Spinemathema podcast · Episode 12 · About 8 minutes · October 2026

Episodes are narrated using an AI model of Mr Sadek’s own voice, from scripts he has written and approved.

Read the full article with references: Surgery for Spinal Cord Compression From Cancer: The Patchell Trial

Transcript

Hello and welcome to the Spinemathema podcast. I’m Ahmed Sadek, a neurosurgeon. In this episode I want to talk about a condition that every person living with cancer, and everyone who cares for them, should know about. It’s called metastatic spinal cord compression. And I’ll go through a landmark trial, published in twenty oh five, that changed how we think about treating it.

Let’s start with what it is. Some cancers can spread to the bones of the spine. Doctors call that spread metastasis. If one of those deposits presses on the spinal cord, or on the bundle of nerves at the bottom of the spine, it can cause pain, weakness, numbness, and problems with the bladder and bowels. That’s metastatic spinal cord compression, often shortened to M S C C. The National Institute for Health and Care Excellence, or NICE, advises that in someone who has, or has had, cancer, signs of cord compression should be treated as an oncological emergency.

Because this is so important, I want to go through the warning signs now, before we get to the trial.

NICE lists several symptoms and signs that suggest cord compression. They are problems controlling your bladder or bowels. Difficulty walking, or a change in the way you walk. Weakness in your arms or legs. Numbness, pins and needles, or loss of feeling. And nerve pain spreading out from the spine.

If you have, or have had, cancer and you develop any of those, please seek help immediately. Contact your cancer team or acute oncology service straight away, and if you can’t reach them, seek emergency care. Don’t wait for a routine appointment.

NICE also describes types of back pain that can suggest cancer has spread to the spine. That includes severe pain that doesn’t let up, pain that keeps getting worse, pain when standing, sitting or moving, pain that’s worse when you cough, sneeze or strain on the toilet, night pain that disturbs your sleep, a tender spot on the spine, and pain or cramping in the legs when walking. For someone with cancer, NICE advises getting specialist advice within twenty four hours if these happen.

Now to the trial. Before it, the standard treatment for this condition was steroids and radiotherapy. The role of surgery hadn’t been established. And being able to walk makes an enormous difference to quality of life. So the question was simple. Would an operation to remove the tumour pressing on the cord, followed by radiotherapy, keep more people on their feet than radiotherapy alone?

The trial was led by Patchell and colleagues, based in Lexington, Kentucky, in the United States. It was run across several institutions and published in The Lancet. People with spinal cord compression caused by cancer that had spread were randomly allocated to one of two groups. Fifty had an operation followed by radiotherapy. Fifty one had radiotherapy alone. Both groups had the same radiotherapy, which was ten treatments of three gray each. Gray is the unit used to measure a radiotherapy dose.

The main thing the researchers measured was whether people could walk after treatment. They also looked at bladder control, muscle strength and function, the need for steroids and strong painkillers called opioids, and how long people lived. The trial wasn’t blinded, so everyone knew which treatment had been given.

And the trial was stopped early. A planned check on the results, part way through, met a stopping rule that had been set in advance. By then, one hundred and twenty three patients had been assessed and one hundred and one had been randomised.

So what did they find? Significantly more people in the surgery group could walk after treatment. Forty two out of fifty, or eighty four per cent, compared with twenty nine out of fifty one, or fifty seven per cent, with radiotherapy alone.

People who had surgery also kept the ability to walk for much longer. The median was one hundred and twenty two days with surgery, compared with thirteen days with radiotherapy alone.

The most striking result was in the thirty two people who couldn’t walk when they joined the trial. After surgery, ten out of sixteen walked again. After radiotherapy alone, it was three out of sixteen. The surgery group also needed significantly less steroid and opioid medication.

The published summary mentions bladder control and survival as other outcomes, but it doesn’t give those figures, so I won’t quote them here.

Now let’s be honest about the limitations. The trial was small, with just over a hundred patients, and the group who couldn’t walk at the start was only thirty two people. It was stopped early, and trials stopped early because of benefit can overestimate how big the effect really is. It wasn’t blinded. Only one hundred and one of the one hundred and twenty three people assessed were randomised, and the summary doesn’t list every reason people were excluded, so these were selected patients. Surgery isn’t suitable for everyone with this condition.

The trial is also now twenty years old, and treatment has moved on. It used ten doses of radiotherapy. Today, NICE recommends a single dose of eight gray for most people with cord compression who are having radiotherapy, with several doses considered for people at high risk of side effects.

So how is care organised in the United Kingdom today? NICE published its guideline on spinal metastases and metastatic spinal cord compression in September twenty twenty three. It asks every area to have a designated service for this condition. The first point of contact is a coordinator, and that role should be covered twenty four hours a day, seven days a week, and based in a cancer service. The team should include cancer specialists, radiologists, spinal surgeons, physiotherapists and palliative care.

If cord compression is suspected, NICE recommends a magnetic resonance imaging scan, or MRI, as soon as possible, and always within twenty four hours. People with neurological symptoms should be offered a steroid called dexamethasone as soon as possible. Before any operation, specialists such as a cancer doctor and a spinal surgeon should agree a plan. Surgery aimed at stopping or reversing nerve damage should be offered as soon as possible after symptoms begin, followed by radiotherapy once the person has recovered. And if surgery isn’t suitable, NICE recommends urgent radiotherapy within twenty four hours, with some exceptions.

So what does this mean for you? For the patients in this trial, removing the tumour pressing on the cord and then giving radiotherapy kept more people walking, and for longer, than radiotherapy alone. Today, NICE includes spinal surgery as one of the core specialties in every service for this condition.

But surgery isn’t right for everyone. NICE guidance takes into account a person’s overall outlook, whether the spine is stable, and whether surgery is suitable, and it recommends that a senior specialist develops a personal care plan with each person. If you’re facing this decision, ask your team what each option is likely to achieve for you, and make sure what matters most to you is part of that conversation.

And the single most important message from today. Speed matters. If you have cancer and notice any of those warning signs, contact your cancer team straight away rather than waiting to see if things settle.

Thank you for listening. This podcast is general information and not a substitute for advice about your own situation, so please speak to your own doctor or specialist. You’ll find the full article, the diagrams and the references at spinemathema dot com. And if you found this useful, please subscribe to the Spinemathema channel on YouTube.

This podcast is general information and is not a substitute for advice about your own situation. Please speak to your GP or specialist.