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Page 1: Metastases of spine


Dr. Sushil Paudel

Page 2: Metastases of spine

Metastatic tumour - most common malignancy of bone

Spine - most common site of osseous metastases

5-10% of the patients with cancer develop spine metastases*

All age groups with highest age incidence in between 40 and 65 years

Male:Female – 3:2

*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethesda

Page 3: Metastases of spine

LOCATION◦ Thoracic spine (60-

80%)◦ Lumbar spine (15-

30%)◦ Cervical spine (<10%)

Page 4: Metastases of spine

PRIMARY*◦ Unknown(33%)◦ Breast (21%)◦ Lung (14%)◦ Prostate(8%)◦ Gastrointestinal (5%)◦ Thyroid (3%)

*Ries LAG, Melbert D, Krapcho M, et al, eds. SEER Cancer Statistics Review,1975–2005. National Cancer Institute. Bethesda

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Basis of anatomic location* Intradural - 5%

◦ Intramedullary◦ Extramedullary – tertiary

drop metastases

Extradural - 95%◦ Pure epidural – rare◦ Arising from the vertebrae -

most frequent

*Perrin RG, Laxton AW. Metastatic spine disease:epidemiology, pathophysiology, and evaluationof patients. Neurosurg Clin N Am 2004;15:365–373

Intramedullary extradural metastases entrapped in cauda equina

Page 6: Metastases of spine

Metastatic properties of primary neoplasia Anatomic properties of the host organism Biologic properties of the skeletal host

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Posterior half of the body is seeded first, anterior half, pedicles and lateral masses are involved later

Local spread to adjacent vertebra Spread to epidural space Induce osteoblastic or lytic lesions, diffuse

osteopenia or variable combination Replacement of marrow tissue with

neoplasm, progressive collapse and finally spinal instability

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Pain – 85%◦ Constant and

localised◦ Radicular◦ Axial

Spinal deformity Neurologic deficit Constitutional


RED FLAG features– Gradual onset, progressive, constant, night time or recumbency pain and axial pain exaberated by movement in all directions

Page 9: Metastases of spine

History Physical examination Laboratory studies Imaging studies

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HISTORY◦ Nature of patient’s symptoms and their onset◦ Exposure to possible carcinogens◦ Family history◦ Review of other systems

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PHYSICAL EXAMINATION◦ Comprehensive◦ Should palpate for

masses diagnostic of a primary breast, thyroid, prostate, or rectal carcinoma

Page 12: Metastases of spine

LABORATORY STUDIES◦ Complete blood counts◦ Serum chemistry◦ ESR◦ Serum and urine protein

electrophoresis◦ Serum tumour markers-

PSA, CEA, CA 19-9, AFP◦ Mammography◦ Bone marrow biopsy

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IMAGING STUDIES Plain radiographs Bone scan CT scan of chest,

abdomen, pelvis and of the suspicious area

MRI PET scan

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History and physical examination

Local plain films, chest radiographsand Laboratory tests

Suspicious or no lesion

Bone scan

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Bone scan

Polyostotic Monostotic

CT scan/MR imaging Perform biopsy

Impending fracture

No impending fracture

Perform biopsy and stabilise

Observe, radiate or perform biopsy

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Primary sarcomaMetastatic carcinoma

Refer to sarcoma surgeon

Renal or thyroid primary

Non Renal or thyroid primary

Treat as indicated

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History and physical examinationChest radiographs and Laboratory tests

MyelomaPrimary not identified

Primary identified

Stage and as indicated

Bone scan, CT scan of chest, abdomen

and pelvis

Skeletal survey; Refer to medical


Page 18: Metastases of spine

Bone scan; CT scan of chest, abdomen and pelvis

Primary identified

Solitary lesion and primary

not identified

Multiple bone lesions and Primary n0t identified

Assume sarcoma;Refer to

orthopaedic oncologist

Perform biopsy on most appropriate


Stage and treat as


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Diagnostic imaging


Page 20: Metastases of spine

PLAIN RADIOGRAPHS◦ Location◦ Pattern of bone destruction◦ Vertebral collapse◦ Winking owl sign ◦ Difficult to detect early lesions

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BONE SCAN◦ Superior sensitivity◦ Extent of dissemination◦ Define the most accessible lesion

to biopsy in cases of unknown primary


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COMPUTED TOMOGRAPHY◦ Improved specificity ◦ Sensitive to alterations in

bone mineralisation◦ Osseous details ◦ Evaluation of cortical


Page 23: Metastases of spine

MAGNETIC RESONANCE IMAGING◦ Superior sensitivity and specificity◦ Method of choice to evaluate spine ◦ Define the intramedullary, intradural and extramedullary lesions ◦ Extent of the lesion ◦ Differentiation from other

pathologies such as infection and osteoporotic ◦ Fat suppression and Gadolinium

enhancement to improve the delineation

Page 24: Metastases of spine

POSITRON EMISSION TOMOGRAPHY◦ Uses Flourine-18-Flouro deoxy

glucose◦ MRgIc calculation by Patlak

analysis in ROI◦ Detection of primary and

metastatic tumours◦ Recurrences of tumour◦ Differentiation of osteoporotic

VCF from pathologic VCF’s

Page 25: Metastases of spine

Tissue diagnosis of lesion guides the treatment

FNAC or needle biopsy Core biopsy Incisional biopsy Excisional biopsy

Page 26: Metastases of spine


Posterior cervical

C 1 – 3= Transoral

Sub axial cervical

Anterior or posterior to sternocleidomastoid

Thoracic and Lumbar

Transpedicular or Postero lateral

Sacral Posterolateral

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Page 28: Metastases of spine

LUNG CANCER Metastatic stage IV – dismal

prognosis, median survival < 6 months

◦ Small cell LC Chemotherapy Radiotherpy

◦ Non small cell LC Combined chemo and

radiotherapy Resection of the tumour with


Page 29: Metastases of spine

PROSTATE CANCER Hormone withdrawal –

bilateral orchidectomies or androgen deprivation (LHRH agonists, flutamide etc)

Radiation therapy Chemotherapy Surgery Average survival around

12 months

Page 30: Metastases of spine

BREAST CANCER Metastatic cancer –

median survival 3 years Chemotherapy Hormonal therapy –

Tamoxifen Bisphosphonates

Page 31: Metastases of spine

THYROID CANCER Thyroidectomy followed by

iodine – 131 at therapeutic doses

Palliative radiotherapy Overall 10 year survival

rate – 35%

Page 32: Metastases of spine

RENAL CELL CARCINOMA Metastatic – median

survival 6 to 9 months Combined

chemo/immune therapy Radiotherapy Pre operative

Embolisation and Surgery

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Page 34: Metastases of spine

Early 1900’ s – surgical treatment such as decompressive laminectomy

1953 - first patient was treated with a linear accelerator

1980’ s – advent of spinal implants Recent developments - Intensity-modulated

radiation therapy (IMRT), stereotactic radiosurgery, and stereotactic radiotherapy

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Life expectancy Biopsy – Histology to predict the response

to non operative management Stability Clinical presentation – Pain and Neurological


Page 36: Metastases of spine

Analgesic treatment Physical therapy and bracing Bisphosphonates Vertebroplasty or Kyphoplasty Radiofrequency ablation Radiation therapy Surgical stabilization in patients with life

expectancy of more than 3 months


Page 37: Metastases of spine

ANALGESIC TREATMENT Three Step model of analgesia

◦ NSAIDS◦ Short acting opioids◦ Pure opioid agonists

Disease-modifying therapies, coanalgesic/adjuvant administration, and interventional strategies (cognitive, behavioral, physiatric etc)

Page 38: Metastases of spine

BISPHOSPHONATES Treat hypercalcemia Potent inhibitors of normal and

pathological bone resorption. Antiangiogenic effects and

Antitumoral activity*PHYSICAL THERAPY AND BRACING Orthoses Bracing

*Diel IJ, Solomayer EF, Costa SD, et al: Reduction in new metastases in breast cancer with adjuvant clodronate treatment. N Engl J Med 339:357–363, 1998

Page 39: Metastases of spine

Emergency whole spine MRI


Radiosensitivity+ -

Unstable spine




Neurological deficit<24 hrs

Surgical candidate




Surgical decompression and stabilization followed by



Page 40: Metastases of spine

CORTICOSTEROIDS Should be prescribed in

all patients presenting with neurological deficit◦ High dose

dexamethasone◦ Standard dose ◦ Methyl prednisolone

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General indications

Page 42: Metastases of spine

EXTERNAL BEAM RADIOTHERAPY◦ Pain-Single fraction radiotherapy◦ Neurological deficit-short course

and long course regimens Intra operative brachytherapy Cobalt-60 teletherapy Injectable radioisotopes Megavoltage therapy Proton/neutron/electron


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IMRT, STEREOTACTIC RADIOSURGERY AND STEREO TACTIC RADIOTHERAPY*◦ Deliver high doses safely◦ Possible to irradiate spine without affecting spinal


*De Salles AA, Pedroso AG, Medin P, Agazaryan N, Solberg T,Cabatan-Awang C, et al: Spinal lesions treated with Novalisshaped beam intensity-modulated radiosurgery and stereotacticradiotherapy. J Neurosurg 101 (3 Suppl):435–440, 2004

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(A) Target planning image. The thick dark pink line surrounds the target volume. The thick dark green line represents the thecal sac (main organ at risk). The remaining lines represent isodose lines. (B) Dose-volume histograms demonstrating steep falloff of radiation, with high doses being applied to the lesion and a low volume of the thecal sac being exposed to significant dose.

Page 45: Metastases of spine


153 and Rhenium – 186◦ Affinity to osteoblastic bone ◦ Local antitumour activity

and analgesic affect*

*Serafini AN: Systemic metabolic radiotherapy with samarium-153 EDTMP for the treatment of painful bone metastasis. Q J Nucl Med 45:91–99, 2001

Page 46: Metastases of spine

Injection of PMMA into the involved vertebral body under fluoroscopic guidance.

Reinforcement of the bone and stabilization of anterior column relieves pain

PMMA – Anti tumour activity

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MECHANISM OF PAIN RELIEF*◦ Stabilization of microfractures◦ Reduction of mechanical forces ◦ Destruction of the nerve terminals by the

cytotoxicity of PMMA

*Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996;200:525–530

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Percutaneous introduction of a KyphX balloon Inflated to reduce the fracture and deflation Void filled with PMMA

Page 49: Metastases of spine

Low extravasation rate

Pain relief equivalent to that of vertebroplasty

Can restore the lost vertebral height

Can correct the sagital balance

Can use more viscous cement

Increases the vertebral body strength

Increases the vertebral body stability

Can provide tissue for diagnosis


Page 50: Metastases of spine

Uses thermal energy to destroy the tumour cells

Combined treatment with vertebroplasty*

*Schaefer O, Lohrmann C, Markmiller M, Uhrmeister P, Langer M. Technical innovation: combined treatment of a spinal metastasis with radiofrequency heat ablation and vertebroplasty. Am J Roent 2003;180:1075–1077

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Radiofrequency Ablation Probe at T9Anterior-posterior (a) and lateral (b) fluoroscopic images of the radiofrequency ablation probe in the T9 vertebral body

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Radiofrequency ablation combined with vertebroplasty/kyphoplasty

Tumour debulking combined with VB augmentation ◦ Ablation using LITT (laser induced thermotherapy)

before cement placement *

*Ahn H, Mousavi P, Chin L, et al. The effect of pre-vertebroplasty tumor ablation using laser-induced thermotherapy on biomechanical stability and cement fill in the metastatic spine. Eur Spine J 2007;16:1171–78. Epub 2007 Apr 20

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A 71-year-old woman with undifferentiated cancer and a lesion at L4. B and C, A void is created in the vertebral body by debulking the spinal tumor using the plasma radio-frequency– based wand before vertebral body augmentation with bone cement. D–F, Axial (D and E) and sagittal (F) views by using MR imaging show excellent anterior placement

Page 54: Metastases of spine

Vertebral body augmentation combined with hardware*◦ Short segment pedicle screw fixation combined

with vertebroplasty/kyphoplasty in lieu of traditional long segment fusion

*Cho DY, Lee WY, Sheu PC. Treatment of thoracolumbar burst fractures with polymethyl methacrylate vertebroplasty and short-segment pedicle screw fixation.Neurosurgery 2003;53:1354–60, discussion 1360-61

Page 55: Metastases of spine

GOALS◦ Obtaining tissue in case

of an unknown diagnosis

◦ Relief of neurologic symptoms by decompression

◦ Relief of pain by stabilization and reconstruction of the spinal column

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Pre operative for vascular metastatic lesions such as renal cell, thyroid carcinoma, squamous and adenocarcinomas of lung

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Resection Decompression Reconstruction and stabilization

Page 58: Metastases of spine

Radiation- and chemotherapy-resistant tumors (e.g., squamous and renal


Acute or progressive spinal cord compression

Recurrent tumor in patients who have already received maximal doses of


Pain associated with collapse in vertebral height of greater than 50%, a 50% kyphotic

deformity, or more than 70% of the vertebral body destroyed

Isolated metastases in which durable remissions can potentially be achieved (e.g.,

renal, breast, thyroid)

Impending fracture

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SCORING SYSTEMS Karnofsky score estimates a patient's ability

to carry out normal activities, work, and care for themselves.

The Tokuhashi index◦ Karnofsky index◦ Neurologic status◦ Metastatic disease◦ Cancer type◦ Surgical resectability.

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Total Tokuhashi score Life expectancy

   0–4    <3 mo

   5–8    <6 mo

   9–12    >6 mo

Tokuhashi score is developed as an assessment tool to select the most suitable surgical procedure with respect to predicted prognosis

Page 64: Metastases of spine

Tomita classification- built on Enneking oncological system

Description of the affected site Metastatic extent

◦ Intracompartmental(1-3)◦ Extracompartmental(4-7)

1. Vertebral body

2. One or both pedicles

3. Lamina and spinous process

4. Epidural canal

5. Paravertebral area

6. Adjacent vertebra

7. Skip lesions

Page 65: Metastases of spine


score Life expectancy


classification Surgical procedure (all receive radiation)

0–4 <3 mo 1–7 Laminectomy and stabilization

5–8 3–6 mo 1–7 Posterior decompression, stabilization, and


9–12 >6 mo 1–3 En bloc with vertebrectomy and 360-degree


4–6 Intralesional vertebrectomy and 360-degree


7 Posterior decompression and stabilization

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Location of the tumour Spinal instability Neurological status

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James weinstein model

Zones IB to IVB – Extraosseous extensions of the tumour beyond cortical boneZones IC to IVC - Associated regional or distant metastases

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• Zones I and II lesions - posterior or posterolateral surgical approach Zone III lesions – anterior surgical approach Zone IV lesions - combined anterior and

posterior approach

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Upper cervical Transoral, Extraoral, Extreme lateral


Lower cervical Southwick Robinson Midline

Cervicothoracic Sternal splitting, Low costotransversectomy


Thoracic ThoracotomyCostotranversectomy


Thoracolumbar 11th rib extrapleural retroperitoneal


Lumbar RetroperitonealTransabdominal


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RECONSTRUCTION AND STABILIZATION◦ Anterior◦ PosteriorSubclassified according to the level

Page 71: Metastases of spine

THORACIC SPINE Disease involving vertebral body at 1 or 2

levels- Transthoracic vertebrectomy and anterior reconstruction

Single stage posterolateral decompression and stabilisation – patients with specific contraindication to thoracotomy

Significant kyphosis with VB collapse, disease involving DL junction – posterior stabilization with anterior reconstruction

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Inclusion of significant portion of chest wall in tumour resection – posterior stabilization to prevent the risk of kyphoscoliosis

Cases of tumours involving VB posterior elements and chest wall – combined approach for resection and VB reconstruction, anterior and posterior stabilization

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INSTRUMENTATION Fixation using rods and screws Vertebral body reconstruction – metal cage,

cement, ceramic spacer, or grafts( autologous or allograft)

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57 year old female of lung carcinoma with metastases D5 underwent circumferential tumor resection and simultaneous anterior and posterior reconstruction by combined approach.

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LUMBAR SPINE Standard retroperitoneal approach –

excellent exposure Single level L1-3 disease – vertebrectomy

and anterior reconstruction Disease limited to L5 – posterolateral

decompression and stabilisation Multilevel disease – palliative posterolateral


Page 76: Metastases of spine

LUMBOSACRAL JUNCTION AND SACRUM Resection and reconstruction by pedicle screws

and rods by modified Galveston technique

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Cure is not the goal

Multidisciplinary approach

Surgery vs Radiotherapy*

Management often not clear cut

Patchell RA, Tibbs PA, Regine WF et al. Direct decompressivesurgical resection in the treatment of spinal cordcompression caused by metastatic cancer: a randomisedtrial. Lancet 2005;366:643-8.

Page 78: Metastases of spine

Adult and Pediatric spine, 3rd edition Spinal Extradural metastases; Review of

current treatment options.CA Cancer J Clin 2008;58;245-259

Spinal instability and deformity due to neoplastic conditions.Neurosurg Focus 14 (1):Article 8, 2003

Bone metastases.Tumors

Page 79: Metastases of spine