Narrative review—diagnosing and managing malignant epidural spinal cord compression: an evidence-based approach

BACKGROUND AND OBJECTIVE: Malignant spinal cord compression (MSCC) is a medical emergency. Clinical deterioration can occur quickly and irreversibly. MSCC is caused predominantly by metastatic cancer spread to the epidural space by epithelial or haematological malignancies. The primary diagnostic test is full-spine magnetic resonance imaging (MRI) since it has excellent soft tissue spatial resolution, and MSCC is multi-level in around one-third of cases. The modalities of therapy for MSCC are steroids, radiotherapy, and surgery. Radiotherapy is a mainstay of treatment since indications for surgery are limited. Recently randomised clinical trials exploring long course vs. short course radiotherapy have been undertaken as well as novel incorporation of stereotactic ablative radiotherapy (SABR). This review summarises these recent trials and identifies and discusses published data for novel treatment paradigms of MSCC. METHODS: Multiple medical databases were searched through January 7(th), 2023 and identified relevant studies that examined the use of radiotherapy with or without surgery in the management of MSCC. KEY CONTENT AND FINDINGS: In addition to a detailed overview of the pathophysiology and diagnosis of cord compression, we also examine all recent phase III clinical trials to date on the use of conventional radiotherapy in managing MSCC. Our review also provides a comprehensive summary and discussion of the novel approaches to the management of cord compression, including the role of SABR and a non-traditional surgical approach as well. CONCLUSIONS: Shorter courses of radiotherapy can be considered for poor prognosis patients. For favourable prognosis patients, longer courses of treatment provide more durable local control. An emerging treatment paradigm is a hybrid approach of surgery and SABR, however this has not been studied prospectively.