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Anterior decompression of the spine for metastatic epidural cord compression A promising avenue of therapy.

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Anterior Decompression of the Spine
for Metastatic Epidural Cord Compression:
A Promising Avenue of Therapy?
Tali Siegal, MD,"t Tzony Siegal, MD, DMDJ Gordon Robin, MBChB, FRCSJ
Isabelle Lubettki-Korn, M D , t and Zvi Fuks, MD"
Most metastatic epidural tumors arise in a vertebral body and invade the anterior epidural space. Therefore, it is
logical to decompress the spine anteriorly and not by traditional laminectomy. Surgical decompression is indicated
if relapse occurs after radiotherapy and further radiation cannot be administered, if there is neurological deterioration during radiotherapy, and when histological diagnosis of the primary tumor is lacking. This pilot study consists
of eleven consecutive anterior decompressions of the spine performed in nine patients. In seven instances other
treatment modalities had been exhausted, and in four patients a tissue diagnosis was lacking. Before operation eight
of the patients were nonambulatory, four of them paraplegic. Following decompression all but one patient became
ambulatory. At operation the main bulk of the compressing tumor was found anterior or anterolateral to the cord.
Spine stabilization was done when stability was a problem. Wound infection in one patient was the only postoperative complication. The encouraging outcome of our management prompts us t o suggest that anterior decompression of the spine should be considered more often in metastatic compression of the cord and cauda equina.
Siegal T, Siegal T, Robin G, Lubetzki-Korn I, Fuks 2 : Anterior decompression of the spine for metastatic
epidural cord compression: a promising avenue of therapy? Ann Neurol 11:28-34, 1982
Recent retrospective studies suggest that the treatment of choice for most patients with metastatic cord
compression should be radiotherapy rather than
surgery [ 3 , 7, 9, 101. Decompressive laminectomy is
nonetheless indicated when (1) the nature of the
primary tumor is not known o r the diagnosis is in
doubt, (2) relapse occurs after radiotherapy and no
further radiation can be administered, or ( 3 ) symptoms progress inexorably despite ongoing radiotherapy.
We adopted the foregoing criteria for surgical intervention despite the fact that they were prompted
by the results of posterior decompression (laminectomy). However, the majority of epidural tumors
arise in a vertebral body [l, 2, 9, 181, invade the
epidural space anteriorly, and remain largely anterior
to the spinal cord. Therefore, the posterior approach
does not allow removal of the anteriorly located
tumor mass and fails to provide adequate decompression of the cord. In addition, removal of the posterior
vertebral elements by laminectomy might render the
spine unstable since the vertebral bodies may already
have been destroyed by tumor infiltration. Accord-
ingly, when surgical decompression is indicated, our
recent preference has been to decompress the spine
through the anterior approach. This pilot study describes eleven anterior decompressions of the spine
performed in nine patients. In seven patients other
treatment modalities had been exhausted, and in four
a tissue diagnosis was lacking.
From the Departments of *Oncology, tNeurology, and $Orthopaedic Surgery (Spinal Unit), Hadassah University Hospital,
Jerusalem, Israel.
Received Jan 6, 1981, and in revised form Apr 7. Accepted for
publication Apr 10, 1981.
Materials and Methods
Metastatic cord and cauda equina compression are considered together under the name epidural spinal cord compression because in recent series [7, 10, 11, 151 there have been
n o differences in outcome. At the Hadassah University
Hospital, patients with metastatic cord compression are
currently treated according to a protocol that entails highdose dexamethasone therapy (60 to 100 mg per day for 3
days, followed by rapid tapering as tolerated) and a course
of radiotherapy to a total dose of 4,000 rads.
Diagnosis of cord compression requires myelographic
evidence of an extradural block greater than 80%. When
t h e block is complete, cisternal myelography is also performed to locate the upper margin of the tumor. Surgical
decompression is indicated when histological diagnosis of
the primary tumor is lacking, if relapse occurs follow-
Address reprint requests to Dr Tali Siegal, Department of OncolPO Box 12000, Jerusalem
91120, Israel.
ogy, Hadassah University Hospital,
28 0364-5 134/82/010028-07$0l.25@ 1981 by the American Neurological Association
Table 1. Metastatic Epidural Compression: Anterior Surgical Approach by Level of Myelogvaphic Block
Preoperative
Spinal
Stability
Indication for
Surgery
Surgical
Approach
Operative
Findings?
Encircling
tumor
Encircling
tumor
No."
Primary Tumor
Myelographic
Block
la
Lymphoma
c3
Unstable
Tissue diagnosis
Anterior
lb
Lymphoma
c3
Stable
Relapse after
surgery and
RT (4,000
rads)
Anterior
2
Nasopharyngeal
T2-4
Stable
Costotransversectomy
Encircling
tumor
3a
Lung
T3-4
Unstable
Left costotransversectomy
Encircling
tumor
3b
Lung
T3-4
Stable
Relapse after
RT (4,000
rads)
Relapse after
laminectomy
and RT
(4,000 rads)
Relapse after
surgery and
RT
Right costotransversectomy
Encircling
tumor
4
Lymphoma
T10
Stable
Tissue diagnosis
Transthoracic
5
Breast
T10
Stable
Deterioration
on RT (3,000
rads)
Transthoracic
Encircling
tumor
Encircling
tumor
6
Lung
L1
Stable
H ypernephroma
L3
Stable
Retropleuralretroperitoneaf
Retroperitoneal
Encircling
tumor
7
8
Carcinoid
L4
Stable
Deterioration
on R T (2,500
rads)
Relapse after
RT (4,000
rads)
Tissue diagnosis
Retroperitoneal
9
Unknown primary
L4
Stable
Tissue diagnosis
Retroperitoneal
Encircling
tumor
Encircling
tumor
Patient
Encircling
tumor
*a = first decompression; b = second decompression.
+The main tumor bulk was located anteriorly or anterolaterally in all patients, gradually thinning out, and encircling the cord.
RT
=
radiotherapy.
ing radiotherapy and further radiation cannot be administered, o r if there is neurological deterioration during
radiotherapy. Accordingly, the first eleven consecutive
surgical decompressions were done through the anterior
approach and not by traditional laminectomy. Only individuals whose general medical status was too poor to permit surgery were excluded. In our short series no patient
with multiple blocks was encountered. The indications
for operation were: relapse after laminectomy, radiotherapy, or both (five cases); deterioration while receiving
radiotherapy (two cases); and tissue diagnosis (four cases)
(Table 1). Spinal instability was not considered an indication for the anterior approach, as stability can easily be
achieved by a posterior approach and instrumentation.
The primary tumors causing metastatic compression of the
cord and cauda equina and the levels of compression in
these patients are presented in Table 1. Two patients had
lung cancer, two had lymphoma, and each of the other five
had a different tumor: breast carcinoma, hypernephroma,
carcinoid tumor, nasopharyngeal carcinoma, and a metastatic adenocarcinoma of unknown origin. The indication
for operation in the two patients with lymphoma was
primarily to establish a tissue diagnosis; in one of them
(Patient 1) a second anterior decompression was necessary
13 months later due to recurrent cord compression at
the same level despite previous surgery followed by
radiotherapy and chemotherapy (No. Ib). Patient 3 also
required a second anterior decompression 10 months after
the first one (No. 3b). In that patient, rapid neurological
deterioration suggested recurrent cord compression, and
fluoroscopic myelography, which had shown free passage
of contrast material postoperatively, again revealed complete block at the same level.
In five instances the compression was in the thoracic
spine: three high in the cord (T2 to T4) and two at the T10
level. The other four patients had compression of the lumbar spine (see Table 1). In all patients, plain roentgenograms of the spine suggested the diagnosis by the presence
of vertebral body wedge compression, pedicular erosions,
or both. In Patient 4 a soft tissue paravertebral mass was
present.
At the time of diagnosis, all patients presented with
Siegal et al: Anterior Decompression of Spine for Metastatic Cord Compression
29
Table 2. Metastutic Epidural Compression: Signs at Diagnosis
Patient
No."
Primary Tumor
Myelographic
Block
Pain
c3
c3
+
+
la
lb
2
3a
Lymphoma
Lymphoma
Nasopharyngeal
Lung
T2-4
T3-4
3b
Lung
Lymphoma
Breast
Lung
T3-4
T10
T10
L1
H ypernephroma
L3
L4
L4
4
5
6
7
8
9
Carcinoid
Unknown primary
*a = first decompression; b = second decompression.
?Weakness = muscle strength less than normal (4/5);paresis
function (0-215).
UE = upper extremities; LE = lower extremities.
-
+
+
+
+
+
+
+
+
=
Muscle
Weakness?
UEweakness
Tetraparesis
Sensory
Loss
LEweakness
Paraplegia
+
+
+
+
+
+
+
Parapare si s
Paraplegia
Paraplegia
Paraplegia
LE weakness
Parapare si s
LEweakness
+
+
-
+
BoweUBladder
Function
Normal
Normal
Incontinent
Incontinent
Incontinent
Incontinent
Incontinent
Incontinent
Normal
Normal
Normal
antigravity muscle function only (3/5); plegia
muscle weakness (Table 2). Their muscle strength was
assessed on a scale of five in which 0 indicated no muscle
activity; 1, slight contractility but no joint motion; 2, good
range of motion when gravity is eliminated; 3, complete
range of motion against gravity; 4, complete range of motion against gravity with some resistance; and 5, full muscle
power. All patients were divided into three clinical groups
according to their muscle strength and motor function:
plegia denoted no antigravity muscle function (0-2/5);
paresis denoted antigravity muscle function only (3/5); and
weakness denoted muscle strength less than normal (4/5).
Grossly, this classification correlated well with ambulatory
status. Patient 2 was exceptional because, although his
muscle power was graded as 4/5, severe ataxia precluded
ambulation.
Eight of the nine patients had pain and sensory loss. The
single patient who did not (Patient 2) presented with severe
ataxia and urinary retention. Five patients had bladder and
bowel dysfunction (see Table 2). With six of the eleven
compressions, preoperative neurological deterioration had
occurred within 4 days; in the other five instances, deterioration developed over the course of one week. Pain usually
preceded neurological signs by a few days to several weeks.
All patients received an intravenous bolus of 60 to 100
mg of dexamethasone immediately after myelography
when the diagnosis was established. Decompression was
performed within hours. Patients then continued receiving
the initial high doses of dexamethasone for 3 days, including the day of operation and the first postoperative day,
then had the dosage rapidly tapered by 50% every second
day. I n four patients (Nos. la, 4, 8, and 9), decompression
preceded radiotherapy because a tissue diagnosis was lacking, and a course of radiotherapy was usually started in the
second postoperative week to a total dose of 4,000 rads.
Two patients (Nos. 5 and 6) deteriorated while receiving
radiotherapy (see Table l), necessitating anterior decompression. They completed the radiotherapy course to a
total dose of 4,000 rads in the postoperative period (see
Table 4).
The surgical approach was chosen according to the level
of compression (see Table 1).In the cervical spine the an-
30 Annals of Neurology Vol 11 N o 1 January 1982
=
Ataxia
-
Severe
-
-
no antigravity muscle
terior approach was standard [13], using an incision anterior to the sternomastoid muscle. In the high thoracic
spine (T2 to T4), our approach to the vertebral body was
through a costotransversectomy with resection of the posterior quarter of the ribs [4]. Partial resection of the vertebral body can be performed extrapleurally. From T4 to T10,
the approach was transthoracic and involved resection of
one or two ribs according to the level of spinal block. The
chest was entered through the rib bed and pleura, and anterior access to the vertebral body was readily obtained
[13]. In the lumbar spine, the approach was through a lateral incision and access to the vertebral body was retroperitoneal [ 4 , 131. In general, no more than two vertebrae were involved.
The part of the vertebral body containing metastatic
tumor was curetted, together with the adjacent discs (Figure). Decompression of the cord was then undertaken,
gently removing the posterior cortex of the vertebral body
and the posterior longitudinal ligament of the spine. Tumor
was removed from the anterior and lateral epidural space,
and decompression was extended proximally o r distally (or
both) as necessary. Stabilization of the spine was considered if more than 50% of the width of the vertebra was
being removed or if the spine had been rendered unstable
by a former laminectomy or by tumorous involvement of
the posterior elements. Stabilization was achieved by instrumentation (Harrington's) in Patient 3a, bone grafting in
Patients 1, 4, and 9, or cement (methyl methacrylate) in
Patients 3b, 6, and 8. Patient 5 had stabilization by both
bone and cement. Patients 2 and 7 did not require stabiiization. Only two patients (Nos. 1 and 3) were regarded as
having an unstable spine before operation. In the other
cases, internal stabilization by reconstitution of the excised
vertebral body with either bone graft or cement was done
as a preventive measure to ensure postoperative stability.
Results
The results of t r e a t m e n t are summarized in Table 3.
No p a t i e n t deteriorated after surgical intervention.
In e i g h t instances, patients were nonambulatory prior
A
Anterior decompreuion o j - metastatic epidural tunzor.
(A) Metu.rtatic tumor involzw the vertebral body and invades
the epidural spa(-ebut remain.! largely anterior to the compressed jpinal cord. Thtn. tuniorouJ film encircled the cord.
( B ) The purt ojthe zpertebral body inzdzied with metasjuiir tumor is curetted. Decompre.rsion of the cord is undertaken
and tumor rs remoued jiom the anterior and lateral epidural
rpace. (C) The spznai cord i.r decomprmed. Mechanical dirtortion of the neural tissues i.r relieved.
to surgery: four had only antigravity function and
four were paraplegic. Three patients were still ambulatory but with muscle weakness. A t 30 days after
decompression, all patients but o n e were ambulatory.
Patient 6 improved from paraplegia to antigravity
muscle function ( 3 / 5 ) and remained nonambulatory.
Two patients (Nos. 7 and 9 ) did not show improvement in muscle strength but maintained stable
neurological status and ambulation (Tables 3 , 4). Six
patients with Madder/howel dysfunction regained
normal function (see Table 3 ) . Dysfunction was permanent in the patient in whom ambulation was not
restored (Patient 6). After operation the first signs of
neurological recovery occurred within a few days,
steadily improving to ambulation within 30 days. T h e
rate of recovery varied from patient to patient and
was positively correlated with the duration of the
neurological deficit prior to surgery. Although all patients regained ambulation within 30 days after operation, most of them continued to improve in motor
performance afterward. Neurological recovery occurred independently of postoperative radiotherapy
since improvement was evident prior to its administration. In Patient 4 , for example, motor and
autonomic function returned to normal before
radiotherapy, which was delayed due to wound infection. The rate of recovery and duration of ambulation did not differ between the four patients in
whom surgery was not followed by radiotherapy and
those who completed postoperative irradiation. Tapering the high-dose dexamethasone did not affect
neurological improvement in any of the patients. All
Siegal et al: Anterior Decompression of Spine for Metastatic Cord Compression
31
Table 3. Treatment Resrdts at 30 Days According to Preoperative Ambulatory Status
Ambulatory Status+
Patient
No.'
Primary
Tumor
la
Lymphoma
Compression
c3
Hypernephroma L3
Unknown primary L4
Lymphoma
c3
Nasopharyngeal
T2-4
Lung
T3-4
Carcinoid
L4
Lung
T3-4
Lymp homa
T10
Breast
T10
Lung
L1
7
9
lb
2
3b
8
3a
4
5
6
BoweVBladder Function
Level of
Preoperative
Postoperative
Preoperative
Postoperative
Ambulatory
Ambulatory
Ambulatory
Nonambulatory
Nonambulatory
Nonambulatory
Nonambulatory
Paraplegic
Paraplegic
Paraplegic
Paraplegic
Ambulatory
Ambulatory
Ambulatory
Ambulatory
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Incontinent
Ambulatory
Incontinent
Ambulatory
Ambulatory
Ambulatory
Ambulatory
Ambulatory
Nonambulatory
Incontinent
Normal
Incontinent
Incontinent
Incontinent
Incontinent
*a = first decompression; b = second decompression.
tNonambulatory = paresis with antigravity muscle function only.
Table 4. Duration of Ambulation and Outcome following Anterior Decompression
Fluoroscopic
Myeiography
Ambulation
after
Operation
(mo)
Block on
Patient
No.'
Primary
Tumor
Level of
Compression
Postoperative
Radiotherapy
(rads)
la
lb
Lymphoma
Lymphoma
c3
c3
4,000
None
Open
Present
13
12
2
3a
3b
4
5
Nasopharyngeal
Lung
Lung
Lymphoma
Breast
Lung
T2-4
T3-4
T3-4
T10
T10
L1
None
None
None
4,000
1,000
1,500
Open
Open
Open
Open
Open
Hypernephroma
Carcinoid
Unknown primary
L3
L4
L4
None
4,000
4,000
Present
10
10
5
5
18
3 (nonambulatory)
10
20
5
6
7
8
9
*a
=
first decompression; b
=
...
...
Recompression
Died (nonambulatory 8
days before death)
Still alive (ambulatory)
Recompression
Still alive (ambulatory)
Died (ambulatory)
Died (ambulatory)
Died (nonambulatory)
Still alive (ambdatory)
Still alive (ambulatory)
Died (ambulatory)
second decompression.
patients en joyed lasting pain relief immediately after
operation. Recurrence of pain at the same site
heralded recompression (Patients 1 and 3).
The constant finding at operation was tumor encircling the cord (see Figure, A). The main bulk of
the compressing tumor was located anteriorly or anterolaterally, the tumor gradually thinning out as it
passed around the cord. In all cases, the dura was
compressed but not penetrated by tumor.
Repeat fluoroscopic myelography was performed
60 to 90 days after decompression in eight instances
(see Table 4). In six there was free passage of contrast
material, and in two the block was still present although ambulation was maintained. Patient 1b recovered from tetraparesis to normal neurological
status although myelography showed a block at C3.
Wound infection with sepsis in one lymphoma pa32 Annals of Neurology
...
Outcome
Vol 11 No 1 January 1982
tient (Patient 4 ) was the only postoperative complication encountered. Recumbency after operation was
kept to a minimum (no more than 4 days). Since the
spine was stable after surgery, no external braces or
piaster jackets were necessary.
Four patients are still alive and ambulatory, one 20
months and two 10 months after decompression. The
fourth patient (No. 3 ) underwent a second decompression 10 months after the first and was ambulatory
5 months following the second decompression (see
Table 4). Five patients died. Three survived less than
6 months and succumbed to generalized metastatic
disease, two at 5 months and one at 3 months after
operation. Of the other two patients, one died at 18
months (Patient 5 ) and the other (Patient 1) died 12
months after the second decompression and 25
months after the first. Four patients died without
neurological deterioration, and Patient 1 became
nonambulatory 8 days before deach (see Table 4).
The following case report illustrates the efficacy of
anterior decompression when previous laminectomy
and radiotherapy had failed.
Patient 3, a 50-year-old man, presented elsewhere with
back pain and paraparesis. Radiographs of the chest revealed a round lesion in the right middle lobe, and spine
roentgenograms showed erosion of the pedicles at T3 and
T 4 with a block at T3 demonstrated by myelography. Decompressive laminectomy at T3 through T6 revealed
metastatic adenocarcinoma of the lung. The patient was
then referred to our hospital for radiotherapy (4,000 rads,
T2 to T8) and chemotherapy (methotrexate, Cytoxan,
CCNU, Adriamycin). Neurological recovery was complete.
Two months after the laminectomy he returned with severe back pain, the sudden onset of paraplegia, and urinary
retention. Lumbar and cisternal myelography revealed a
complete block extending from T3 to T4. Dexamethasone,
100 mg per day, was started, and anterior decompression of
the spine was immediately carried out through a left costotransversectomy. At operation the main bulk of the tumor
was located anteriorly and encircled the dural sac. Since the
posterior elements were missing because of the previous
laminectomy, the spine was stabilized by a Harrington rod
fortified by the addition of bone cement. Relief of pain was
immediate and the postoperative course was uneventful.
The patient was sitting the day after operation and walked
on the eighth postoperative day. H e regained full muscle
strength and bladder control and could walk, but with mild
spasticity. Fluoroscopic myelography 2 months postoperatively showed free passage of contrast material.
Recurrent localized back pain and increased spasticity
were noted 10 months after the anterior decompression.
Three days later the patient was admitted with paraparesis,
marked spasticity, and bowel and bladder incontinence.
Fluoroscopic myelography revealed a recurrent complete
block at the same level (T3 to T4). Dexamethasone, 100
mg intravenously, was started and a second anterior decompression through a right costotransversectomy was
undertaken. Again, the main bulk of tumor was anteriorly
situated, compressing the cord and strangulating it by thin,
encircling extensions. The vertebral body was reconstituted by bone cement to render the spine stable since more
than 50% of the width of the vertebral body was curetted
at operation. The postoperative course again was uneventful, and neurological improvement was noted on the first
postoperative day with steady progress to arnbulation
within a week. Pain relief was immediate, and the patient
regained sphincter control at the end of the first postoperative week. However, marked spasticity remained,
although he improved over 4 months to almost normal
muscle tone. At last follow-up, 5 months after the second
anterior decompression, the patient was fully ambulatory
and working part time in a sedentary job.
Discussion
Most metastatic tumors that compress the epidural
space involve the vertebral body and remain largely
anterior to the cord [ l , 2, 10, 181. Therefore, anterior decompression appears preferable for removal
of the anteriorly located tumor. However, this approach has not gained general favor, although it has
been recommended by a few authors [ 3 , 8, 121. The
available published studies on this mode of treatment
d o not offer full information about preoperative neurological status and previous modalities of
therapy, if any, or about postoperative follow-up.
However, the reports indicate low surgical morbidity, relief of pain, short recumbency, and “recovery
from the neural deficit more than anticipated” [8,
121. O u r results support these claims.
In our study, patients were considered for surgery
only if other modalities of treatment had been
exhausted (seven patients) or if a tissue diagnosis was
lacking (four patients). Considering the recommended therapeutic approach for metastatic cord
compression [ 3 , 101, the seven previously treated
patients probably would have been doomed to
paraplegia or inexorable neurological deterioration.
This is further supported by our finding at operation
that the main bulk of the compressing tumor was located anteriorly or anterolaterally, encircling the cord
and gradually thinning out as it passed posteriorly
(see the Figure). Posteriorly, only the thin film of the
strangularing tumor can be exposed for decompression. Unavoidably, “decompressive” laminectomy
would result in merely temporary relief, if at all.
Furthermore, if the body of the vertebra is destroyed
by tumor and the posterior elements are resected for
the sake of decompression (laminectomy), painful
segmental instability can ensue. This instability will
further damage the cord.
Unlike the series reported by Conley [6] and by
Perrin [16], instability was not a cause of neurological
dysfunction in our patients. We added spinal stabilization as a preventive measure, and this was not an
indication for an anterior approach. Spine stabilization, if desired, can be better achieved by inserting
Harrington rods through the posterior approach.
Pain, either localized or radicular, is usually the
initial symptom [ 3 , 10, 111. T h e mechanism of
pain involves stretching or compression of painconducting nerve fibers, which are situated in the
anterior and posterior spinal ligaments, in the annulus of the intervertebral disc, and in the dura and
the apophyseal joints. Anterior spinal fusion led to
reduction of pain in Conley’s patients [GI. However,
others have achieved good pain control by laminectomy plus radiotherapy [lo, 151 or radiotherapy
alone [lo, 111. Prompt pain relief can also be obtained by high-dose dexamethasone [ 111 before
other modalities of therapy are commenced. All our
patients enjoyed immediate relief of pain, which can
be attributed to the combined effect of high-dose
dexamethasone and decompression of the cord. Lasting
Siegal et al: Anterior Decompression of Spine for Metastatic Cord Compression
33
pain relief is probably related to removal of tumor
and maintenance of spinal stability. Recurrence of
pain heralded recompression in our patients. Our
protocol entails initial administration of high doses of
dexamethasone, based on other studies that documented rapid and complete amelioration of pain
with minimal morbidity 1111. In human [ 5 , 171 and
animal [19] studies with dexamethasone, some relief
of neurological deficit has also been reported.
Extradural tumor compression results in vasogenic
edema of the spinal cord [141, a diminished blood
supply to the area of compression [ 191, stasis and occlusion of the epidural venous plexus [14], and mechanical distortion of the neural tissues. If unrelieved, these changes produce paraplegia. Patients
paraplegic at the onset of treatment are most likely to
remain so, regardless of the mode of therapy. Previous studies [2, 3, 7, 10, 111 have concluded that patients who were ambulatory at the onset of treatment
had the best outcome. In our study seven of the patients were nonambulatory, four of them paraplegic.
Following anterior decompression, ambulation and
boweVbladder function were restored in all patients
but one. Although our group of patients treated by
anterior decompression is too small to allow definite
conclusions, the rate of recovery to ambulation is
higher than would be expected with other modalities
of therapy [31.
When surgery for spinal cord compression is indicated, the approach should be directed toward the
location of the main tumor bulk. If spine roentgenograms and myelograms indicate anteriorly situated
epidural tumor, it is most accessible to surgery
through the anterior approach. Tumor excision relieves epidural compression and mechanical distortion of neural tissues. This procedure may also relieve stasis in the epidural venous plexus and enhance
the resolution of spinal cord edema. We believe our
results support these assumptions. Our encouraging
results prompt us to suggest that anterior decompression of the spine should be considered more often in
treating metastatic cord compression.
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