What are the management options for spinal metastasis?

Management Options for Spinal Metastases

The optimal management of spinal metastases requires a multidisciplinary approach with treatment selection based on the patient's estimated survival, spinal stability, and expected treatment outcomes, with radiotherapy being the first-line treatment for most symptomatic cases. 1

Initial Assessment and Diagnosis

When spinal metastases are suspected, prompt diagnosis is critical:

• Warning symptoms requiring urgent evaluation:

  • New/increasing severe back or neck pain
  • Pain between shoulder blades
  • Back pain when lying down that improves when sitting up
  • Radiating pain to stomach, chest, arms, or legs
  • Decreased strength in extremities
  • Numbness or tingling
  • Difficulty walking 1

• Diagnostic imaging:

  • MRI of the full spinal column is the first-choice imaging modality
  • Timing depends on symptoms:
    • Within 12 hours if suspected spinal cord compression
    • Within 1 week for unilateral radicular pain
    • Within 2 weeks for local back pain only 1

Treatment Selection Algorithm

First-Line Treatment: Radiotherapy

External beam radiation therapy is recommended as first-line treatment for pain due to bone metastases (Grade 1A). 1

• Conventional radiotherapy:

  • Single fraction of 8 Gy is equally effective for immediate pain relief and more cost-effective than higher fractionated doses 1
  • Complete pain response rates are limited (10-20%) 2

• Stereotactic body radiotherapy (SBRT):

  • Superior complete response rates for pain (35% vs 14% with conventional RT) 2
  • Recommended dose: 24 Gy in two daily fractions 2
  • Provides 90% local control at 1 year for de novo cases 1
  • For previously irradiated spinal metastases, SBRT offers 76% local control at 1 year 1

Adjunctive Treatments

• Bisphosphonates:

  • Recommended in addition to external beam radiation for pain relief (Grade 1A) 1
  • Zoledronic acid is effective for preventing skeletal-related events 3

• Vertebral augmentation procedures:

  • Recommended for painful vertebral compression fractures (Grade 1A) 1
  • Kyphoplasty provides significant improvement in back-specific functional status 1

Surgical Intervention

Surgery is indicated in the following scenarios:

1. Spinal instability 1
2. Recurrence/progression of pain and/or neurological deficits after radiotherapy 1
3. Neurological deterioration during radiotherapy and corticosteroid treatment 1
4. Pathologic fracture risk: Surgical fixation for lytic lesions involving >50% of the cortex in weight-bearing bones with expected survival >4 weeks 1

Special Considerations

Reirradiation

• For previously irradiated spinal metastases, SBRT is safe and effective with:
  • 76% local control at 1 year
  • 65-81% improvement in pain scores
  • Low risk of complications (vertebral fracture 12%, radiation myelopathy 1.2%) 1

Systemic Therapy

• Primary treatment if high chance of response (e.g., multiple myeloma, some lymphomas) 1
• Should be integrated with local therapies for optimal outcomes

Potential Complications and Management

• Vertebral compression fractures:

  • Occur in 9.4% of patients after SBRT 1
  • Vertebral augmentation procedures (kyphoplasty) recommended for symptomatic fractures 1

• Spinal cord injury:

  • Rare with modern techniques (0.2% with SBRT) 1
  • Requires careful treatment planning and quality assurance

Emerging Approaches

• Minimally invasive surgery:

  • Separation surgery combined with SBRT is emerging as an effective approach for patients with epidural disease 4

• Percutaneous interventions:

  • Cementoplasty for painful lesions without neurological compromise 4

The management of spinal metastases continues to evolve with technological advances in both surgical and radiation techniques. Treatment decisions should be made through multidisciplinary tumor boards to optimize outcomes while considering the patient's overall disease burden, performance status, and life expectancy.