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Oncology: C. H. Fürstenberg, B. Wiedenhöfer, H. J. Gerner, and C. Putz The effect of early surgical treatment on recovery in patients with metastatic compression of the spinal cord J Bone Joint Surg Br 2009; 91-B: 240-244 [Abstract] [Full text] [PDF]

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Another 48 hours

Andrew Clarke, Graham Edwards, Alwyn Jones   (20 February 2009)

Another 48 hours 20 February 2009
Andrew Clarke, Spinal Fellow University Hospital of Wales, Cardiff, United Kingdom, Graham Edwards, Alwyn Jones Send letter to journal: Re: Another 48 hours kluver_bucy{at}hotmail.com Andrew Clarke, et al.	Sir, We read with interest Fürstenberg's article on surgery for malignant spinal cord compression. It is very important for an open and informed discussion to be held on this topic. Our concern with this paper, however, is the 48 hour message. The only large scale, prospective randomised trial had a minimum of 48 hours of symptoms, except total paralysis, as an inclusion criterion.1 Despite this, the authors saw significant improvements in their patients' post-operative neurological function. The two main mechanisms of damage to the spinal cord are thought to be direct compression, which is reversible, and secondary vascular injury leading to spinal cord infarction, which is irreversible.2 There is no time stipulation as to when the injury becomes irreversible. We feel that the key to good treatment lies with assessment of the patient clinically by a spinal surgeon capable of performing the required surgery. The surgeon needs to decide on suitability of the patient for surgery, and most importantly, ask the patient what they want. The use of a 48-hour time limit is not evidence-based, nor is it a solid foundation upon which to advise management. We do not advocate operating on all patients with malignant spinal cord compression. We believe in careful assessment and selection. Unfortunately, this paper does not help with the decision making in this complex and emotive condition. A. Clarke, Spinal Fellow, G. Edwards, Foundation 2 Doctor, A. Jones, Consultant Spinal Surgeon, University Hospital of Wales, Cardiff, UK. 1. Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005;366:643-8. 2. Posner JB. Spinal Metastases. In: Neurologic Complications of Cancer. Philadelphia: Oxford University Press, 1995:111-42.