American College of Radiology
ACR Appropriateness Criteria®

Metastatic Epidural Spinal Cord Compression and Recurrent Spinal Metastasis

Variant 1: 60-year-old man with stage IV non–small-cell lung cancer with KPS 80 and known asymptomatic spinal metastasis at T7 received first line systemic therapy then developed severe pain from the T7 metastasis (Brief Pain Inventory: 8 out of 10) associated with moderate epidural spinal cord compression leading to a gradual onset of sensory level above the umbilicus and bilateral lower extremity weakness (motor power 4 out of 5). MRI of the thoracic spine showed no cerebrospinal fluid (CSF) around the mildly deformed cord at T7. PET/CT shows stable primary tumor in the lung and lung metastases. No bony retropulsion.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hospice after RT Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
EBRT alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and EBRT May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and OI and EBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic radiopharmaceuticals alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention alone May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention followed by EBRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and OI Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
SBRT alone May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention followed by SBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
15–18 Gy/1 fraction May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
20–24 Gy/2 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
21–27 Gy/3 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
20–30 Gy/5 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Posterior field only May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Anterior/posterior fields Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Posterior obliques Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
SBRT (postoperative) May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 2: 65-year-old woman with known multiple myeloma but with no prior therapy, develops gradual onset of a sensory level in the lower chest and moderate bilateral lower-extremity weakness (motor power 3 out of 5) over one week from an epidural spinal cord compression at T5. There is associated moderate pain (Brief Pain Inventory: 6 of 10). MRI shows circumferential compression of the spinal cord by myeloma. There is no evidence of vertebral compression fracture. KPS is 70. Skeletal survey reveals several other sites of asymptomatic lytic metastases throughout the axial and appendicular skeleton.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Steroid therapy and EBRT, followed by OI and chemotherapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Surgical decompression, followed by SBRT Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and EBRT, followed by chemotherapy Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and EBRT, followed by OI May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and EBRT May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and OI and chemotherapy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and chemotherapy Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy and OI Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
EBRT alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Steroid therapy alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
OI alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Hospice after EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Observation Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Surgical decompression alone Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Surgical decompression, followed by EBRT Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
SBRT alone Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
Systemic radiopharmaceuticals alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
20 Gy/10 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Posterior field only May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Anterior/posterior fields Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Posterior obliques Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Variant 3: 75-year-old woman with known progressive metastatic colon cancer resistant to 2 lines of systemic therapy develops increased pain in the middle back and sudden onset of total paralysis of bilateral lower extremity weakness 1-week prior to admission to hospital from a nursing home. Her KPS is 50. The pain is rated 7 out of 10 on Brief Pain Inventory. The lower extremity power was 0 out of 5 and the sensory level was located above the umbilicus. MRI of the spine shows diffuse spinal metastasis and circumferential compression of the spinal cord at T8 from bulky metastasis with no surrounding CSF. She has no prior history of EBRT to T8. CT scan shows diffuse lung and liver metastases.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Hospice after EBRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement May be appropriate TBD TBD 6 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy and EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy and OI and EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic radiopharmaceuticals alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Chemotherapy and OI Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
SBRT alone Usually not appropriate 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Posterior field only Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Anterior/posterior fields Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Posterior obliques Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 1 n/a 0 0 0 0 0 0 0 0 0
Variant 4: 45-year-old man with known metastatic renal cell carcinoma develops increased pain in the lower back. He has received sunitinib for his systemic disease. His KPS is 80. The pain is rated 8 out of 10 on Brief Pain Inventory. There are no associated sensory or motor deficits in the lower extremities. He has a history of palliative EBRT to spinal levels T12-L2 to a dose of 30 Gy in 10 fractions one year prior to this presentation. MRI shows progression of spinal metastasis at L1 vertebral body and there is no epidural extension or vertebral compression fracture. CT scan shows that the lungs are the only other organs with metastatic renal cell carcinoma and they have demonstrated good response to sunitinib.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical intervention alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and EBRT and systemic radiopharmaceuticals Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy, surgical intervention and EBRT Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
SBRT alone Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and SBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and SBRT and systemic radiopharmaceuticals Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy, surgical intervention and SBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and SBRT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and surgical intervention May be appropriate 6 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and systemic radiopharmaceuticals May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment (surgery or SBRT) of the spine Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Systemic radiopharmaceuticals alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
OI alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
20 Gy/8 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
15–18 Gy/1 fraction Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
20–24 Gy/2 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
21–27 Gy/3 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
25–40 Gy/5 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Posterior field only Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Anterior/posterior fields Usually not appropriate 3 n/a 0 0 0 0 0 0 0 0 0
Posterior obliques May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually appropriate TBD TBD 8 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Variant 5: 56-year-old post-menopausal woman with known metastatic breast carcinoma, estrogen and progesterone receptors and HER2 positive, develops increased pain in the upper back and gradual onset of bilateral lower extremity weakness (motor power 4+ out of 5) over the more than 2 weeks. Her KPS is 80. The pain is rated 7 out of 10 on Brief Pain Inventory. She has a history of palliative EBRT to spinal levels T2-T6 to a dose of 30 Gy in 10 fractions two years prior to this presentation. MRI shows progression of spinal metastasis at T4 and there is epidural extension from the vertebral body and left pedicle, compressing on the spinal cord with no CSF surrounding the cord. There is no associated vertebral compression fracture. She has received two lines of systemic therapy with stable metastatic disease in the lungs and in multiple sites in the bones apart from the T4 vertebra on PET/CT.
Procedure Appropriateness Category SOE Adult RRL Peds RRL Rating Median Final Tabulations
1 2 3 4 5 6 7 8 9
Surgical intervention alone May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
EBRT alone Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and EBRT May be appropriate TBD TBD 5 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and EBRT and systemic radiopharmaceuticals May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy, surgical intervention and EBRT May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and EBRT Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
SBRT alone May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and SBRT Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and SBRT and systemic radiopharmaceuticals May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy, surgical intervention and SBRT Usually appropriate 8 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and SBRT May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy and surgical intervention May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
Surgical intervention and systemic radiopharmaceuticals May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Hospice after treatment (surgery or SBRT) of the spine Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Systemic radiopharmaceuticals alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Direct hospice placement Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Systemic therapy alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
OI alone Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
8 Gy/1 fraction Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
20 Gy/5 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
20 Gy/8 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
25 Gy/10 fractions May be appropriate 5 n/a 0 0 0 0 0 0 0 0 0
30 Gy/10 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
35 Gy/14 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
40 Gy/20 fractions Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
15–18 Gy/1 fraction Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
20–24 Gy/2 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
21–27 Gy/3 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
25–40 Gy/5 fractions Usually appropriate 7 n/a 0 0 0 0 0 0 0 0 0
CT simulation Usually appropriate TBD TBD 9 n/a 0 0 0 0 0 0 0 0 0
Fluoroscopic simulation May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
Clinical simulation Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Posterior field only Usually not appropriate TBD TBD 3 n/a 0 0 0 0 0 0 0 0 0
Anterior/posterior fields May be appropriate 4 n/a 0 0 0 0 0 0 0 0 0
Posterior obliques May be appropriate TBD TBD 4 n/a 0 0 0 0 0 0 0 0 0
SBRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
IMRT Usually appropriate TBD TBD 7 n/a 0 0 0 0 0 0 0 0 0
Proton therapy to the bone metastasis Usually not appropriate TBD TBD 2 n/a 0 0 0 0 0 0 0 0 0
Appendix Key

A more complete discussion of the items presented below can be found by accessing the supporting documents at the designated hyperlinks.

Appropriateness Category:The panel’s recommendation for a procedure based on the assessment of the risks and benefits of performing the procedure for the specified clinical scenario.

SOE: Strength of Evidence. The assessment of the amount and quality of evidence found in the peer reviewed medical literature for an appropriateness recommendation.

  • References: The citation number and PMID for the reference(s) associated with the recommendation.
  • Study Quality: The assessment of the quality of an individual reference based on the number of study quality elements described in the reference.

RRL: Relative Radiation Level. A population based assessment of the amount of radiation a typical patient may be exposed to during the specified procedure.

Rating: The final rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Median: The median rating (1-9 scale) for the procedure as determined by the panel during rating rounds.

Final tabulations: A histogram showing the number of panel members who rated the procedure as noted in the column heading (ie, 1, 2, 3, etc.).

Additional supporting documents about the AC methodology and processes can be found at www.acr.org/ac.