Treatment of Cancer Affecting the Nerves or Spinal Cord

Diagnosis and Treatment

The National Comprehensive Cancer Network recommends magnetic resonance imaging (MRI) of the entire spine as the gold standard for diagnosis, which should be performed within specific timeframes based on clinical presentation 1, 2, 3
For patients with back pain only, MRI should be performed within 2 weeks 1, 2
For patients with unilateral radicular pain, MRI should be performed within 1 week 1, 2
For patients with progressive radicular deficit (>7 days), MRI should be performed within 48 hours 1, 2
For patients with progressive radicular deficit (<7 days), MRI should be performed within 24 hours 1, 2
For patients with suspected epidural metastatic spinal cord compression (MESCC), MRI should be performed within 12 hours 1, 2
The American College of Radiology recommends that MRI with contrast (T1 and T2) is superior to conventional radiographs, computed tomography, or bone scintigraphy for demonstrating spinal metastases and compression of the spinal cord or cauda equina 4, 3

The National Comprehensive Cancer Network recommends that corticosteroids should be administered immediately upon clinical-radiological diagnosis of spinal cord compression 4, 5
Dexamethasone is the drug of choice 5
The minimum recommended dose is 4 mg every 6 hours (16 mg/day) 4, 5
Doses may vary from 10-100 mg, with evidence from randomized trials supporting high doses 4
Gradual reduction over 2 weeks 5

The American Society for Radiation Oncology recommends that radiation therapy is the preferred treatment for patients with symptomatic spinal metastases when an adequate dose can be administered 1, 2
Provides pain relief in 50-58% of cases, with complete disappearance of pain in 30-35% 5
Hypofractionated regimens are the approach of choice 5
More prolonged regimens (5×4, 10×3 Gy) may be used in selected patients with a prolonged life expectancy 5
Stereotactic body radiation therapy (SBRT) achieves local tumor control and pain relief >80%, with faster relief compared to three-dimensional conformal radiation therapy 6

The National Comprehensive Cancer Network recommends that surgery is indicated in specific situations and requires a life expectancy of ≥3 months 4, 1, 2, 3
Absolute surgical indications include spinal instability, recurrence or progression of pain/neurological deficit after radiation therapy, and neurological deterioration during radiation therapy and corticosteroids 4, 1, 2
Contraindications for surgery include hematological tumors, paraplegia >24 hours, and life expectancy <3 months 4, 3

The American Society of Clinical Oncology recommends that bisphosphonates and denosumab should be administered to delay the first and subsequent skeletal-related events (SREs) 6, 5
Zoledronic acid, denosumab, or pamidronate are options 6, 5
Dental preventive measures are necessary before initiation to prevent osteonecrosis of the jaw 5
Bisphosphonates should not be considered an alternative to analgesic treatment 5

The National Comprehensive Cancer Network recommends that vertebroplasty or kyphoplasty can relieve pain from vertebral fractures 4, 6, 3
Pain relief within 1-3 days 6
Additive effects when combined with radiation therapy 6
Can be combined with radiofrequency ablation or cryoablation to reduce tumor mass 6

The American College of Surgeons recommends that urgent multidisciplinary consultation (ad hoc) including the responsible physician, radiation oncologist, and spinal surgeon is required in cases of progressive neurological deficit 1, 2
Treatment should be initiated within 24 hours after diagnosis of MESCC 1, 2