Monday, August 22, 2005

Surgery better than radiation & steroids for metastatic spinal cord compression

Lancet has published a randomized controlled trial comparing immediate surgery + XRT with XRT & steroids alone in patients with spinal cord compression from metastatic CA.  50 patients were randomized to each arm and the results are impressive.  84% of the surgery group vs 57% in the XRT group were able to walk afterwards; the surgery patients retained the ability to walk for longer (122 days vs 13).  These findings applied as well to those patients who were ambulatory at the time of presentation (94% vs. 74% were walking at the time treatment ended & those in the surgery group walked for 150 days vs 50 days in the non-surgery group).  Ambulation was defined as the ability to walk 4 steps with or without an assistive device.  There was a modest mortality benefit in the surgery group as well (126 vs. 100 days).  To me the trial seemed well put together, the effects were large & consistent and clinically relevant & all of this adds up to a practice changing paper.  The authors' caveats are as follows:
"The patient population studied consisted of those patients for whom surgery would be regarded as a realistic treatment option. Patients with very radiosensitive tumours, multiple areas of spinal cord compression, or total paraplegia for longer than 48 h were excluded."

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