The surgical management of metastatic spinal tumors based on an Epidural Spinal Cord Compression (ESCC) scale

Background context: There have been no previous studies looking at the outcome of surgical decompression (+/-stabilization) for various grades of epidural spinal cord compression (ESCC) due to spinal metastases.

Purpose: The aim of this study was to determine the outcome of surgical treatment in patients with ESCC using the Bilsky six-point scale.

Study design/setting: This was a retrospective cohort review of prospectively collected data.

Patient sample: A consecutive series of 101 patients managed over the period of 3 years for ESCC due to spinal metastases in a tertiary spine surgery referral unit were included.

Methods: Data on age, gender, revised Tokuhashi score, preoperative Frankel grade, tumor histology, magnetic resonance imaging scan-based Bilsky cord compression grade, postoperative Frankel grade at last follow-up, complications, and survivorship were collected.

Outcome measures: Frankel grading system for function was used to evaluate the patient's preoperative and postoperative neurologic status. Patient survival and postoperative complications were also collected.

Results: Average patient age was 64.7 years (13-88 years): 62 males and 39 females. Mean follow-up was 7.3 months (3-23.3 months). Most primary tumors were in prostate, breast, renal, lung, and the blood dyscrasias. Within the lower grade of compression (Group 1; Bilsky Grades 0,1a, 1b, and 1c; n=40), 29 patients (72.5%) had no improvement in Frankel grade, seven patients (17.5%) improved, whereas four patients (10%) deteriorated neurologically after surgery. Within the higher compression grade (Group 2; Bilsky Grades 2 and 3; n=61), 37 patients (60%) did not experience neurologic change, 20 (33%) improved, whereas neurology worsened in four patients (7%). When compared with Group 2 patients, Group 1 patients had better preoperative Frankel scores but a greater number of patients in Group 2 improved their Frankel scores significantly postoperatively. The mean revised Tokuhashi score for Groups 1 and 2 was 10 and 9.1, respectively (p=.1). The complication rate for Groups 1 and 2 was 25% and 42.6%, respectively (p=.052). Survival analysis showed no difference between the groups (Group 1: median 376 days [12-1052]; Group 2: median 326 days [12-979]; p=.62).

Conclusions: Surgery can achieve improvements in neurology even in higher grades of cord compression. There is a trend toward more complications and worse survival with spinal surgery in patients with higher grades of compression.