A Comprehensive Patient Guide to Diagnosing and Treating Spinal Metastases

Table of Contents

• Introduction: Understanding Spinal Metastases
• Symptoms and Clinical Presentation
• Assessment Scales and Treatment Decision Tools
• Diagnostic Imaging Approaches
• Treatment Strategies and Approaches
• Clinical Implications for Patients
• Study Limitations
• Patient Recommendations
• Source Information

Introduction: Understanding Spinal Metastases

Spinal metastases are much more common than primary spine tumors, affecting a significant number of cancer patients. Research shows that about 6.9-8.6% of patients with generalized cancer develop bone metastases. The skeletal system is the third most frequent location for cancer spread after the lungs and liver.

Although bone metastases indicate advanced cancer, they are sometimes the first detectable sign of cancer. The average time between detecting the primary tumor and the onset of metastasis is 18.9 months. This varies by cancer type - lung cancer metastases appear quickest (around 9 months), while breast and prostate cancer metastases take longer (14.9 and 17.4 months respectively).

The spine is the most frequent site of bone metastasis. Autopsy studies show that 30-70% of cancer patients have spinal metastases. The most common primary cancers that spread to the spine include:

• Breast cancer
• Prostate cancer
• Kidney cancer
• Lung cancer
• Multiple myeloma
• Thyroid cancer

About 18% of patients have metastases in more than one spinal section. Different cancers show preferences for specific spinal areas - lung and breast cancers often metastasize to the thoracic spine, while prostate and colon cancers frequently affect the lumbar region.

Symptoms and Clinical Presentation

Pain is often the first symptom of spinal metastasis, occurring in more than 90% of patients. Researchers identify three main types of pain associated with spinal metastases:

Root pain results from tumor pressure on spinal nerve roots. This pain is sharp, piercing, and radiates to specific skin areas (dermatomes). It may disappear with changes in body position.

Bone pain comes from periosteal stretching, increased pressure within the bone, or inflammatory responses caused by metastasis. This type of pain typically occurs in morning and evening hours, located at the tumor site, and increases with movement.

Mechanical pain results from vertebra damage due to cancer spread, which compromises spinal stability and reduces load resistance.

As the disease progresses, patients may develop limb weakness (paresis), decreased sensation below the level of spinal cord damage, and bladder or bowel dysfunction. Cancer can also lead to chronic or acute spinal cord ischemia (reduced blood flow).

Assessment Scales and Treatment Decision Tools

Treatment decisions require comprehensive assessment using specialized scales that evaluate multiple patient factors. Doctors use these tools to determine the best approach for each individual.

The Karnofsky Scale assesses functional status on a 0-100 point system, where 100 represents perfect health and 0 equals death. Higher scores indicate better quality of life.

The ASA Physical Status Classification evaluates surgical risk on a six-point scale. Patients classified as grade IV-VI are typically not candidates for spinal metastasis surgery.

Neurological assessment scales including the Frankel scale and American Spinal Injury Association Impairment Scale (AIS) evaluate nerve function. Patients classified as groups A and B on the Frankel scale rarely regain walking ability after surgery, while those in groups C and D often show neurological improvement.

The Visual Analogue Scale (VAS) measures pain intensity on a 10-point scale, with 0 being no pain and 10 representing unbearable pain.

Spinal Instability Neoplastic Score (SINS) identifies patients who would benefit from surgical treatment. This scale considers six criteria: metastasis location, mechanical pain, type of bone lesion, spinal alignment changes, vertebral compression fractures, and involvement of posterior vertebral elements. Scores of 0-6 indicate stable spine (no surgery needed unless cord compression), 7-12 suggest impending instability, and 13-18 indicate definite instability requiring surgical consultation.

Other important assessment tools include:

• De Wald score - evaluates cancer advancement stage (I-V)
• Tomita's surgical classification - assesses metastasis extent via MRI images
• Harrington scale - five-stage system assessing bone changes
• Epidural Spinal Cord Compression scale (ESCC) - measures compression severity
• Tokuhashi scale - predicts survival time and guides treatment decisions

These scales help doctors create individualized treatment plans based on specific patient factors including cancer type, metastasis extent, neurological status, and overall health.

Diagnostic Imaging Approaches

Accurate diagnosis requires advanced imaging techniques to identify spinal metastases and plan appropriate treatment.

X-ray examinations can show vertebral damage including compression fractures, dislocations, and collapses. However, changes only become visible on X-rays when 50-75% of bone is already destroyed. The "winking owl sign" visible in posterior-anterior views indicates damage. X-rays remain useful for monitoring metastases and assessing fracture risk due to their ability to show cortical bone.

Magnetic Resonance Imaging (MRI) is the preferred imaging method for metastatic spine changes. MRI shows contrast between water and fat components in bone marrow. Since bone marrow composition changes with age (from 40% fat at birth to 80% in adults), MRI helps distinguish normal age-related changes from cancerous ones.

In osteoblastic metastases (bone-forming), increased cell proliferation raises water content, making these areas appear isointense or hypointense on T1-weighted images compared to surrounding muscle or disc tissue.

Treatment Strategies and Approaches

Treatment of spinal metastases requires a multidisciplinary approach combining various specialists. The primary goals are spinal cord decompression, pain relief, preservation or restoration of neurological function, and spinal stabilization.

Surgical treatment should meet three criteria: release spinal cord and nerve roots, restore normal spinal anatomy, and ensure internal spinal stabilization. Successful surgery enables continuation of other treatments including radiotherapy, chemotherapy, hormone therapy, and targeted molecular therapy.

Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) represent advanced treatment methods that are more effective than conventional external beam radiotherapy. These techniques allow higher radiation doses precisely targeted to the tumor site while sparing surrounding healthy tissue.

Treatment algorithms like NOMS consider four key factors: neurological status (myelopathy and spinal cord compression grade), oncological factors (tumor radiation sensitivity), mechanical factors (spinal stability), and systemic factors (patient's overall condition and procedure tolerance).

Clinical Implications for Patients

This research emphasizes that spinal metastasis treatment requires personalized approaches based on comprehensive assessment. The various scoring systems help doctors predict survival times and determine whether patients are better suited for aggressive surgical treatment, palliative care, or non-surgical approaches.

Patients with better scores on assessment scales (like Karnofsky scores above 70 and Tokuhashi scores of 12-15) typically have predicted survival times exceeding 12 months and may be candidates for radical surgical treatment. Those with intermediate scores (9-11 on Tokuhashi scale) often receive palliative surgery, while patients with lowest scores (0-8) typically receive conservative or palliative care only.

The research confirms that surgical intervention focuses on three main goals: decompressing neural structures, restoring spinal alignment, and providing mechanical stability. Successful treatment directly impacts quality of life and enables patients to continue other cancer treatments.

Study Limitations

While this review comprehensive covers current knowledge about spinal metastases, several limitations should be noted. Some assessment scales were created years ago and may not fully reflect modern treatment capabilities. Each patient presents unique medical history, physical condition, and personal circumstances that cannot be completely captured by standardized scales.

No single scale or treatment paradigm is perfect for all patients. The complex nature of spinal metastases means treatment decisions must be individualized based on multiple factors beyond what any scoring system can capture. Additionally, new treatments and technologies continue to emerge that may change current treatment recommendations.

Patient Recommendations

Based on this comprehensive review, patients with spinal metastases should:

1. Seek comprehensive evaluation at a center with multidisciplinary expertise in spinal oncology
2. Understand assessment scales that doctors use to determine optimal treatment approaches
3. Discuss all treatment options including surgical decompression, stabilization, stereotactic radiosurgery, and conventional radiation
4. Consider second opinions for complex treatment decisions involving multiple specialties
5. Focus on quality of life outcomes when evaluating treatment options
6. Ask about clinical trials investigating new approaches to spinal metastasis treatment
7. Maintain realistic expectations about treatment outcomes based on individual prognostic factors

Early intervention is crucial for preserving neurological function. Patients experiencing back pain, especially those with cancer history, should seek prompt evaluation to detect possible spinal metastases before significant damage occurs.

Source Information

Original Article Title: Holistic Approach to the Diagnosis and Treatment of Patients with Tumor Metastases to the Spine

Authors: Hanna Nowak, Dominika Maria Szwacka, Monika Pater, Wojciech Krzysztof Mrugalski, Michał Grzegorz Milczarek, Magdalena Staniszewska, Roman Jankowski, Anna-Maria Barciszewska

Publication: Cancers 2022, 14(14), 3480

Note: This patient-friendly article is based on peer-reviewed research and maintains all original data, statistics, and clinical findings from the scientific publication.