Abhishek Kumar1, Michael H Weber, Ziya Gokaslan, Jean-Paul Wolinsky, Meic Schmidt, Laurence Rhines, Michael G Fehlings, Ilya Laufer, Daniel M Sciubba, Michelle J Clarke, Narayan Sundaresan, Jorrit-Jan Verlaan, Arjun Sahgal, Dean Chou, Charles G Fisher. 1. *Department of Orthopedics, Louisiana State University, LA †Division of Orthopedics, McGill University Health Centre, Montreal, QC, Canada ‡Department of Neurosurgery, Brown University, Rhode Island §Department of Neurosurgery, Johns Hopkins University, Baltimore, MD ∥Department of Neurosurgery, University of Utah, Salt Lake City, UT ¶Department of Neurosurgery, MD Anderson Cancer Centre, Houston, TX #Division of Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada **Department of Neurosurgery, Memorial Sloan Kettering Cancer Centre, New York, NY ††Department of Neurologic Surgery, Mayo Clinic, Rochester, MN ‡‡Department of Neurosurgery, The Mount Sinai Medical Center, New York, NY §§Department of Orthopedic Surgery, University Medical Center Utrecht, Heidelberglaan, Utrecht, The Netherlands ∥∥Department of Radiation Oncology, Odette Cancer Centre, University of Toronto, Toronto, ON, Canada ¶¶Department of Neurosurgery, University of California San Francisco Spine Center, San Francisco, CA ##Vancouver Spine Surgery Institute, University of British Columbia, Vancouver, BC, Canada.
Abstract
STUDY DESIGN: Systematic review. OBJECTIVES: We conducted a systematic review of the literature to answer the following questions regarding the use of steroid therapy in metastatic spinal cord compression (MSCC): 1. In cases of MSCC, what is the effect of steroid administration before definitive radiotherapy or surgery on ambulatory status, bowel and bladder function and survival? 2. What steroid dosing regimens are associated with the best outcomes concerning neurological symptoms and complication prevention in cases of MSCC? SUMMARY OF BACKGROUND DATA: Currently, there is significant variation in the initial bolus dose, daily maintenance dose and duration of treatment when steroids are used as a bridge to definitive therapy for MSCC. METHODS: A literature search following PRISMA guidelines was conducted in June 2016, using Medline via Ovid SP, Medline via PubMed, Embase, Biosis Previews and the Cochrane Library. Search terms used in each database varied slightly to optimize results. All generic steroid formulations were included along with spinal cord compression or myelopathy combined with metastatic or malignant tumors. Papers discussing acute traumatic causes of spinal cord compression were excluded, as were papers discussing cord compression from nonmetastatic tumors or epidural lipomatosis. Subjects were limited to adult humans undergoing definitive treatment with radiotherapy or surgery. RESULTS: Of the 309 papers retrieved, 66 full text studies were reviewed and 6 papers were found to address the stated questions. CONCLUSIONS: There is a paucity of high quality literature evaluating the use of steroids in MSCC. On the basis of the evidence available an initial 10 mg intravenous bolus of dexamethasone followed by 16 mg PO QD has been associated with fewer complications compared with 100 mg bolus and 96 mg QD. Weaning of steroids should occur rapidly after definitive treatment. Risk of gastric bleeding or perforation can be managed with the routine use of proton-pump inhibitors. LEVEL OF EVIDENCE: Level IIIa.
STUDY DESIGN: Systematic review. OBJECTIVES: We conducted a systematic review of the literature to answer the following questions regarding the use of steroid therapy in metastatic spinal cord compression (MSCC): 1. In cases of MSCC, what is the effect of steroid administration before definitive radiotherapy or surgery on ambulatory status, bowel and bladder function and survival? 2. What steroid dosing regimens are associated with the best outcomes concerning neurological symptoms and complication prevention in cases of MSCC? SUMMARY OF BACKGROUND DATA: Currently, there is significant variation in the initial bolus dose, daily maintenance dose and duration of treatment when steroids are used as a bridge to definitive therapy for MSCC. METHODS: A literature search following PRISMA guidelines was conducted in June 2016, using Medline via Ovid SP, Medline via PubMed, Embase, Biosis Previews and the Cochrane Library. Search terms used in each database varied slightly to optimize results. All generic steroid formulations were included along with spinal cord compression or myelopathy combined with metastatic or malignant tumors. Papers discussing acute traumatic causes of spinal cord compression were excluded, as were papers discussing cord compression from nonmetastatic tumors or epidural lipomatosis. Subjects were limited to adult humans undergoing definitive treatment with radiotherapy or surgery. RESULTS: Of the 309 papers retrieved, 66 full text studies were reviewed and 6 papers were found to address the stated questions. CONCLUSIONS: There is a paucity of high quality literature evaluating the use of steroids in MSCC. On the basis of the evidence available an initial 10 mg intravenous bolus of dexamethasone followed by 16 mg PO QD has been associated with fewer complications compared with 100 mg bolus and 96 mg QD. Weaning of steroids should occur rapidly after definitive treatment. Risk of gastric bleeding or perforation can be managed with the routine use of proton-pump inhibitors. LEVEL OF EVIDENCE: Level IIIa.
Authors: Ori Barzilai; Stefano Boriani; Charles G Fisher; Arjun Sahgal; Jorrit Jan Verlaan; Ziya L Gokaslan; Aron Lazary; Chetan Bettegowda; Laurence D Rhines; Ilya Laufer Journal: Global Spine J Date: 2019-05-08