Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression

Abstract

Purpose Metastatic spinal cord compression (MSCC) requires expeditious treatment. While there is no ambiguity in the literature about the urgency of care for patients with MSCC, the effect of timing of surgical intervention has not been investigated in detail. The objective of our study was to investigate whether or not the 'timing of surgery' is an important factor in survival and neurological outcome in patients with MSCC. Methods All patients with MSCC presenting to our unit from October 2005 to March 2010 were included in this study. Patients were divided into three groups-those who underwent surgery within 24 h (Group 1, n = 45), between 24 and 48 h (Group 2, n = 23) and after 48 h (Group 3, n = 53) from acute presentation of neurological symptoms. The outcome measures studied were neurological outcome (change in Frankel grade post-operatively), survival (survival rate and median survival in days), incidence of infection, length of stay and complications. Results Patients' age, gender, revised Tokuhashi score, level of spinal metastasis and primary tumour type were not significantly different between the three groups. Greatest improvement in neurology was observed in Group 1, although not significantly when compared against Group 2 (24-48 h; (p = 0.09). When comparisons of neurological outcome were performed for all patients having surgery within 48 h (Groups 1 and 2) versus after 48 h (Group 3), the Frankel grade improvement was significant (p = 0.048) favouring surgery within 48 h of presentation. There was a negative correlation (-0.17) between the delay in surgery and the immediate neurological improvement, suggesting less improvement in those who had delayed surgery. There was no difference in length of hospital stay, incidence of infection, post-operative complications or survival between the groups. Conclusions Our results show that surgery should be performed sooner rather than later. Furthermore, earlier surgical treatment within 48 h in patients with MSCC resulted in significantly better neurological outcome. However, the timing of surgery did not influence length of hospital stay, complication rate or patient survival.

Decompression surgery for spinal metastases: a systematic review

“…No study reported a significant effect of time-to-surgery following the onset of spinal cord compression symptoms on survival. 36 Quraishi et al 36 reported that there was no significant difference between 3 groups treated with surgery within 24 hours, between 24 and 48 hours, and over 48 hours from acute presentation of neurological symptoms with respect to survival (p = 0.99). Finally, in a randomized, multiinstitutional, nonblinded trial, Patchell et al 32 found that surgical treatment followed by radiotherapy compared with radiotherapy alone resulted in increased median survival time (126 days vs 100 days, respectively; RR 0.6, p = 0.03).…”

The Michel Benoist and Robert Mulholland Yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2013

“…Another paper dealing with surgical treatment of spinal metastasis was that of Quraishi et al [44]. They retrospectively reviewed 121 patients admitted and operated upon in their unit, 45 within 24 h, 23 between 24 and 48 h, and 53 after 48 h. Although the time of surgery did not influence time of hospital stay, incidence of infection postoperative complications or survival, it did influence the degree of neurological recovery.…”

New imaging characteristics for predicting postoperative neurologic status in patients with metastatic epidural spinal cord compression. A retrospective analysis of 81 cases

“…Favorable functional outcome is associated with duration of paralysis less than 48 hours [4], pretreatment ambulation, good performance status [5,6], surgery [2,7], high Tokuhashi score [8], high Japanese Orthopaedic Association score [9], and absence of visceral metastases [10]. Perhaps, the duration of paralysis, the pretreatment ambulatory status, and therapeutic methods were the most important factors for functional outcome.…”

“…Several clinical characteristics related to postoperative functional outcome have been proposed: the duration of paralysis [4], pretreatment ambulatory status, preoperative performance status [5,6], therapeutic methods (surgery or radiotherapy) [2,7], Tokuhashi score [8], Japanese Orthopaedic Association score [9], and visceral metastases [10]. Moreover, Rades et al [11] developed a scoring system for predicting postradiotherapy ambulatory outcome, which comprised five prognostic factors, including primary tumor type, interval between tumor diagnosis and MESCC, visceral metastases, motor function, and time until motor deficits developed, in a series of 2,096 patients.…”