Management of Spinal Metastases

Department of Neurosurgery
Tribhuvan University Teaching Hospital
SPINAL METASTASES
MANAGEMENT
Sandesh Dahal
Moderator- Dr Amit B Pradhanang
2078.02.23

INTRODUCTION
• Occur in up to 10%-40% of people with cancer
• About 10% of cases present with cord compression
features
• Epidural is the commonest site for mets, then
intradural about 2-4 %
• Intramedullary mets is extremely rare about 1-2%
cases
• Thoracic spine is the most common about half of all
cases

INTRODUCTION
• Routes of metastasis to spine:
1. Hematogenous- venous: via spinal epidural veins (Batson’s
plexus)
2. perinervous or direct spread
• Hematogenous route- the commonest route
• Initially to the vertebral body, then erodes the pedicles into
the neural canal
• Intramural mets- drop mets with leptomeningeal spread,
from primary or secondary brain tumor, might occur
during manipulation in surgery

INTRODUCTION
• Site of Involvement in spine
• Thoracic- most common
• 70 % of all cases
• Lumbar-
• 20 % of all cases
• Cervical spine and
• Sacrum- least involved

TUMORS METASTASIZING

PRESENTATION
• The main function of spine
• Protection of spinal cord
• Mechanical support
• The symptoms are explained on the basis of
disturbance of the any of those function

PRESENTATION
• Pain-
• Most common symptom
• Presentation problem in 95% of the people with metastases
• Types of pain
• Radicular- sharp shooting pain in the distribution of the
affected nerve
• Either due to compression by mass or nerve compression in
the foramina due to vertebral body collapse

PRESENTATION
• Types of pain-
• Biological pain-
• deep vague pain that is stable with positional change
• worsens at night, and
• improves with steroids or nonsteroidal anti-inflammatory
drugs (NSAIDs)
• This pain is likely due to periosteal stretch and
inflammation by tumor, or paraspinal muscle infiltration,
and
• It may improve with radiation or vertebroplasty

PRESENTATION
• Types of pain
• Mechanical pain-
• that worsens with upright posture and loading of the spine
• It does not resolve well with NSAIDs
• This may be due to associated fractures, deformity, or
instability
• It dictates a more proactive surgical intervention or bracing if
the patient is not a suitable candidate for surgery.

PRESENTATION
• Neurological dysfunction
• Can present as radiculopathy, myelopathy or conus-cauda
syndrome
• Might occur as sensory, motor or autonomic dysfunction
• Motor or autonomic dysfunction: the second most common
presentation.
• Up to 85% of patients have weakness at the time of diagnosis.
• Leg stiffness may be an early symptom.
• Bladder dysfunction (urinary urgency, hesitancy, or retention) is the
most common autonomic manifestation
• Others include constipation or impotence.

PRESENTATION
• Sensory dysfunction:
• anesthesia, hypoesthesia, or paresthesia usually occur with motor dysfunction.
• Cervical or thoracic cord involvement may produce a sensory
level
• Other presentations:
• pathologic fracture. Bone metastases can sometimes produce
hypercalcemia (a medical emergency).

PRESENTATION
• The greater the neurologic deficit, the worse the chances for recovery of
lost function
• 76% of patients have some weakness by the time of diagnosis
• 15% are paraplegic on initial presentation, and < 5% of these can
ambulate after treatment
• Median time from onset of symptoms to diagnosis is 2 months
• The prognosis for neurologic recovery after surgery is directly related to
the degree and duration of neurologic compromise

EVALUATION
• Imaging characteristics depend on the nature of the tumor
• Osteoblastic tumors are
• prostate carcinoma
• osteosarcoma
• medullary thyroid carcinoma
• Osteolytic (might often mixed with osteosclerotic areas)
• breast cancer
• lymphoma
• urothelial carcinoma

• Osteolytic tumors
• Lung cancer
• Gastrointestinal tract cancers
• Renal cell carcinoma
• Melanoma
• Multiple myeloma

EVALUATION
• MRI with contrast if gold standard for
evaluation of mets.
• Most of the Mets appear slight hypointense on
T1 and slight hyperintense on T2
• Axial cuts show involvement of posterior
vertebral line with involvement of one or both
pedicle.
• DWI to differentiate the pathological fracture
from osteoporotic compression fracture

T2 image

AXIAL IMAGES

PATHOLOGICAL VS OSTEOPOROTIC
FRACTURE

PATHOLOGIC VS OSTEOPOROTIC
FRACTURE
Puzzle sign
Deformed vertebrae, hypointense
with convex bowing of the
posterior surface s/o malignant
fracture

MALIGNANT LESION

DIFFUSION RESTRICTION
• Benign
• There is tissue edema
• It permeates the free flow of
extracellular water
• No diffusion restriction seen
• Malignant
• There is hypercellularity
• This impedes the free water
molecule movement
• Hence there is diffusion
restriction

DWI IN OSTEOPOROTIC VS
PATHOLOGICAL FRACTURE

TB VS METASTASES

D/D OF METASTASIS
Multiple myeloma
- Can involve any bone including mandible and
appendicular skeleton
- Multiple lytic lesions only
- Alkaline phosphatase might be normal
- Mean age is similar
- Lesions are almost uniform in size
- Pedicles and posterior elements are less commonly
involved

X RAY
• Initial modality of
investigation
• Relatively less
sensitive unless
large area of
bone destruction
• Winking pedicle
sign or absent
pedicle sign is
seen on x ray

X RAY
• Other findings
• Lytic areas
• Pathological
compression fracture
• Scalloping of vertebral
body
• Vertebral body sclerosis
eg in ca prostate

X RAY
Vertebral body scalloping Ivory vertebrae sign

PLAIN CT SCAN
• Very good for bone detail
• Often helpful for surgical planning
• By itself, has low sensitivity for spinal cord
compression by tumor
• Sensitivity is increased with intrathecal contrast (CT-
myelogram)
• Ideally should include at lease 2 levels up and down
for planning

CT MYELOGRAPHY
• Indicated when MRI cannot be done
(contraindications, unavailability...).
• Advantages over MRI:
● Can obtain CSF (when performing LP to inject contrast) for
cytological study
● Excellent bony detail
● Can be performed in patients with pacemaker,
claustrophobia

CT MYELOGRAPHY
• Disadvantages of myelography over MRI:
• Invasive
• May require second procedure (C1–2 puncture) if there is a complete
block (providers proficient in this technique are becoming fewer)
• Risk of neurologic deterioration from LP in patient with complete block
• Cannot detect lesions that do not cause bony destruction or distortion
of the spinal subarachnoid space
• Cannot demonstrate paraspinal lesions
• Does not image spinal cord parenchyma
• Can not reveal lesion below the level of complete block

CT MYELOGRAPHY

PET SCAN
• 18- FDG PET
• Used in metastatic work
up with known or
unknown primary
• Sensitivity is high, but
spatial resolution and
specificity are low
• So often must be used
with CT and/or MRI

OTHER METASTATIC WORKUP
• careful physical exam including lymph nodes
• Routine blood, LFT, RFT, urine, and alkaline
phosphatase
• CT of chest, abdomen and pelvis: assess tumor
burden, staging, prognostication (which factors into
decisions regarding surgery)
• bone scan: looks for other sites of skeletal
involvement
• serum prostate specific antigen (PSA) in males
• mammogram in females

BONE SCAN
• Uses Tc-99m or 18-FDG
• Shows areas of hyper metabolism
• Sensitivity- about 60-90 %
• But poor specificity
• Cannot distinguish from infective or
inflammatory lesion
• But can add in biopsy because biopsy
from the metabolic lesion
• Similar concept also applies to the PET
scan

COMPARISON OF MODALITIES

MANAGEMENT
• Goals of management- morbidity control and palliation.
Mostly they don’t have effect on overall survival.
• Assessment of neurologic involvement and timeline of neurologic
changes
• Delineation of the degree of spinal involvement
• Determination of a histologic diagnosis: this affects management
• Preservation or restoration of neurologic function
• Preservation or restoration spinal stability
• Controlling pain

SURGICAL INDICATIONS
1. unknown primary and no tissue diagnosis (CT guided needle biopsy
is an option for accessible lesions). NB: lesions such as spinal epidural
abscess can be mistaken for metastases
2. spinal instability
3. deficit due to spinal deformity or compression by bone rather than
by tumor (e.g. due to compression fracture with collapse and
retropulsed bone)
4. radio-resistant tumors (e.g. renal-cell carcinoma, melanoma…) or
progression during XRT (usual trial: at least 48 hrs, unless significant or
rapid deterioration)
5. recurrence after maximal XRT
6. rapid neurologic deterioration

RELATIVE CONTRAINDICATIONS
1. very radiosensitive tumors (multiple myeloma, lymphoma…) not
previously radiated
2. total paralysis (Brice and McKissock group 4) > 8 hours duration,
or inability to walk (B&M group > 1) for > 24 hrs duration (after this,
there is essentially no chance of recovery and surgery is not
indicated)
3. expected survival: ≤ 3–4 months
4. multiple lésions at multiple level
5. patient unable to tolerate surgery: for patients with lung lesions,
check PFTs
Brice and McKissock
group
1. Mild- able to walk
2. Moderate- able to
move legs but not
against gravity
3. Severe- slight
motor and sensory
function with deep
pain sensation
4. Complete- no
motor sensory or
sphincter function
below lesion

MANAGEMENT
• Chemotherapy and radiotherapy with or without surgery is the
mainstay of therapy.
• Different scoring systems are there to asses which patients will
benefit from surgery
• NOMS is one of the system, which includes
• Neurology
• Oncology
• Mechanical stability and
• Systemic disease condition
• Memorial Sloan-Kettering Cancer Center (MSKCC), New York has
developed it

NEUROLOGY
• Includes clinical and radiological evaluation
• Neurology to asses are,
• Functional radiculopathy
• Myelopathy and
• Epidural compression in MRI
• Epidural compression is graded according to Bilsky et
al classification

BILSKY ET AL. CLASSIFICATION
Grade 2 and
3= high
grade

ONCOLOGY
• Tissue diagnosis to find out radio sensitivity status of
tumor
• Radiosensitive tumors like small cell lung ca, hematological
malignancy don’t require surgery
• Moderate sensitive tumors- breast cancer, colon cancer,
and non-small cell lung cancer might require combined
approach
• Radioresistant- melanoma, thyroid tumors, renal cell
carcinoma, and sarcoma often require decompression and
SRS

MECHANICAL STABILITY
• Scoring done with SINS score (spinal instability neoplastic
score)
• Factors taken into account are
• Location- junction, mobile or fixed vertebra
• Pain
• Nature of lesion- lytic, sclerotic or mixed
• Spine alignment
• Vertebral collapse
• Posterior elements involvement

SINS SCORE

SYSTEMIC DISEASE
• The patients are already stage IV disease
• Surgery is not justified if life expectancy is less than 3
months
• En bloc resection is justified only if life expectancy is
more than one year. If not, limited resection is offered
• Functional status and other comorbidity for general
anesthesia should be studied independent of tumor
burden

MANAGEMENT ACCORDING TO NOMS
FRAMEWORK

MANAGEMENT- NOMS

SURGERY
• Planning on case to case basis
• Extraspinal disease should be included in planning
• Instrumentation is used for stabilization rather than
the fusion unlike other diseases
• Approach can be variable
• Combined approaches are rarely done because they
have high morbidity and mortality

UPPER CERVICAL LESIONS
• 0.5% of all cases
• Large spinal canal so pain is commonest symptom
• Neurological symptoms in 15% and quadriparesis /
plegia in 6% only
• Anterior approaches are difficult and mostly not done
• Radiation with immobilization helps healing
• If fixation required- posterior fixation

LOWER CERVICAL SPINE
• Anterior approach with corpectomy directly deals with
metastasis
• Standard neck approach is used
• ENT help is sought for preop vocal cord analysis and
those with prior radiated patients

THORACIC REGION
• Anterior approach or posterior approach can be used
• Anterior- high morbidity and mortality
• Requires CTVS surgeon
• Manubrio-sternotomy for T1-T4
• Left extrapleural thoracotomy for T4-S1 lesions
• Posterior approach- is easier and enables direct
decompression of cord
• It can also be applied for transpedicular
decompression

LUMBOSACRAL SPINE
• Anterior
• From L2-L5 through left extraperitoneal approach
• Transpedicular decompression can be done if required
• Posterior approach can be done with fixation 2 levels up
and down with/out transpedicular corpectomy
• For S1 and S2, posterior approach with transpedicular
decompression can be used
• Decompression with posterior instrumentation in load
sharing method (no option for vertebral body
reconstruction)

OPTIONS FOR VERTEBRAL BODY
RECONSTRUCTION
• Cages that can be used
• Titanium cage
• PEEK cage (polyetheretherketone)
• Polymethylmethylacrylate cage
• PEEK is advantageous because
• It is totally translucent in CT, MRI and X rays and hence
progress can be well studied
• There is less chance of subsidence or sinking of cage (10% vs
30% )

MINIMALLY INVASIVE APPROACH
• Depending on the goal, the posterior stage may be
done in a minimally invasive surgery
• It seems to provide comparable outcomes to open
procedures
• It cause less blood loss and shorter hospital stays
• Robot-assisted posterior instrumentation was also
reported to be comparable to conventional
instrumentation in terms of accuracy and infection
rates

RADIOTHERAPY
• It is the primary modality of therapy with mild
compression
• It alleviates biological pain but not mechanical pain
which needs to be stabilized
• Modalities are
• External beam radiotherapy eCBRT- 30Gy in 10 fractions
• SRS- can be single dose or hypofractinated
Even radioresistant tumors or prior radiated tumors not responded
have 70% response rate with SRS.

SRS AKA SBRT
• Types
• Single high dose of 16-24 Gy or
• Hypofractinated 24-30 Gy in 2-3
sessions
• Can be used as
• Standalone therapy
• After surgery- after 3 weeks and
• After eCBRT- 3 months

INDICATIONS
• radio-resistant primary
tumors
• tumors extending one to
two levels, and
• failure after prior
conventional radiation
• Complete spinal cord injury
• Three or more contiguous
involved segments
• Complete cord effacement
with no CSF interjecting
between the tumor and cord
(Bilsky grade 3)
CONTRAINDICATIONS
SRS

SRS EFFECTS
There might be radiation toxicity
symptoms with SRS but myelopathy is
as low as 0.04% in a series of 1075
patients, and hence it is considered safe.
Vertebral fractures have been 6-39%

VERTEBROPLASTY AND KYPHOPLASTY
• Transpedicular injection
of PMMA under
fluoroscopy without
balloon (vertebroplasty)
and after balloon inflation
(kyphoplasty)
• It restores the vertebral
height to some extent

BENEFITS
• Restores height
• Decrease screw pullout if done
with posterior approach
• Pain alleviation by mechanical
stability and thermal ablation of
nerves
• Prophylactic use increase efficacy
of SRS and decrease the fractures
after SRS
• Extravasation of PMMA
• 30-90 % in vertebroplasty and
• 7-25% in cases of kyphoplasty
• But neurological and embolic
complications due to
extravasation are rare about 0-
4%
COMPLICATIONS
VERTEBROPLASTY/KYPHOPLASTY

OTHER ADJUVANT THERAPIES
• Radiofrequency ablation therapy for radio resistant
tumors
• Spine laser interstitial therapy (SLIT)
• Medication, analgesia and steroids
• Bisphosphonates to decrease bone resorption- reduce
fracture by 50% and effect fades after 3 years
• Opioids, rhizotomy and intrathecal opioids

PRACTICAL APPROACH TO
MANAGEMENT
• Asses general and neurological status
• If there is
• New onset deficit or progressive neurological symptoms like
progressive weakness, cauda symptoms etc then URGENT
admission and investigation is required
• Start dexamethasone- reduce pain and reverse neurological
deficit to some extent (dose 10mg iv or PO QID)
• X ray of entire spine
• Immediate MRI with contrast

• Myelogram if MRI not feasible
• Rest treatment based on radiology
• If no epidural mass- systemic chemotherapy for primary
disease
• If epidural mass, then start radiotherapy or surgery on
emergency basis
• In patients with radiculopathy or only pain with no
neurological issues, evaluation on out patient basis can be
done over days.

CONCLUSION
• Spinal metastases is as common as 10% in ca patients
• Most are epidural, and mostly present with pain
• Neurological deficit warrants urgent investigation and
treatment
• Radiotherapy with or without surgery is the mainstay
of treatment
• Decision to plan surgery depends on neurology,
stability, histology and other patient characters

Management of Spinal Metastases

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