Patchell RA et al. (2005) Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 366: 643–648

A randomized multicenter trial has demonstrated that surgical resection is more effective than radiotherapy in patients undergoing surgery for spinal cord compression caused by metastatic cancer. Although standard treatment is radiotherapy and steroids, data from uncontrolled surgical studies encouraged Patchell et al. to investigate the effectiveness of surgical treatment, using ambulation as a primary endpoint.

The original intention to randomize 100 patients into two treatment groups—one receiving surgery within 24 h of randomization followed by radiotherapy, the other beginning radiotherapy alone within 24 h. Both groups received steroids. Recruitment was halted, however, after interim analysis showed surgical treatment to be superior in terms of ambulation rates (84% vs 57%, P = 0.001), duration of ambulatory ability, recovery of ambulatory ability, and use of corticosteroids and analgesics.

Eligible patients fulfilled strict criteria, including tissue-proven cancer diagnosis (not radiosensitive cancer, or cancer of CNS or spinal column origin), a single point of MRI-confirmed spinal-cord displacement, no unrelated neurological problems, and no previous spinal radiation preventing delivery of the study radiation dose. Also, patients could not have had total paraplegia for >48 h prior to study entry. Although the authors concede that their conclusions cannot be extrapolated to patients not fulfilling these criteria, the study shows surgical treatment to be markedly superior to radiotherapy in this context.