety: not reported
General comments: -
Shehadi, J. A., Sciubba, D. M., Suk, I., Suki, D., Maldaun, M. V. C., McCutcheon, I. E., Nader, R., Theriault, R., Rhines, L. D. & Gokaslan, Z. L. (2007) Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients. European Spine Journal, 16: 1179–1192.
Design: retrospective case series, Evidence Grade 3
Country: US

Aim: To assess the outcomes of patients who have had spinal surgery due to metastatic breast cancer.
Inclusion criteria
Patients had to be medically stable enough to undergo spinal surgery and to have at least one of the criteria:
  1. Obvious spinal deformity with intractable pain
  2. Retropulsed bone or disc fragment in the spinal canal causing significant spinal compression
  3. Prior irradiation of the site or progressive spinal involvement with cord compression.
  4. medically intractable mechanical, local or radicular pain.
Exclusion criteria
Patients with end-stage disease with <3 months survival, absence of biomechanical instability, significant spinal deformity or major neurological deficit as well as patients who did not consent to participate.
Population
87 patients met the inclusion criteria, and had 125 spinal operations
Interventions
Surgical Techniques included:
Anterior approach (38% of 87 patients)
Posterior approach (35% of 87 patients)
Combined anterior-posterior simultaneous (6%)
Anterior or posterior portion of staged procedure (21%)

Instrumentation of all procedures
Incidence of any instrumentation (92%)
Incidence of PMMA usage (60%)
(Further details of fixation can be obtained from study)
Outcomes
  • Post operative neurological function
  • Post operative pain
  • Length of stay post op (LOS also included time spent on rehab service)
  • Complications (early = within the first 30 days post-op, late >30 days post-op)
  • Tumour recurrence
  • Survival
  • Follow-up: time of discharge, 1, 3, 6 months and 1 year after surgery. Median overall duration of follow up = up to 13 months
  • Comparisons b/w pre op and post op Frankel grade, VAS pain scores, pain medication usage
Results
Post operative neurological function
  • 87% were ambulatory pre op and 98% were ambulant post op.
  • Of the 11 patients (13%) not ambulant pre op, 4 were alive 3 months post op and 3 regained ambulation.
  • 85% of patients maintained or improved Frankel scores from pre op to immediate post op time point and up to 1 year.
Post operative pain
  • A significant difference between the Pre op median VAS score (6) and the post op median score (2) was reported, p <0.001. The post op median score was significantly lower at all time points.
  • Pre op median analgesic score = 4 and dropped to 3 at discharge. It remained at this point for time points: 1, 3 6 months and 1 years. This was a significant reduction for all post op time points when compared to pre op scores, p<0.05.
LOS and Complications
  • Median LOS = 11 days
  • 33% required post op rehabilitative services.
  • 39% of patients experienced 39 complications (26% were major and 24% were minor)
  • 34 complication were early, 5 complications were classed as late. (1 patient died within 24hours of surgery)
  • Instrument failure was the most common complication reason
  • Combined–staged surgical approach had the most major complications (38% occurring in this group)
  • When a multivariate analyses was conducted to determine risk factors for major early complications, the only significant factor = instrumentation of ≥ 5 spinal levels, (RR=7.2, 95%CI 1.5–35.5, P=0.01)
Tumour recurrence
  • Median overall duration of follow up = up to 13 months
  • 20 patients had tumour recurrence; 7 local, 10 distant 3 had both.
  • Re-treatment which included surgery in 11 patients and RT on 9.
Survival
  • Median survival interval after original breast cancer diagnosis = 80 months
  • Survival rate after date of primary breast cancer diagnosis was 96% at 1 year, 81% at 3 years, 69% at 5 years.
  • Median survival time after spinal surgery = 21 months.
  • Survival rate after patients’ first spinal surgery was 62% at 1 year, 33% at 3 years, 24% at 5 years.
General comments
Study Identification:St Clair S.F., McLain, R.F. (2006)Posterolateral spinal cord decompression in patients with metastasis: an endoscopic assisted approach. Surgical Technology international, 15: 257–66
Design:Case reports; evidence level 3
Country / Setting:USA
Population:3 patients with MSCC
Intervention:Laminectomy and posterolateral decompression; vertebrectomy; bone graft and titanium cage; posterior spinal fusion with bone graft and pedicle screw instrumentation; intralesional vertebrectomy with posterolateral endoscopic decompression.
Outcomes:Neurologic function
Follow-up:1 year; 18 months; 5years;
Results:Endoscopic assisted posterolateral decompression has been beneficial in the 3 reported cases. Postoperative morbidity was minimal, even in patients with known lung pathology. Neurological recovery and maintenance have been excellent in each case.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: reported as absent

Overall survival: 18 months for one patient who died of subsequently developed intracranial metastases. Not reported for the other 2 patients outside the follow-up period.

Symptom control: patients reported as neurologically intact, ambulant and pain free.

Rate of revision surgery/ recovery: not reported

QOL: not reported coherently

Economics: not reported directly: inpatient times reported averaged 4.6 days and ICU days have averaged 1/3 day per patient, lower than in traditional surgical approaches.

Complications/safety: the article reports no respiratory complications (pneumonia, atelectasis)
General comments: -
Study Identification:Witham, T.F., Khavkin, Y.A., Gallia, G.L. Wolinsky, J.P., Gokaslan, Z.L. (2006) Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nature Clinical Practice Neurology, 2006, 2 (2) 87–94
Design:Systematic review of RCTs, prospective cohort studies and retrospective case series; evidence level 3
Country / Setting:international
Population:5536 patients diagnosed with MSCC reported in 81 studies
Intervention:Studies reporting on circumferential surgical decompression with concomitant spinal cord stabilisation, vertebroplasty, kyphoplasty
Outcomes:Neurological function, Ambulatory status
Follow-up:Majority of studies included in the review had long-term follow-up
Results:Patients treated with a combination of surgery followed by RT can remain ambulatory longer and those who are not ambulatory at presentation have a better chance of regaining ambulatory function.
OUTCOME OF INTERESTCOMPARISONRESULT
Long term deformities: not reported

Overall survival: not reported

Recovery rate: not reported

Symptom control: neurological function and ambulatory status:
Neurological function following RT reveals a mean of 36% patients improved and 17% worsened. This result is similar to those obtained in a series of trials of laminectomy with or without RT which resulted in improved neurological function in a mean of 42% and worsened function in a mean of 13%. Laminectomy series had the added disadvantage of associated surgical morbidity and mortality of 6%. If a posterior decompressive procedure was performed in conjunction with a stabilisation procedure functional outcomes were better. If the stabilisation procedure was subsequent to posterior decompression a mean motor improvement of 64% was reported. Pain relief was achieved in a high percentage (mean 88%) with a mean mortality rate comparable to laminectomy alone (5%). Functional improvement after anterior approaches have a mean of 75% and a mortality rate largely unchanged 10%.
Results of treatment
Functional outcome
MethodNo of studiesPatientsimprovedworsePain improvedMortality
RT alone20139636%17%-
Laminectomy with or without RT27235542%13%6%
Posterior decompression and stabilisation16101064%88%5%
Vertebral body resection and stabilisation1877575%84%10%
Rate of revision surgery/ recovery: not reported

QOL: not reported

Economics: cost of surgery and rehab not reported

Complications/safety: mortality reported above
General comments: this is a review of clinical presentation, diagnostic work-up and general management of MSCC; it is not evident which studies are pertaining to the surgical management. Also, patient characteristics are not reported in sufficient detail.

From: Chapter 6, Treatment Selection and Strategies

Cover of Metastatic Spinal Cord Compression
Metastatic Spinal Cord Compression: Diagnosis and Management of Patients at Risk of or with Metastatic Spinal Cord Compression.
NICE Clinical Guidelines, No. 75.
National Collaborating Centre for Cancer (UK).
Copyright © 2008, National Collaborating Centre for Cancer.

No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licenses issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

PubMed Health. A service of the National Library of Medicine, National Institutes of Health.