© 2005 by the Society forNeuro-Oncology
A meta-analysis of surgery versus conventional radiotherapy for thetreatment of metastatic spinal epidural disease
Departments of Neurosurgery (P.K., J.R.W.K., M.H.S.)and Family & Preventive Medicine (C.S.T.) and Spinal Oncology Service, Huntsman Cancer Institute(M.H.S.), University of Utah, Salt Lake City, UT 84108, USA
1 Address correspondence to Meic H. Schmidt, Department of Neurosurgery,University of Utah, 30 North 1900 East, Suite #3B-409 SOM, Salt Lake City, UT84132-2303, USA(meic.schmidt{at}hsc.utah.edu).
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Abstract |
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Radiotherapy has been the primary therapy for managing metastatic spinaldisease; however, surgery that decompresses the spinal cord circumferentially,followed by reconstruction and immediate stabilization, has also proveneffective. We provide a quantitative comparison between the "new"surgery and radiotherapy, based on articles that report on ambulatory statusbefore and after treatment, age, sex, primary neoplasm pathology, and spinaldisease distribution. Ambulation was categorized as "success" or"rescue" (proportion of patients ambulatory after treatment andproportion regaining ambulatory function, respectively). Secondary outcomeswere also analyzed. We calculated cumulative success and rescue rates for ourambulatory measurements and quantified heterogeneity using a mixed-effectsmodel. We investigated the source of the heterogeneity in both a univariateand multivariate manner with a meta-regression model. Our analysis includeddata from 24 surgical articles (999 patients) and 4 radiation articles (543patients), mostly uncontrolled cohort studies (Class III). Surgical patientswere 1.3 times more likely to be ambulatory after treatment and twice aslikely to regain ambulatory function. Overall ambulatory success rates forsurgery and radiation were 85% and 64%, respectively. Primary pathology wasthe principal factor determining survival. We present the first known formalmeta-analysis using data from nonrandomized clinical studies. Although weattempted to control for imbalances between the surgical and radiation groups,significant heterogeneity undoubtedly still exists. Nonetheless, we believethe differences in the outcomes indicate a true difference resulting fromtreatment. We conclude that surgery should usually be the primary treatmentwith radiation given as adjuvant therapy. Neurologic status, overall health,extent of disease (spinal and extraspinal), and primary pathology all impactproper treatment selection.
Received March 29, 2004; Accepted July 29, 2004
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