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Spinal Metastasis

Metastatic Neoplasm to the Spine

Spinal metastasis is an important manifestation of many tumors encountered in clinical practice. Back pain, arising either during the night and early morning or due to movement, is by far the most frequently reported symptom, accompanied by pain or weakness in the extremities, hyperreflexia, and an overall decrease in the ability to move and perform daily activities. The diagnosis rests on a detailed clinical assessment and imaging modalities such as plain radiography, computed tomography (CT), myelography, bone scintigraphy, and magnetic resonance imaging (MRI).


Presentation

Back pain, which can precede the appearance of other signs indicating a spinal metastasis by months or even years, is the single most important component of the clinical presentation [1] [2]. Studies discriminate two types of pain [1] [2]:

  • Tumor-related pain - Pain developing during the night or early morning in a localized fashion is thought to occur as a result of the tumor's expanding effect in the spine, causing increased pressure [1] [2]. Although it may increase in severity, it resolves with activity and becomes absent during the day [1] [2]:
  • Mechanical pain - Pathological compression of the spine and possible fractures that develop due to the presence of the tumor inevitably leads to pain that becomes aggravated by activity or in the setting of higher load on the spine (for example, during walking or standing) [1] [2]. Another distinguishing feature of mechanical pain is that it is not responsive to steroid therapy, unlike tumor-related pain [1].

In addition to back pain, neurological findings are the second important element of spinal metastases [1] [2]. Radiculopathy is perhaps the predominant type of neurological deficit, manifesting as weakness or pain in the upper or lower extremities (depending on the level of the lesion) [1] [2]. Band-like pain is reported in the case of a thoracic radiculopathy, whereas hyperreflexia, a positive Babinski sign, and deficits of the spinothalamic tract functions (pain/temperature/sensation) are hallmarks of a myelopathy [1] [2]. If the tumor is located in the sacral region and affects the conus medularis, autonomic dysfunction (poor sphincter and bladder control) can be noted [1]. Although rare, an asymptomatic clinical course is possible [1] [2].

Turkish
  • A 41-year-old Turkish man was treated with radiofrequency tumor ablation and percutaneous vertebral augmentation for spinal metastasis.[ncbi.nlm.nih.gov]
  • Turkish Neurosurgery 8: 276-280. Nijjar TS, Simpson WJ, Gadalla T, McCartney M (1993) Oligodendroglioma: The Princess Margaret Hospital Experience (1958-1984). Cancer 71: 4002-4006.[jneuro.com]
Back Pain
  • A 41-year-old male presented with a 1-month history of severe back pain radiating to both legs. The patient underwent a right nephrectomy for treatment of a RCC 1-year before admission.[ncbi.nlm.nih.gov]
  • In addition to back pain, neurological findings are the second important element of spinal metastases.[symptoma.com]
Low Back Pain
  • MATERIAL AND METHODS: A 79-year-old male patient presented with low back pain since 1 year and severe sacral pain irradiating to the left leg, paraparesis, urinary dysfunction and leg weakness since one week.[ncbi.nlm.nih.gov]
  • Metastatic choriocarcinoma is a rare differential diagnosis of low back pain after pregnancy and should be considered in differential diagnoses.[omicsonline.org]
Spine Pain
  • Pain mainly when you sit or stand usually means that the tumor is causing weakness or instability in the bones of your spine. Pain primarily at night or in the early morning that gets better as you move is often the first symptom of a tumor.[mskcc.org]
Bilateral Leg Weakness
  • A 63-year-old man presented with acute back pain and bilateral leg weakness 5 months after having a surgical treatment for moderately differentiated vocal cord squamous cell cancer (T2 N0 M0).[ncbi.nlm.nih.gov]
Hyperreflexia
  • Band-like pain is reported in the case of a thoracic radiculopathy, whereas hyperreflexia, a positive Babinski sign, and deficits of the spinothalamic tract functions (pain/temperature/sensation) are hallmarks of a myelopathy.[symptoma.com]
Foot Drop
  • Echocardiography revealed a left atrial tumor in a 59-year-old man with back pain that concurrently worsened with left foot drop and loss of the left ankle reflex soon after admission to our hospital.[ncbi.nlm.nih.gov]
Gait Ataxia
  • The radicular symptoms and the gait ataxia disappeared, postoperatively. One year later, however, new metastases were present. Patients with hemangiopericytoma should be controlled regularly for local recurrence and systemic tumor spread.[ncbi.nlm.nih.gov]

Workup

The spine is the most common site of skeletal tumor spread and it is estimated that up to 70% of individuals who suffer from a malignant disease (the breast, prostate, thyroid, kidney, pancreas, and lung all spread to the musculoskeletal system) will eventually develop a spinal metastasis [3] [4]. Hence, this entity must be considered in the diagnostic workup of such patients, particularly in the presence of back pain. The physician is obliged to perform a detailed history, during which all important symptoms should be covered, as well as their course and progression, whereas the physical examination provides crucial findings that aid in localizing the etiology. Still, to confirm the diagnosis and establish the exact level of metastatic tumor spread, imaging studies need to be employed. Plain radiography is commonly used as the first-line study in the assessment of spinal-related pathologies, but for a tumor to be visualized on X-rays, it needs to be at least 1 cm in size and cause significant vertebral damage (destruction of 30-50% of the vertebral body) [1] [2] [3] [4] [5]. For this reason, advanced studies are often required. CT and myelography were very useful until the introduction of MRI, one of the most important diagnostic modalities when it comes to spinal metastasis [1] [2] [3] [4] [5] [6]. Bone scanning (99mTc) is a great study that allows detection of tumors and inflammation throughout the entire skeleton, not only the spine, and is frequently used in combination with MRI and other studies [1] [4] [5] [6]. If an opportunity for a biopsy exists, an open biopsy is the favored approach [5] [7].

Treatment

  • Preliminary report of new antitumor treatment. To evaluate the effectiveness of electrochemotherapy as a novel treatment of spinal metastasis.[ncbi.nlm.nih.gov]

Prognosis

  • Further analysis of factors predicting prognosis should be conducted with respect to each type of primary tumor to help accurately predict prognosis.[ncbi.nlm.nih.gov]

Etiology

  • The physician is obliged to perform a detailed history, during which all important symptoms should be covered, as well as their course and progression, whereas the physical examination provides crucial findings that aid in localizing the etiology.[symptoma.com]
  • Assessments performed by the physiatrists assist the oncologists in distinguishing between types of back pain, identifying neurologic impairments and spinal instability, and determining the etiology of symptoms.[ascopost.com]

Epidemiology

  • STUDY DESIGN/SETTING: This was an epidemiologic study using national administrative data from the Nationwide Inpatient Sample (NIS) database.[ncbi.nlm.nih.gov]
  • Lurain JR (2010) Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J ObstetGynecol 203: 531-509.[omicsonline.org]
  • Perrin RG, Laxton AW (2004) Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients. Neurosurg Clin North Am 15:365–373 CrossRef Google Scholar 26.[link.springer.com]
  • Epidemiology, clinical presentation, and biomechanical ramifications of these lesions are summarized and treatment regimes, clinical outcomes, and complications and technical issues associated with treatments are presented.[ajnr.org]
Sex distribution
Age distribution

Pathophysiology

  • To describe the diagnosis, pathophysiology, and treatment of a papillary renal cell carcinoma that developed an intradural spinal mass with cauda equina infiltration.[ncbi.nlm.nih.gov]

Prevention

  • Impending paralysis was prevented in all six patients by this surgical intervention. There has been no recurrence of the local tumour after surgery. After a median follow up period of 14.1 months, 12 patients have survived.[ncbi.nlm.nih.gov]
  • The goals are to achieve bony and neuronal decompression, preserve function, and stabilize to reduce mechanical pain and to prevent or correct spinal deformity.[emedicine.medscape.com]
  • This will not only treat the patient’s symptoms but prevent further bony destruction of the vertebrae, avoid open surgery, prevent neurologic dysfunction and preserve quality of life.[princetonneurologicalsurgery.com]

References

Article

  1. Bilsky MH, Lis E, Raizer J, Lee H, Boland P. The diagnosis and treatment of metastatic spinal tumor. Oncologist. 1999;4(6):459-469.
  2. Delank K-S, Wendtner C, Eich HT, Eysel P. The Treatment of Spinal Metastases. Dtsch Arztebl Int 2011;108(5):71-80.
  3. Shah LM, Salzman KL. Imaging of Spinal Metastatic Disease. International Journal of Surgical Oncology. 2011;2011:769753.
  4. Singh K, Samartzis D, Vaccaro AR, Andersson GB, An HS, Heller JG. Current concepts in the management of metastatic spinal disease. The role of minimally-invasive approaches. J Bone Joint Surg Br. 2006;88:434–442
  5. Dunning EC, Butler JS, Morris S. Complications in the management of metastatic spinal disease. World J Orthop. 2012;3(8):114-121.
  6. Quraishi NA, Gokaslan ZL, Boriani S. The surgical management of metastatic epidural compression of the spinal cord. J Bone Joint Surg Br. 2010;92:1054–1060.
  7. Datir A, Pechon P, Saifuddin A. Imaging-guided percutaneous biopsy of pathologic fractures: a retrospective analysis of 129 cases. AJR Am J Roentgenol. 2009;193:504–508.

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Last updated: 2019-06-28 11:51