Spinal Metastasis

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Spinal metastasis is common in with cancer. The is the third most common site for cancer cells to metastasize, following the lung and the liver. This amounts to 70% of all osseous metastases. Approximately 5–30% of with systemic cancer will have spinal metastasis; some studies have estimated that 30–70% of patients with a primary tumor have spinal metastatic disease at autopsy. Spinal metastases are slightly more common in men than in women and in adults aged 40–65 years than in others. Fortunately, only 10% of these patients are symptomatic, and approximately 94–98% of those patients present with epidural and/or vertebral involvement. Intradural extramedullary and intramedullary seeding of systemic cancer is unusual; they account for 5–6% and 0.5–1% of spinal metastases, respectively.

Spread from primary tumors is mainly by the arterial route. Retrograde spread through the Batson plexus during Valsalva maneuver is postulated. Direct invasion through the intervertebral foramina can also occur. Besides the mass effect, an epidural mass can cause cord distortion, resulting in demyelination or axonal destruction. Vascular compromise produces venous congestion and vasogenic edema of the spinal cord, resulting in venous infarction and hemorrhage.

About 70% of symptomatic lesions are found in the thoracic region of the , particularly at the level of T4-T7. Of the remainder, 20% are found in the lumbar region and 10% are found in the cervical . More than 50% of patients with spinal metastasis have several levels of involvement. About 10-38% of patients have involvement of several noncontiguous segments. Intramural and intramedullary metastases are not as common as those of the vertebral body and the epidural space. Isolated epidural involvement accounts for less than 10% of cases; it is particularly common in lymphoma and renal cell carcinoma. Most of the lesions are localized at the anterior portion of the vertebral body (60%). In 30% of cases, the lesion infiltrates the pedicle or lamina. A few patients have disease in both posterior and anterior parts of the spine.

Primary sources of spinal metastatic disease include the following:

Lung – 31%

– 24%

GI tract – 9%

Prostate – 8%

Lymphoma – 6%

Melanoma – 4%

Unknown – 2%

Kidney – 1%

Others including multiple myeloma – 13%

The outcome of metastatic disease to the spine and associated structures is uniformly bleak. [1]  Median survival of patients with spinal metastatic disease is 10 months.

Spinal metastasis is one of the leading causes of morbidity in cancer patients. It causes pain, fracture, mechanical instability, or neurological deficits such as paralysis and/or bowel and bladder dysfunction. The latter compromises the of life of patients with cancer and puts an additional burden on their caregivers. Cord compression is normally seen as a pre-terminal event. Median survival at that stage is about 3 months.

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Khan L, Mitera G, Probyn L, Ford M, Christakis M, Finkelstein J, et al. Inter-rater reliability between musculoskeletal radiologists and orthopedic surgeons on computed tomography imaging features of spinal metastases. Curr Oncol. 2011 Dec. 18(6):e282-7. [Medline]. [Full Text].

Wibmer C, Leithner A, Hofmann G, Clar H, Kapitan M, Berghold A, et al. Survival analysis of 254 patients after manifestation of spinal metastases: evaluation of seven preoperative scoring systems. Spine (Phila Pa 1976). 2011 Nov 1. 36(23):1977-86. [Medline].

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Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010 Oct 15. 35(22):E1221-9. [Medline].

Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26. 366 (9486):643-8. [Medline].

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Spratt DE, Beeler WH, de Moraes FY, Rhines LD, Gemmete JJ, Chaudhary N, et al. An integrated multidisciplinary algorithm for the management of spinal metastases: an International Spine Oncology Consortium report. Lancet Oncol. 2017 Dec. 18 (12):e720-e730. [Medline].

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Ibrahim A, Crockard A, Antonietti P, Boriani S, Bünger C, Gasbarrini A, et al. Does spinal surgery improve the of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. J Neurosurg Spine. 2008 Mar. 8(3):271-8. [Medline].

Ahmed KA, Stauder MC, Miller RC, Bauer HJ, Rose PS, Olivier KR, et al. Stereotactic Body Radiation Therapy in Spinal Metastases. Int J Radiat Oncol Biol Phys. 2012 Feb 11. [Medline].

Boehling NS, Grosshans DR, Allen PK, McAleer MF, Burton AW, Azeem S, et al. Vertebral compression fracture risk after stereotactic body radiotherapy for spinal metastases. J Neurosurg Spine. 2012 Jan 6. [Medline].

Wang XS, Rhines LD, Shiu , Yang JN, Selek U, Gning I, et al. Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1-2 trial. Lancet Oncol. 2012 Jan 26. [Medline].

Weitao Y, Qiqing C, Songtao G, Jiaqiang W. Open vertebroplasty in the treatment of spinal metastatic disease. Clin Neurol Neurosurg. 2011 Nov 14. [Medline].

Victor Tse, MD, PhD Clinical Professor, (Affiliated Clinical Educator Line), Department of Neurosurgery, Stanford University School of Medicine; Neurosurgeon, Kaiser Neuroscience of Northern California

Disclosure: Nothing to disclose.

Maziyar Arya Kalani, MD Assistant Professor, Mayo Medical School; Senior Associate Consultant in Neurosurgery, Mayo Clinic Arizona

Maziyar Arya Kalani, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Spinal Metastasis

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