e-session 553000

Radiotherapy for spinal cord compression

Expert: Dr Nassim Bougaci, CRHU Besançon, Besançon, France

Expert: Dr Berardino De Bari, Réseau Hospitalier Neuchâtelois, La Chaux-de-Fonds, Switzerland

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Surgical management of spine
metastasis-
spinal cord compression
e-session 553000

Clinical features/decisional tools/frameworks

Dr BOUGACI Nassim
Neurosurgery department CHU de Besançon
Besançon, France
 Anatomy of CNS and vertebra

Spinal cord
Pia mater
Sub arachnoid space arachnoid
Dura mater

Epidural space Epidural fat

Nerve root
Vertebral body
Transverse process
Intervertebral disk

Epinous process

• Cancer survival improvement
• Spinal metastasis >60% of
metastasis
• 10% =neurological signs
Localization
• 70 % thoracic spine
• 20% lumbar spine
• 10% cervical spine
Compression mechanisms
1. direct compression from an enlarging soft
tissue mass,
2. pressure caused by fracture and retropulsion of bony
fragments into the canal, (posterior wall)
3. severe kyphosis following vertebral collapse,
4. extension of a paraspinal tumor through the intervertebral
foramen.(rare)
 Gradually progressive
Clinical presentation
ACUTE EMERGENCY

PAIN NEUROLOGICAL SIGN

Local Radicular= level of lesion Myelopathy: motor/sensory loss Radicular

Spontaneous Intercostal gait disturbance,
Provoked Cervicobrachial spasticity,
syndrome weakness, pyramidal irritation
Multiple sensory loss,
autonomic dysfunction.
Bowel and
bladder dysfunction,

FRANKEL score
 Determination of the degree of spinal cord
Epidural compression compression is facilitated by the epidural spinal cord
compression (ESCC) score

ESCC score : 0-3

Low grade Bone-only disease or mild epidural tumor extension

without spinal cord compression

high grade spinal cord displacement and/or compression.

Neurologic deficits :
sensory or motor deficits, bowel bladder dysfunction,
and/or loss of ambulation
AOSpine foundation
Therapeutic strategies

• No consensus
• Collegial discussion
• Adapted to clinical status
• Multimodal evaluation : Spine MRI AND CT-scan

Desease burden Mechanical stability

Decisional framework for spinal compression

• Idealy during multidisciplinary staff

• Bone specialists : oncologist,radiotherapist,radiologist,neurosurgeon
• Clinical evaluation : Frankel scale
• Mechanical pain
• Oncologic status :
• Primary site
• General work up
• Prior treatments
• Therapeutic project
• General condition: WHO Performans status/Karnofsky index
Frankel classification
Tokuhashi score
Prognostic classification

Sum score 0 - 8:
85% lives < 6 months => conservative
treatment or palliative surgery

Sum score 9 - 11:

73% lives > 6 months (and 30% > 1 year) =>
palliative surgery or (exceptionally)
excisional surgery

Sum score 12 - 15:

95% lives > 1 year => excisional surgery

Determines the aim of the treatment strategy

Tokuhashi et al. A revised scoring system for preoperative evaluation metastatic

spine tumors prognosis.Spine 2005
Therapeutic strategies

Carcinologic treatment Palliative treatment/ symptomatic

Tumor resection Vast majority of surgical indications

Vertebral reconstruction Objective : restaure or preserve quality of life
Neurologic decompression • Autonomy
• Pain
Local Tumoral control
Improvement of oncologic prognosis
Favour less invasive technics:
• Frail patients
• Limited life expectancy
But :
Benefit/risks ratio unfavorable
Oncologic therapies delayed
Selection criteria :
• controlled cancer
• Preserved performans status
• Tokuhashi >13
Proposal for decisional framework for spinal
compression
< 48hrs
Surgery/RT
yes <12hrs cauda equina

Spinal metastasis Neurologic signs yes Stabilization surgery

instability
no yes RT
(SINS)

no pain

no Clinical follow up/radiological

Patchell et al. the Lancet 2005

Motor deficit
Combination surgery +radiation therapy 84% vs 57% functional improvement Bladder control
survival
 Initial assessment algorithm 1

De spratt et al. Lancet oncol 2017

 MNOP algorithm

Mechanical stability

Neurological risk

Oncological parameters

Preferred treatments
SINS Spinal neoplastic instability score

• 0-6 No mechanical instability.

• 7-12 Indeterminate stability
• Patients who experience mechanical pain generally
benefit from stabilization.
• 13-18 Mechanically unstable fractures.
Stabilization is normally required
SURGICAL OPTIONS

• Laminectomy alone?
• Iatrogenic instability
• Separation surgery
• Anterior Compressions : 70 % = instability induced by laminectomy =
stabilization
Summarized criteria for surgery

• Rapid onset
• Important osteolysis
• Favorable cancer : breast, kidney, thyroid….
• Radioresistant cancer : colorectal
• Tokuhashi>8
• Comorbidities (risk factors for complications)10-40% : smoking, diabetes,
ASA3, KPS<80, >3 vertebral levels, Frankel A-B
• Complications : up to 20-40%
Surgery can be done before compression…!

Unstable lesion (SINS):

• Preventive surgery for pathologic fractures
• Deformations
• Pain
• Stabilization surgery improves pain and quality of life
• Less invasive possible (percutaneous technics, MIS…)
Conclusion
• Spinal metastasis are frequent and can affect quality of life
• Preventive treatment of threatning lesions must be discussed systematically
• No consensus and multiplicity of therapeutic arsenal justify multidisciplinary
management
• Surgical indications depend on diagnostic stage
• Prefer early surgery than too late, less iatrogenic, best prognosis
• Patients with symptomatic high-grade epidural spinal cord compression from
metastases originating from solid tumors should, especially in case of neurological
deficit, in general be considered as surgical candidates for spinal cord
decompression.
• Exceptions: metastases highly sensitive to chemotherapy (hematological
malignancies) or radiotherapy
Thank you for your
attention
Radiotherapy for spinal cord compression
Dr Berardino DE BARI, PD, MerClin
Radiation Oncology department, Réseau Hospitalier Neuchâtelois
University of Lausanne

e-session 553000
Normal anatomy
How can we treat it with RT?
How should we treat it with RT?
Timing of RT
How can we treat it?
Analgesia

Corticoids

Vertebroplasty

Surgery

Radiotherapy
How can we treat it with RT?
Analgesia

Corticoids

Vertebroplasty

Surgery

Radiotherapy
Timing of RT
How to deliver RT?
How should we deliver RT?
Who is the candidate
for urgent RT?
Surgery and RT…timing?
 The problem
of fractionation
 The problem
of fractionation
 The problem
of fractionation

Prospective non randomized trial: 20/5Fr vs 30/10 fr

 The problem
of fractionation

Prospective non randomized trial: 20/5Fr vs 30/10 fr

 The problem
of fractionation

Prospective non randomized trial: 20/5Fr vs 30/10 fr

 The problem
of fractionation

Prospective non randomized trial: 20/5Fr vs 30/10 fr

 The problem
of fractionation
 The problem
of fractionation
 The problem
of fractionation
 The problem
of fractionation
How can we treat it with RT?
 The problem
of fractionation
Objectives

To determine the efficacy and safety of RT,

surgery and corticosteroids in spinal cord
compression.

Selection criteria

Randomised controlled trials (RCTs) of RT,

surgery and corticosteroids in adults with
spinal cord compression.
 The problem
of fractionation
Main results

This update includes seven trials

involving 876 (723 evaluable) adult
participants (19 to 87 years) in high-
income countries.

Most were free of the risk of bias.

 The problem
of fractionation
 The problem
of fractionation
 The problem
of fractionation
 The problem
of fractionation
Should we add
steroids to RT?
Steroids and RT
Steroids and RT
Steroids and RT
Steroids and RT
Surgery and RT…timing?
Surgery and RT

Surgery + RT
RT

Surgery + RT
RT
Surgery and RT
The problem of timing
Who is the candidate
for urgent RT?
The problem of timing
The problem of timing

World Neurosurg. 2018 Aug;116:e278-e290.

The problem of timing

World Neurosurg. 2018 Aug;116:e278-e290.

The problem of timing

World Neurosurg. 2018 Aug;116:e278-e290.

The problem of timing

World Neurosurg. 2018 Aug;116:e278-e290.

The problem of timing

World Neurosurg. 2018 Aug;116:e278-e290.

A pragmatic approach?
A pragmatic approach?

Group I = Best supportive care or single-dose RT

Group II = single-dose RT or short course RT

Group III = long course RT +/- surgery

A prognosis based approach?
A prognosis based approach?

Ugly = Best supportive care or single-dose RT

Bad = single-dose RT or short course RT

Good = long course RT +/- surgery

World Neurosurg. 2018 Aug;116:e278-e290.

Radiotherapy for spinal cord compression

Thank you for kind attention

Dr Berardino DE BARI, PD, MerClin
Radiation Oncology department, Réseau Hospitalier Neuchâtelois
University of Lausanne

e-session 553000
 Thank you!
for participating in this
Dedicated ESCO e-session
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