Abstract
Introduction
Early and effective management of the neurologic sequelae of metastatic spinal cord compression (MSCC) is critical as the potential for return to function is directly related to severity of symptoms. Systemic corticosteroids have been used as a first-line agent to limit disease progression; however, the data supporting this practice are limited. Currently, there is no defined protocol for the role of steroids in the acute management of MSCC.
Materials and Methods
A systematic review of the literature was conducted utilizing the key concepts of MSCC, steroids, and outcome measures to answer the following questions: (1) What is the effect of steroid administration on the ambulatory status, bowel and bladder function, and survival in cases of MSCC? (2) What steroid dosing regimens are associated with the best outcome considering neurologic symptoms and complication prevention in cases of MSCC?
Results
Of 327 articles retrieved, 57 abstracts were reviewed and 29 full-text articles were evaluated. Of these, a total of 12 articles detailing the use of steroid administration in MSCC were found. Basic science studies showed that steroids were effective in reducing vasogenic edema of the spinal cord as quantified by the water content of compressed versus control segments of the spinal cord (p < 0.001), wet to dry weight of the spinal cord (p < 0.0001) as well as permeability of the blood spinal cord barrier (p < 0.007). Animal models receiving steroid therapy displayed higher functional outcome scores (p < 0.001, p < 0.05, and p < 0.0006), delay to onset of paraplegia (p < 0.05), and an overall lower incidence of paraplegia (p < 0.05). Clinical studies showed that when compared with a control, patients receiving steroids had a better chance of maintaining ambulatory status at the 6-month follow-up (p = 0.05); however, this effect was not maintained at the 1-year mark. A case series where patients were given a high dose bolus (100 mg) followed by a high dose regimen (96 mg/d) showed that along with radiotherapy, steroid administration was able to provide substantial pain relief with minimal incidence of side effects. However, a subsequent cohort study of patients receiving either high dose or low dose steroid protocols (96 vs. 16 mg/d) showed no significant differences between treatment groups regarding ambulation rate, and demonstrated a significantly greater number of both serious and total side effects in the high dose group (p = 0.0429 and p = 0.0284, respectively). Another case series using the same dosing regimen revealed that patients who started treatment later than 12 hours after the onset of symptoms were 6.22 times more likely to remain nonambulatory (p < 0.001).
Conclusion
The use of steroids in cases of MSCC is widespread, likely because of extrapolation of data from basic science investigations, studies of metastases to the brain, and the NASCIS trials. Based on the available literature, the use of steroids in MSCC is most effective in patients when administered within 12 hours of symptom onset and before the onset of paralysis or bowel and bladder symptoms. Use of a high dose protocol likely does not confer a better functional outcome while exposing the patient to a significantly greater risk of potentially serious complications.