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).
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  . Studies discriminate two types of pain  :
In addition to back pain, neurological findings are the second important element of spinal metastases  . 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)  . 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  . If the tumor is located in the sacral region and affects the conus medularis, autonomic dysfunction (poor sphincter and bladder control) can be noted . Although rare, an asymptomatic clinical course is possible  .
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  . 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)     . 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      . 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    . If an opportunity for a biopsy exists, an open biopsy is the favored approach  .