The Use of Corticosteroid Treatment Protocols in Compressive Epidural Spinal Metastases: Current Practice and the Need for Consensus.

STUDY

DESIGN

Systematic review.

OBJECTIVE

To evaluate current protocols for corticosteroid use in patients with compressive epidural spinal metastasis.

SUMMARY OF BACKGROUND DATA: Spinal metastases are common in oncological patients. Although spinal cord compression is a less frequent manifestation, its occurrence represents a medical emergency. Despite over three decades of literature reporting recommendations for corticosteroid use in patients with metastatic spinal cord compression, there remains a lack of consensus regarding the optimal timing, dosage, and duration of treatment.

METHODS

A systematic review was conducted in May 2025, including terms for epidural spinal metastasis and corticosteroids. Eight hundred thirty-five articles were screened for compressive metastatic epidural spinal lesions treated with systemic corticosteroids. Ultimately, 39 articles were included for final analysis, which included patient demographics, clinical characteristics, treatment modalities, adverse effects, and survival and ambulation outcomes. Studies were grouped into pre- and post-1997 based on NASCIS III, as well as evenly across three time periods.

RESULTS

Dexamethasone, hydrocortisone, methylprednisolone, and prednisone were used, with dexamethasone being the most common. The proportion of patients receiving steroid treatment and experiencing adverse effects was both significantly higher pre-1997 ( P <0.0001). Survival outcomes were significantly higher post-1997 at all time frames. Pretreatment ambulation was significantly higher post-1997 ( P <0.0001). The proportion of patients ambulating pretreatment was significantly higher with each subsequent period (42.11% vs. 62.72% vs. 70.59%; P <0.0001, P <0.0001, P <0.0001).

CONCLUSION

There remains a lack of consensus in the literature for steroid use in compressive metastatic spine disease. Recent studies generally suggest 12 to 32 mg/day of dexamethasone. There are improvements in overall survival but not ambulation in patients with symptomatic metastatic spine disease, likely from improved overall oncological care but not necessarily treatment of the spinal metastases themselves. Development of clear guidelines for corticosteroid use in this population is imperative to optimize prognostic outcomes.