The examining physician should rst take a thorough history, taking note of specic symp­toms (dropping things, trouble buttoning shirt, difculty with utensils or counting change, gait imbalance, or bowel/bladder dysfunction) and signs (hyperreexia, clonus, decreased rectal tone, or a positive Hoffman, Babinski, Romberg, Spurling’s, or Lhermitte’s sign). Motor or sensory decits can be determined by one of the several commonly used grading scales. The American Spinal Injury Association (ASIA) classication is commonly used, ranging from neurologically intact (E) to a complete injury (A) [13], which is

Radiologic ESCC is best evaluated by a six­point grading scale [16] that was developed from a previous four-point grading scale [17]. The six- point grading scale describes bone-only disease (0), epidural impingement without deformation of the thecal sac (1a), deformation of the thecal sac without spinal cord abutment (1b), deformation of the thecal sac with spinal cord abutment (1c), spinal cord compression with CSF visible (2), and spinal cord compres­sion without CSF visible (3) (Fig. 4.2). In a study of seven spine surgeons, 25 MRI scans of

Armed with a reliable neurologic and ESCC assessment, low-grade ESCC is universally con­sidered for radiation treatment in the absence of any mechanical instability, regardless of radio­sensitivity. For high-grade ESCC with or without neurologic decit (Grades 2 and 3), separation surgery is offered unless the tumor is radiosensi­tive, in which case radiation is pursued. As previ­ously stated, the role of 1c ESCC remains ill dened and depends on the patient’s neurologic status. If there is a signicant neurologic decit due to tumor abutment and/or inammation, sur­gery may be more suitable. However, if the patient is neurologically intact, a hypofraction­ated radiation regimen may provide desired response while avoiding surgery.

as radiosensitive. In 1995, Maranzano and Latini [20] conducted a prospective trial and reported that when diagnosed early or late, radiosensi­tive histologies (myeloma, breast, prostate) were associated with higher median response times and improved survival. The more recent litera­ture agrees with these early results. Rades and colleagues [21] retrospectively analyzed 238 patients with ESCC secondary to myeloma and found that cEBRT alone led to a positive response in 97%—motor improvement in 53% and stable motor decit in 44%. The same group treated 29 patients with lymphoma causing ESCC and found that 72% improved motor function and 28% were stable with cEBRT alone [22]. Similarly favor­able results were reported in four young men with seminomas [23]. Tumors with radiosensi­tive histology also respond signicantly better to increased doses of radiation, even when doses extend beyond 30Gy [24]. Breast and prostate cancers are also radiosensitive but less so than the nonsolid tumors. The NOMS framework states that for radiosensitive tumors, even with high­grade ESCC, cEBRT can be used for local tumor control [25]. However, in cases of symptomatic spinal cord compression, especially by solid radiosensitive malignancies, surgery still plays an important role.