Approach To Spinal Metastasis

1. Approach to Spinal Metastasis
by
Nawaz Hussain b Mohd Amir
Spine Unit
Dept. of Orthopaedics
HUSM
8th August 2006

2. Introduction
 Bone is a common site for carcinoma metastasis
 Approximately 70% of pts with cancer have
evidence of metastasis at the time of their death
 Spinal Column is the most common location for
osseous sites for metastatic deposits
 Up to 40% of pts with cancer has spinal column
involvement.

3. Introduction
 Not all spinal metastasis lead to neurologic
disorder
 Spinal cord compression from epidural
metastasis occurs in 5-10 % of cancer pts
 10-20% of this will be symptomatic
(25 000 pts a year in US –Klimo and Schmidt-2004)

4.  Metastatic spine disease can involve one
of 3 locations
- Vertebral column – 85% - post. half
- Paravertebral region – 10-15%
- Epidural/subarachnoid/intramedullary
space - < 5%

6.  Intradural metastasis – extremely rare but
there are reported cases
 Multiple level at noncontiguous levels –
10-40%

7. Primary site
Coleman - 1994
 Breast – 73%
 Prostate -68% 80%
 Lung-36%
 Thyroid , kidney , GIT ,endometrium,
cervix,bladder -< 20%
- Klimo and schimdt -2004
- Prostate ,breast, melanoma, lung – 90.5%,74.3%,54.5%,44.9%

8. Primary site
 Frequency of neurologic deficit secondary to epidural
spinal cord compression varies with the site of primary
disease
- Breast – 22%
- Lung - 15%
- Prostate -10%
Some pts present with neurologic dysfunction and
spinal pain without knowing primary site – in old literature
frequency is up to 70% and 50% of them found to be from
lung

9. Approach
 History
i. General / conventional symptoms
- bony pain , back pain ,numbness ,
weakness – bladder / bowel control
- LOA , LOW
ii Specific history
-Breast – past history ,lumps ,pain, similiar family hx
-prostate – past hx , urinary Sx
-lung - past hx , smoking,cough,hemoptysis
- thyroid – past hx, swelling , hyperthyroidism

10.  Physical Examination.
ii. General – general condition
- cachexia, anemia , hydration,
nutritional
vi. Potential primary site –
- breast , prostate, lung ,thyroid ,
abdomen ,etc
- lymph nodes

11. Approach…..
 P/E……
iii. Full neurological examination
motor , sensory…etc.

12. Investigation
 1 . Blood
- Anemia
- thrombocytopenia
- Increase LDH / u.acid / cal. /ALP/
Acid Phophotase(prostate)/ TFT
-Serum markers – CEA , Ca 125 , PSA

13. Ix
 Imaging
 Plain x-ray
- Bone mets can be purely lytic, blastic ,mixed
i. Most metastasis are predominantly lytic
- lung,kidney,breast,GIT,melanoma
ii Blastic – prostate , bronch. carcinoids,bladder,stomach
iii. Mixed – breast ,lung,GIT

14. Plain X-ray
- In cancellous bone lytic lesion remain occult until it
completely destroys trabaculae and reach 2-3 cm in
diameter. Needs 30 – 50 % of destruction.
- In cortical bone – small lytic lesion can de detected
earlier

15.  Plain x-ray
Depends on whether the primary is known or not
I . Primary is known
Asymptomatic – not for skeletal survey
- bone scan is method of choice
- if bone scan positive confine x-ray to
site of localisation
Symptomatic - Localised x-ray , skeletal survey

16.  ii. Primary is unknown
- usually has local symptoms
- local x-ray , skeletal survey
 During follow ups , course of tumour therapy

17. Ix
Imaging
Bone Scan
- Most sensitive diagnostic tool
- But it gives multiple levels of involvement without
clarifying the level
- All cancer pts regardless primary known ,unknown
- Follow ups

18.  Ct scan
-Allows visualization of
i. even small areas of vertebral destruction
ii. Assessment of extent of paravertebral soft tissue
masses
iii. Extent and direction of impingement of spinal cord
by bone debris / tumour
- Limitation – failure to identify second site of mets.
- 10% of pts

19.  MRI
Superior in evaluating
iii. soft tissue mass
iv. Neural elements
v. Multiple level of vertebral involvement
Findings – Hypointense T1 , hyperintense in T2 and
gadolinium enhanced T1

20.  Biopsy
- Most literature suggest some type e.g ct guided
biopsyof biopsy in order to specify correctly the
type of malignancy
- Even in known primary
- However , here the problem of consent limits
the use of this method in establishing diagnosis
due to its invasiveness .

21. Management
 General Mx
 Medical Mx / Radiotherapy Mx
 Surgical Mx
 Pain Mx

22.  General Mx.
- Anemia
- Nutritional Status
- Hydrational status
- Supplements

23.  Medical Mx
i.Chemotherapy
ii.Hormonal
iii Biphosphonate

24.  Chemotherapy
Given as therapeutic and palliative treatment especially in
Breast , lung , Renal cell ca. , prostate(less)
Needs multi disciplinary approach

25.  Hormonal
- Breast , prostate and endometrial ca.
- Endocrine dependant organs.
- Regulate and manipulate regulatory hormones as
anti -tumour therapy

26.  Biphosphonate
- Inhibit osteoclast-mediated resorption
- Induce osteoclast apoptosis
- Standard treatment in hypercalcemia in malignancy
- Reduces metastatic bone pain esp. clodronate and
pamidronate ( Ernst et al-1992 , Coleman et al -1996)
- Recalcification

27.  Radiotherapy
- Pain relief – mode of action not really
understood – reduces tumour bulk,
reduces pain mediator (PG)releasing cells
- Post fixation irradiation
- Prevention of spinal cord compression-
recent vertebral collapse
- Pts with contraindication for surgery

28. Surgical Mx
 Mostly Palliative
Indications
iii. Intractable pain unresponsive to non operative
measures
iv. Obvious spinal instability
v. Clinically significant neural compression from
retropulsed bone or spinal instability
vi. Radioresistant tumours

29. Depends on
iii. Pts tolerability to surgery e.g general
medical condition
iv. Estimated life expectancy

30.  Goals of Surgery
ii. Correct and prevent deformity by
stabilizing deformity
iii. Decompressing neural structures
iv. Open biopsy if primary unknown

31.  Pre-operative prognostic values/scoring
Score = < 5 dies within 3 months
> 9 survives average 12 mths
Surgery = <5 non surgical , > 9 surgical

33. Category iii – grey area , either medical or surgical .
- if there is severe epidural cord compression
non radiosensistive , needs surgery

34. Score
2-3 – wide / marginal for long term survival
4-5 – marginal/intralesional
6-7 – palliative surgery for short term palliation
8-10 – non operative supportive care

35. Surgical approach
 Anterior approach
- modern era
- Predominant area of metastasis
- Does not disturb posterior stability in
presence of the kyphosis
- Pain relief in 80 – 95% of pts
- Neurologic improvement in 75% of pts

36. Surgical approach……
 Post decompressive laminectomy
- old era
- limited value in regaining neurologic
function
- Laminectomy + radiotx no more
effective than radiotx alone.

37.  Anterior –posterior approach
- High grade instability
- Ant and posterior compression
- Contiguous vertebral involvement
- Need for en-bloc resection of tumour

38.  Other approches
-costotransversectomy – thoracic region
-pt unable to tolerate
thoracotomy
-Postolateral approach – cervical / lumbar
region

39.  VERTEBROPLASTY ( deramound 1990)
- Good stabilisation and analgesia to the
diseased vertebra.
- But must have intact cortex
- Used if contraindicated for surgery eg post
irradiated patient

40. Conclusion
 Spine is the most frequent location for skeletal
metastasis
 Mode of treatment and can be chosen by using the
many scoring systems(Tokuhashi , Harrington , Tomita
etc) but it must be tailored according to each patient
 Advances in imaging and instrumentation allowed
improvements in the techniques of excision of tumour
and stabilisation.
 Surgical decision making is a complex issue but the
treatment of spinal mets. remains largely palliative.