Treatment by Radiotherapy of Spinal Cord Compression Due to Extradural Metastases

The occurrence of spinal cord compression marks one of the few genuine emergencies in the practice of radiotherapy. It is a dramatic and not infrequent presentation of metastatic disease. Its appearance can have a devastating impact upon the patient and his family, and the resulting nursing problems can become an overwhelming burden. A general aura of pessimism pervades the undertaking of treatment of cord compression, yet with successful therapy the symptoms may be relieved, and on occasion the patient may resume his usual activities. How frequently is treatment successful? What is the relation of duration or extent of symptoms to the outcome of treatment? To get some answers to these questions the experience of the Department of Radiation Therapy at Memorial Hospital was reviewed. Between January 1958 and December 1964, 82 patients fulfilling the clinical, neurological, and radiological specifications of spinal cord compression syndrome were treated. The results obtained in these cases form the basis of this report. Material All patients had a histological diagnosis of cancer. None presented with cord compression as the primary manifestation of the disease. All had been treated previously for varying lengths of time by various therapeutic methods before this complication developed. Only two patients were under the age of ten years, all the remaining 80 being more than twenty-one years old when treated. In 36 patients the primary tumor was malignant lymphoma, in 22, carcinoma of the breast. In the remaining patients there were a few cases each of a variety of primaries. Of considerable interest is the lack of patients with carcinoma of the lung, although well over 100 patients with metastases to the vertebrae from lung primaries were seen during this same period. Only in one had a verified cord compression syndrome developed. The reasons for this are obscure. Diagnosis The primary means of diagnosis was evaluation by consultant neurologists. The earliest symptom was localized pain, present in 69 patients. When the upper cervicodorsal vertebral area was involved, the pain was usually of a girdle type. Otherwise, it was described as following a radicular course down the arms, along the intercostals, or down the legs. Some patients also experienced hyperesthesias in the affected dermatomes. Motor impairment was present in 67 patients. Most of the patients showed increased deep tendon reflexes, ankle clonus, and positive Babinski's sign. Progressive weakness of the lower extremities was usually observed. Paraplegia was found in 32 patients. Sensory disturbances other than pain generally followed the onset of motor signs and were encountered in 46 patients. In most, these disturbances were concurrent with the onset of motor signs, although 10 patients showed impairment of sensory pathways without ever manifesting motor disturbances.