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Systematic literature review from 1970 to 2007.This study reports the results of a systematic review comparing surgical decompression ± radiation to radiation therapy alone among patients with metastatic spinal cord compression.Currently, the optimal treatment of metastatic spine lesions is not well defined and is inconsistent. Radiation and surgical excision are both accepted and effective. There appears to be a favorable trend for improved neurological outcome with surgical excision and stabilization as part of the management.A review of the English literature from 1970 to 2007 was performed in the Medline database using general MeSH terms. Relevant outcome studies for the treatment of metastatic spinal cord compression were selected through criteria defined a priori. The primary outcome was ambulatory capacity. A random effects model was built to compare results between treatment groups, based on calculated proportions from each study.Of the 1595 articles screened, 33 studies (2495 patients) were selected based on our inclusion and exclusion criteria. Sixty-four percent of the patients who underwent surgical decompression, tumor excision, and stabilization had neurological improvement from nonambulatory to ambulatory status. Twenty-nine percent of the radiation therapy group regained the ability to ambulate after treatment (P < 0.001). Paraplegic patients had a 4-fold greater recovery rate to functional ambulation with surgical intervention than with radiation therapy alone (42% vs. 10%, P < 0.001). Pain relief was noted in 88% of the patients in the surgical studies and in 74% of the patients in studies of radiation therapy (P < 0.001). The overall surgical complication rate was 29%.This systematic review suggests that surgical excision of tumor and instrumented stabilization may improve clinical outcomes compared with radiation therapy alone, with regard to neurological function and pain. However, most data in the current literature are from observational studies, where variations in patient population and treatments cannot be controlled. This compromised our ability to compare the results of both treatments directly.