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Clinical Outcome of Metastatic Spinal Cord Compression Treated With Surgical Excision ± Radiation Versus Radiation Therapy Alone: A Systematic Review of Literature

Kim, Jaehon M. MD*; Losina, Elena PhD*,†,‡; Bono, Christopher M. MD*; Schoenfeld, Andrew J. MD*; Collins, Jamie E. MA*,‡; Katz, Jeffrey N. MD, MSc*,†; Harris, Mitchel B. MD*

doi: 10.1097/BRS.0b013e318223b9b6
Literature Review
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Study Design. Systematic literature review from 1970 to 2007.

Objective. This study reports the results of a systematic review comparing surgical decompression ± radiation to radiation therapy alone among patients with metastatic spinal cord compression.

Summary of Background Data. 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.

Methods. 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.

Results. 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%.

Conclusion. 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.

A systematic review of literature was performed analyzing the neurologic outcome of surgery ± radiation versus radiation alone for the treatment of spine metastasis. Tumor excision and stabilization resulted in improved recovery from nonambulatory to ambulatory status. Direct comparison between surgical intervention and radiation alone is limited by patient selection bias.

*Department of Orthopaedic Surgery;

Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Harvard Medical School;

Department of Biostatistics, Boston University School of Public Health, Boston, MA.

Address correspondence and reprint requests to Mitchel B. Harris, MD, FACS, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; E-mail: mbharris@partners.org

Acknowledgment date: May 7, 2010. First revision date: November 18, 2010. Second revision date: December 28, 2010. Acceptance date: January 10, 2011.

The manuscript submitted does not contain information about medical device(s)/drug(s).

In support of their research, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health (P60 AR47782 and K24 AR057827).

No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

© 2012 Lippincott Williams & Wilkins, Inc.