Clinical Outcomes of Surgery Versus Radiotherapy in Bilsky Grade 3 Metastatic Epidural Spinal Cord Compression

<b>Background/Objectives</b>: Surgery is generally recommended for higher Bilsky grade metastatic epidural spinal cord compression (MESCC); however, Bilsky grades 2-3 are often grouped together, leaving limited evidence for managing patients with Bilsky grade 3 MESCC who have not developed neurological deficits. This study aimed to evaluate whether, and when, surgery should be performed in Bilsky grade 3 MESCC. <b>Methods</b>: This retrospective cohort study included patients diagnosed with Bilsky grade 3 MESCC from January 2021 to January 2025. A total of 138 patients were assigned to a radiotherapy (RT) group (<i>n</i> = 54) or a surgery group (<i>n</i> = 65) based on initial treatment. Demographics, clinical data, treatment outcomes, and treatment modalities were analyzed. Logistic regression identified risk factors for local progression, motor recovery, and ambulatory outcomes. <b>Results</b>: Ninety-five patients (70.3%) initially presented with weakness. Among 30 patients diagnosed before neurological deficits, interval from diagnosis to onset was 17.2 ± 14 days. Local progression and survival rates did not significantly differ between the groups. Surgery was associated with a higher likelihood of motor recovery (odds ratio [OR] = 10.05, <i>p</i> < 0.001) and better ambulatory function (OR = 0.433, <i>p</i> = 0.003). Higher initial motor grade and lower Eastern Cooperative Oncology Group Performance Status scores were also linked to favorable ambulatory outcomes. <b>Conclusions</b>: In Bilsky grade 3 MESCC, the mean interval from diagnosis to weakness onset was 17.2 days. Local progression and survival did not differ between RT and surgery; however, surgery provided superior motor recovery and ambulatory outcomes. Early surgery may offer improved functional outcomes in Bilsky grade 3 MESCC.