Response

Editor – My thanks to Dr Murray-Brown for raising this important issue. In my article ‘Metastatic spinal cord compression: a rare but important complication of cancer’ I concentrated primarily on the presentation and initial management of these cases. In the short section on rehabilitation I did not discuss the reduction of steroids and I agree that this is a very important part of the management.

In metastatic spinal cord compression patients the high dose steroids are used to reduce swelling and neurological symptoms whilst they start their definitive treatment. In our practice, once patients have commenced their fractionated radiotherapy treatment we reduce the steroids rapidly by half every two days. Most patients will have stopped taking their steroids just after their discharge on completion of radiotherapy treatment. Occasional patients require longer term treatment to control symptoms but this is kept at the lowest dose possible. If the patient deteriorates on reduction then higher doses are resumed short term to try to improve their symptoms.

I agree that patients who are not fit enough for definitive treatment, or who have received a single fraction of radiotherapy should have their steroids reduced gradually. Ideally they should be reduced gradually and then stopped over a 3–4 week period, or reduced and then maintained at the lowest possible dose at which their symptoms are controlled.