eMedicine Specialties > Neurology > Neuro-oncology

Spinal Metastasis and Metastatic Disease to the Spine and Related Structures: Differential Diagnoses & Workup

Author: Victor Tse, MD, PhD, Associate Professor, Department of Neurosurgery, Stanford University Medical Center, Santa Clara Valley Medical Center
Contributor Information and Disclosures

Updated: Mar 31, 2009

Differential Diagnoses

Arteriovenous Malformations
Metastatic Disease to the Brain
Aseptic Meningitis
Neurosarcoidosis
Cervical Spondylosis: Diagnosis and Management
Neurosyphilis
Chronic Inflammatory Demyelinating Polyradiculoneuropathy
Paraneoplastic Encephalomyelitis
Haemophilus Meningitis
Staphylococcal Meningitis
HIV-1 Associated CNS Conditions: Meningitis
Tropical Myeloneuropathies
HIV-1 Associated Neuromuscular Complications (Overview)
Viral Encephalitis
HIV-1 Associated Progressive Polyradiculopathy
Viral Meningitis
Leptomeningeal Carcinomatosis
Meningococcal Meningitis

Other Problems to Be Considered

Back pain
Cervical disk syndromes
Cord infarction or hemorrhage secondary to coagulopathy
Disk herniation
Demyelination
Fat deposition associated with long-term steroid use
Infection of the nerve roots
Leptomeningeal cancer
Necrosis of the cord secondary to radiotherapy
Paraneoplastic myelitis

Workup

Other Tests

  • Diagnostic procedures in evaluation of spinal metastatic disease
    • Thorough metastatic workup is paramount in patients with spinal metastasis. This helps to delineate the nature and the extent of the systemic disease. However, the appropriateness of diagnostic tests depends on the time available. In patients with rapidly progressing symptoms, chest radiography and physical examination is all that is warranted. Plain radiography and, whenever possible, CT of the entire spine should then be performed, followed by MRI with and without contrast enhancement.
    • Plain radiography is used to show erosion of the pedicles or the vertebral body. Owl-eye erosion of the pedicles in the anteroposterior (AP) view of lumbar spine is characteristic of metastatic disease and is observed in 90% of symptomatic patients. However, radiologic findings become apparent only when bone destruction reaches 30-50%. Osteoblastic or osteosclerotic changes are common in prostate cancer and Hodgkin disease; they are occasionally seen in breast cancer and lymphoma.
    • CT scanning is useful in determining the integrity of the vertebral column, especially when surgery is anticipated. CT myelography is used if MRI is not available. CT also allows for an examination of paraspinal soft tissues and paraspinal lymph nodes.
    • Emergency myelography still is used in situations where MRI is not available. The advantage of MRI is its noninvasive nature, whereas myelography allows for cerebrospinal fluid (CSF) sampling. CSF sampling should be deferred if evidence of near-complete or complete spinal block is noted. The risk of neurologic deterioration after myelography is about 14% but less likely than this with C1-2 puncture.
    • With MRI, the sagittal scout image is used for rapid screening of the entire spinal axis and its surrounding soft tissues. MRI is the imaging modality of choice. Contrast-enhanced fat-suppressed images help to differentiate metastasis from degenerative bone marrow. Diffusion-weighted images distinguish metastasis from osteoporotic bone. Osteoporotic fractures are hypointense, and metastases are hyperintense.
  • Bone scanning
    • Bone scans are positive in 60% of patients but they are not specific.
    • Lesions that activate bone metabolism increase technetium-99m uptake.
    • Nuclear studies are useful to determine cancer burden and are effective in scanning the entire axial and appendicular skeleton. The use of single photon emission CT (SPECT) and positron emission tomography (PET)–CT allow for rapid screening and staging of systemic disease. In many ways, this PET-CT is a standard modality to stage systemic disease and tumor burden, and it is extremely useful to guide the aggressiveness of surgical management of metastatic disease to the spine.

More on Spinal Metastasis and Metastatic Disease to the Spine and Related Structures

Overview: Spinal Metastasis and Metastatic Disease to the Spine and Related Structures
Differential Diagnoses & Workup: Spinal Metastasis and Metastatic Disease to the Spine and Related Structures
Treatment & Medication: Spinal Metastasis and Metastatic Disease to the Spine and Related Structures
Follow-up: Spinal Metastasis and Metastatic Disease to the Spine and Related Structures
Multimedia: Spinal Metastasis and Metastatic Disease to the Spine and Related Structures
References
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References

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Further Reading

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Keywords

carcinomatous meningitis, spinal metastasis, cancer, cancer in the spine, spinal metastatic disease, cancer spread, systemic cancer, intradural extramedullary seeding of cancer, intramedullary seeding of cancer

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Contributor Information and Disclosures

Author

Victor Tse, MD, PhD, Associate Professor, Department of Neurosurgery, Stanford University Medical Center, Santa Clara Valley Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Amy A Pruitt, MD, Associate Professor of Neurology, University of Pennsylvania; Attending Neurologist, Hospital of the University of Pennsylvania
Amy A Pruitt, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge Kattah, MD, Head, Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria
Jorge Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and New York Academy of Sciences
Disclosure: Biogen Honoraria Consulting; Bayer Corporation Honoraria Consulting

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Stephen A Berman, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

 
 
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