Further Outpatient Care
At the direction of referral physicians, outpatient care may include ongoing chemotherapy, steroid administration, radiation therapy, surgery, or other treatments.
Physical therapy may be necessary. Hospice referral may be indicated in some cases in coordination with the treatment team.
Further Inpatient Care
Further inpatient care may include steroid administration, chemotherapy, or surgery ordered at the discretion of attending physicians. Treatment is individualized and depends on tumor type, degree of neurologic function, and other factors.
Surgical decompression provides immediate relief of compression but may contribute to spinal mechanical instability. However, if instability is present from tumor destruction, surgery may be necessary for stabilization. A combination of surgical decompression and radiation may be more effective than radiotherapy alone. [11]
Spratt and colleagues have proposed a multidisciplinary algorithm for management of spinal metastases, using the following treatment options [12] :
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Image-guided stereotactic radiosurgery
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Separation surgery
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Vertebroplasty
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Minimally invasive local ablative approaches
Radiation therapy
Radiation treatment to areas of tumor compression should be pursued after appropriate imaging and consultation. Cord compression from an epidural tumor is considered one of the few emergencies in radiation oncology. Spinal cord tolerance to radiation depends on the fraction size and cumulative dose.
Surgical Intervention
Fehlings and colleagues analyzed the outcomes of 142 patients with a single symptomatic metastatic epidural spinal cord compression (MESCC) lesion who were treated surgically and were observed at least up to 12 months. Surgical intervention, as an adjunct to radiation and chemotherapy, was found to provide immediate and sustained improvement in pain-related, neurologic, functional, and health-related quality of life outcomes in patients with at least a 3-month survival prognosis. [13]
Transfer
Transfer may be necessary when specialized services are not accessible at the initial site of evaluation.
Consider administering steroids prior to transfer in cases of suspected spinal cord impairment caused by tumor.
Complications
Potential complications of spinal cord neoplasms include the following:
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Paraplegia
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Quadriplegia
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Urinary tract infections
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Soft-tissue damage
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Respiratory complications
Prognosis
The prognosis for recovery of neurologic deficits secondary to spinal cord compression is related to the duration and severity of the impairment at the start of treatment.
Disturbances in sphincter function are associated with a poor prognosis for recovery.
Primary spinal cord neoplasms are usually not metastatic and generally confer a more favorable prognosis for long-term survival than do metastases.
Patients with leptomeningeal metastases have a poor prognosis.
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Patient with metastatic breast cancer; plain radiograph shows L4 vertebral collapse.
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MRI of plain film above showing intrusion of tumor and vertebral collapse into spinal canal.
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Patient with renal cell carcinoma; MR shows collapse of a thoracic vertebra with spinal cord impingement.
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Axial MR of patient in Media File 3 above with vertebral destruction and spinal cord impingement.
