What are the management options for spinal metastasis pain?

From the Guidelines

Management of spinal metastasis pain requires a multimodal approach, with the most recent and highest quality evidence supporting the use of external beam radiation therapy (EBRT) as the treatment of choice for localized moderate to severe bone pain due to bone metastases, as recommended by the ESMO clinical practice guidelines 1. The management strategy for spinal metastases is essentially based on fracture risk and neurological risk evaluation, with the goal of preventing skeletal-related events (SRE) and maintaining the patient's quality of life 1. Key considerations in the management of spinal metastasis pain include:

• Medication management: acetaminophen and NSAIDs for mild pain, progressing to weak opioids like tramadol (50-100mg every 4-6 hours) for moderate pain, and strong opioids such as morphine (starting at 5-15mg every 4 hours), oxycodone (5-10mg every 4-6 hours), or fentanyl patches (25-100mcg/hour) for severe pain [@Example@].
• Adjuvant medications: gabapentinoids (gabapentin 300-1200mg TID or pregabalin 75-300mg BID) for neuropathic pain, corticosteroids (dexamethasone 4-16mg daily) to reduce inflammation and edema, and bisphosphonates (zoledronic acid 4mg IV monthly) or denosumab (120mg SC monthly) to reduce bone pain and prevent skeletal-related events [@Example@].
• Radiation therapy: highly effective, with external beam radiation providing pain relief in 50-80% of patients within 2-4 weeks, and stereotactic body radiotherapy (SBRT) emerging as a promising technique for pain management, allowing for targeted dose escalation while minimizing exposure to adjacent healthy tissues 1.
• Surgical interventions: vertebroplasty, kyphoplasty, or decompressive surgery may be necessary for patients with spinal instability or cord compression, with the goal of achieving stabilization and preventing SRE 1.
• Interventional procedures: nerve blocks, radiofrequency ablation, or intrathecal drug delivery systems can provide targeted pain relief when conventional approaches fail, with cementoplasty and radiofrequency ablation showing significant pain reduction within the first week and a median overall response rate (RR) for pain reduction of 67% and 74% after a median follow-up of 6 months and 12 months, respectively 1. The Spinal Instability Neoplastic Score (SINS) is used to determine the instability risk of spinal metastases, with higher scores indicating the need for intervention, and the Bilsky classification is used to precise the extent of the spinal cord infiltration in case of metastatic epidural spinal cord compression (MESCC) 1. The most recent evidence recommends a single 8-Gy fraction for painful uncomplicated bone metastases, with prophylactic antiemetics and dexamethasone to minimize nausea/vomiting and pain flare 1.

From the FDA Drug Label

The efficacy of pregabalin for the management of neuropathic pain associated with spinal cord injury was established in two double-blind, placebo-controlled, multicenter studies Treatment with pregabalin 150–600 mg/day statistically significantly improved the endpoint weekly mean pain score, and increased the proportion of patients with at least a 30% and 50% reduction in pain score from baseline. The fraction of patients achieving various levels of improvement in pain intensity from baseline to Week 12 is presented in Figure 11 Some patients experienced a decrease in pain as early as week 1, which persisted throughout the study.

Management options for spinal metastasis pain include:

• Pregabalin (PO) 150-600 mg/day, which has been shown to statistically significantly improve the endpoint weekly mean pain score and increase the proportion of patients with at least a 30% and 50% reduction in pain score from baseline 2
• Fentanyl (TD) with a recommended initial dose based on the daily oral morphine dose, and titration as needed to achieve analgesic efficacy 3 Key considerations:
• Pregabalin has been established as effective for neuropathic pain associated with spinal cord injury, but its efficacy for spinal metastasis pain is not directly addressed in the provided drug labels.
• Fentanyl transdermal system dose should be individualized and titrated based on the patient's response to the initial dose, with a recommended initial dose based on the daily oral morphine dose. Note: The provided drug labels do not directly address the management of spinal metastasis pain. The information provided is based on the management of neuropathic pain associated with spinal cord injury and the use of fentanyl transdermal system for pain management.

From the Research

Management Options for Spinal Metastasis Pain

The management of spinal metastasis pain involves a multidisciplinary approach, including medical and radiation oncology, surgery, and rehabilitation 4. Various treatment options are available, including:

• Open surgery
• External beam radiotherapy
• Minimally invasive technologies, such as separation surgery
• Non-operative interventions, such as percutaneous cementoplasty and stereotactic radiosurgery 5
• Radiation therapy, radiosurgery, chemotherapy, and targeted therapies 6

Decision-Making Process

The decision-making process for spinal metastasis treatment requires a multidisciplinary approach, taking into account the patient's overall health, tumor type, and treatment goals 4, 7. Clinical decision aids and prognostic scores have been developed to help facilitate construction of care plans that meet patient goals and expectations 5.

Treatment Modalities

Recent advances in treatment modalities, such as stereotactic radiosurgery and minimally invasive surgical techniques, have reshaped clinical practices concerning patients with spinal metastasis 4. Multidisciplinary management of spinal metastasis using a combination of tumor ablation techniques with vertebral stabilization has been recommended, with significant decreases in visual analog scale scores and low rates of symptomatic complications reported 7.

Role of Imaging

Imaging plays an increasingly important role in disease detection, pre-treatment planning, and assessment of patient outcomes 8. Radiologists should be familiar with imaging algorithms, best practices for surgery and/or radiotherapy, and imaging findings in the post-treatment period that may indicate disease recurrence.

Multidisciplinary Approach

A multidisciplinary approach to patient evaluation, treatment, and follow-up is essential for effective management of spinal metastasis pain 6, 8. This approach should involve close collaboration between spine surgeons, radiation oncologists, radiologists, and oncologists to provide optimal care for patients with spinal metastasis.