Cancer can take a significant and profound turn for the worse with spinal cord compression. Spinal cord compression may be a presenting symptom of metastatic disease, as it is in our patient example. Such a serious presentation requires a careful assessment of treatment options and there are a few.

Decisions to go ahead with surgical decompression are generally guided by the oncological prognosis—this is not as straightforward as it may seem—and the prediction of ambulation in a patient who has pretreatment motor function. What is mostly true is that a patient who can walk at the time of the intervention will continue to walk, and patients who have developed motor deficits slowly may have a better outcome than patients with more rapid onset. Life expectancy prediction in general has been difficult, but scoring systems have been devised. One example is the Tokuhashi score (Table 10.1). There are several elements that take life expectancy into account and in this scoring system, the primary site of the neoplasm and the neurologic deficit are the most important elements to predict survival.

In our patient the first priority is an assessment of the degree of metastatic epidural compression of the spinal cord. The potential instability of the spine is unquestionably severe.

There are several ways to approach this clinical problem medically and surgically (Table 10.2). Corticosteroids are administered immediately in all patients. There is little certainty whether a high-dose dexamethasone (96 mg per day) or moderate dose (16 mg per day) should be used. Most physicians would prefer an aggressive approach in patients who have had rapid progressive motor symptoms and use a high dose.

The next priority is to determine whether the patient is a surgical candidate. In patients with pain only, stable neurologic findings and a radiosensitive tumor, radiotherapy is the first option. Criteria that have been used to favor an operative management include rapid progression of motor deficit, instability of the spine on MRI scan, medically intractable pain, and incomplete neurologic injury. Some algorithms also include complete sensory and motor paraplegia over 24 hours as a reason to proceed with surgery. However, external-beam radiotherapy is used in most patients, and this requires a total of 30 GY in 10 fractions. Radiotherapy is not considered in radioresistant tumors, such as renal cell carcinoma. If the tumor is not radiosensitive, vertebroplasty or kyphoplasty with or without open stabilization surgery is an option.

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