Posterior aggressive debulking versus minimal decompression surgery in patients with metastatic spinal cord compression: propensity-score–matching analysis from a multicenter study cohort

OBJECTIVE The goal of this study was to evaluate the comparative outcomes of aggressive debulking (AD) and minimal decompression (MD) surgeries for metastatic spinal cord compression based on surgical burden, functional improvement, and symptomatic local recurrence (SLR). METHODS In this retrospective analysis from 2 tertiary hospitals, the authors assessed patients with metastatic spinal cord compression treated via AD and MD surgeries between 2010 and 2022. The evaluation included patient demographics, Eastern Cooperative Oncology Group performance status (ECOG-PS), primary tumor type, modified Tokuhashi scores, surgical burden, and SLR. Propensity-score matching (1:1 ratio) was conducted based on oncological status for intergroup comparisons. Survival analysis and logistic regression analyses were conducted. RESULTS A total of 264 patients were included in the study. After 1:1 propensity-score matching, a total of 156 matched patients were analyzed (78 patients each in the AD and MD groups). Operation time, estimated blood loss, transfused red blood cell units, and inpatient medical complications were significantly higher in the AD group compared to the MD group (p = 0.001, p = 0.002, p = 0.006, and p = 0.035, respectively). There was no significant difference in distribution of postoperative ECOG-PS between the AD and MD groups (OR 1.461, 95% CI 0.821–2.599, p = 0.197). In initially nonambulatory patients (ECOG-PS of grade 3 or 4), the AD group showed a higher proportion of patients regaining ambulatory function compared to the MD group (56.5% vs 36.2%; OR 2.294, p = 0.049). In cases with a preoperative ECOG-PS of grade 3, the difference in ambulation recovery between AD and MD was not statistically significant (60.0% vs 53.3%, p = 0.577). However, for severely impaired patients (ECOG-PS of grade 4), the AD group showed a higher proportion of patients regaining ambulatory function compared to the MD group (33.3% vs 5.9%, p = 0.086). Symptomatic SLR-free survival showed no significant differences at final follow-up (p = 0.095). Multivariate analysis identified the modified Tokuhashi score as the sole predictor of SLR (OR 1.871, p = 0.001). CONCLUSIONS This study found that MD surgery significantly reduced surgical burden compared to AD. AD surgery led to slightly better functional recovery showing greater rescue ratios, especially in patients with a preoperative ECOG-PS of grade 4. However, no difference in rescue ratio was observed in patients with a preoperative ECOG-PS of grade 3. There was no significant difference in SLR rates between the AD and MD groups.