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].

• Weakness

  When patients with cranial glioblastoma develop weakness, a rare differential diagnosis is spinal metastases. Chart and literature reviews were performed. [ncbi.nlm.nih.gov]

  These MR images are from a patient with metastatic lung cancer and known brain metastases who presented with progressive lower limb weakness. [svuhradiology.ie]

• Surgical Procedure

  RESULTS: Surgical procedures were performed on the same day of embolization in 21 cases (same day-group), and on the next day after embolization in 39 cases (next-day group). Five surgical procedures were performed 2 days later. [ncbi.nlm.nih.gov]

  Although the name suggests SRS involves surgery, SRS is a non-surgical procedure where no incisions are required. The word surgery simply refers to the surgical precision with which the radiation is delivered. [dukecancerinstitute.org]

  Segmental stability and life-time prognosis of the patient are important factors to decide on the best surgical procedure. [link.springer.com]

• Wound Infection

  Wound infection rates are generally higher in patients undergoing surgery for spinal metastasis. Risk factors of wound infection in these patients are poorly understood. [ncbi.nlm.nih.gov]

  A preoperative neurological deficit contributed a 19% increase in mortality and a 71% increase in the risk of postoperative wound infection. We found an overall major complication rate of 27%. [online.boneandjoint.org.uk]

  infection; GI bleeding necessitating nasogastric tube placement; pulmonary embolism Minor complications: durotomy status after intraop closure; wound infection responsive to treatment w/antibiotics; UTI; pleural effusion; thrombocytopenia & anemia requiring [thejns.org]

  […] complication rate in our series was 14.2% with the wound infection rate being 4.2%. [asianjns.org]

  Other complications included pneumonia, wound infections, cerebrospinal fluid leaks, and incisional hernias. [neupsykey.com]

• Rigor

  The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study." [benthamopen.com]

  Peer Review All articles undergo a rigorous, double-blind peer review, conducted by at least two independent experts in the field to ensure articles are balanced, objective, and relevant to the current clinical landscape. [touchoncology.com]

  We assessed the quality of the studies and evaluated the strength of the overall body of evidence for each preoperative predictor identified through our sensitive and rigorous literature review. [journals.plos.org]

  This approach is rigorous but not consummate. In addition, many of the papers made analysis difficult due to the presentation of their data. Spinal metastasis was rarely isolated as a subgroup. [headandneckoncology.biomedcentral.com]

• Fever

  In addition, patients may have constitutional symptoms such as low-grade fever, night sweats, fatigue, malaise, and/or loss of appetite, among others. Physical Findings The physical findings for patients with a spine tumor are limited. [uscspine.com]

  The patients' vital signs were stable and she had no fever. In laboratory studies, complete blood cell count showed mild leukocytosis (10100/mm3 with 7480/mm3 neutrophils), hemoglobin level of 13.8 g/dL, and platelet count of 227000/mm3. [jksronline.org]

  Common side effects are fatigue, fever, nausea, vomiting, diarrhea, anemia, weakness, arthralgia, myalgia, and bone/joint pain. [physio-pedia.com]

  Minimum complication rate in the study group (one case of subfebrile fever in 5 days), very good overview in operation field with the possibility to treat also another pathologic findings concern the authors together with short hospital stay a clear advantages [sav.sk]

• 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]

  Hence, this entity must be considered in the diagnostic workup of such patients, particularly in the presence of back pain. [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]

• Spine Pain

  The type of pain can provide important information about the tumor. Pain mainly when you sit or stand usually means that the tumor is causing weakness or instability in the bones of your spine. [mskcc.org]

  The patient underwent left lateral temporal bone resection, which provided him with good pain relief. One month later, the patient returned with numbness and weakness of his right arm and posterior low cervical spine pain. [jamanetwork.com]

• Incontinence

  One month later, after finishing the scheduled treatment, the patient was admitted to the hospital again with symptoms of low back pain that radiated to bilateral lower legs with painful paresthesias, urinary incontinence, and constipation. [ncbi.nlm.nih.gov]

  The bladder is massively distended to the level of the umbilicus, in keeping with the patient’s presenting complaint of urinary incontinence (overflow). [casereports.bmj.com]

  If untreated, metastatic epidural compression inexorably progresses, causing paralysis, sensory loss, and sphincter incontinence. [nejm.org]

• Myelopathy

  Known complications of radiosurgery to spinal column tumors include radiation myelopathy and delayed vertebral compression fractures; however, the concept of pseudoprogression of spinal column tumors has not been previously described. [ncbi.nlm.nih.gov]

  Patients go on to develop a transverse myelopathy, a Brown-Sequard syndrome, or an ascending or descending myelopathy. The course of the illness is subacutely progressive. The most common primary tumors arise in the lung and breast. [medlink.com]

• Meningism

  CONCLUSION: In the case of misinterpretation of a MRI picture of contrast-positive thickenings of the meninges, a patient is erroneously regarded as having tumor metastases and is subject to more intensive treatment. [ncbi.nlm.nih.gov]

  […] cover the brain and spinal cord (meninges). [cancer.ca]

• 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]

  Myelopathy begins as hyperreflexia, a Babinski reflex and clonus, but progresses to weakness, proprioceptive sensory loss, and loss of pain and temperature below the level of the spinal cord compression. [theoncologist.onlinelibrary.wiley.com]

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].

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

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]

Scoring system for prediction of metastatic spine tumor prognosis. World J Orthop 2014;5:262–271. Crossref, Medline, Google Scholar 16. Schiff D, O’Neill BP, Suman VJ. [online.boneandjoint.org.uk]

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]

Etiology Most common spine metastasis involving primary metastasis originate from the following tumors in descending order: breast (21%), lung (19%), prostate (7.5%), renal (5%), gastrointestinal (4.5%), and thyroid (2.5%). [ncbi.nlm.nih.gov]

STUDY DESIGN/SETTING: This was an epidemiologic study using national administrative data from the Nationwide Inpatient Sample (NIS) database. [ncbi.nlm.nih.gov]

Methods - Epidemiological and biological data, as well as treatment protocols and secondary localization were analyzed for 650 consecutive patients diagnosed with MM from January 2006 to January 2017. [ibrain.univ-tours.fr]

Epidemiology 80% cancer patients have spinal metastasis at autopsy Spine is number one site for bony metastasis (50%) Cause Hexagon: PBBLTK Prostate Breast Bronchus MM Lymphoma Bowel Renal Thyroid NHx 20% of develop cord compression 30% survive >12/12 [52.62.202.235]

Overview of the epidemiology, clinical presentation, diagnosis, and management of adult patients with bone metastasis. http://www.uptodate.com/home. Accessed Jan. 2, 2015. Longo DL, et al. Harrison's Principles of Internal Medicine. 18th ed. [mayoclinic.org]

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]

Although myelitis can be prevented largely by instituting dose constraints, it is less clear what the fracture risk of a structurally compromised vertebra is, and what should be done in terms of stabilization and dosimetry to mitigate this risk. [ncbi.nlm.nih.gov]

The brain is often and for good reason protected by a barrier called the blood brain barrier (BBB) that normally serves to prevent toxic substances from entering. [dukecancerinstitute.org]

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