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Spinal Metastasis

  • Author: Victor Tse, MD, PhD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
 
Updated: Mar 31, 2014
 

Background

Spinal metastasis is common in patients with cancer. The spine is the third most common site for cancer cells to metastasis, following the lung and the liver. Approximately 5-30% of patients with systemic cancer will have spinal metastasis; some studies have estimated over 30-70% of patients with a primary tumor have spinal metastatic disease at autopsy. Spinal metastases are slightly more common in men than in women and in adults aged 40-65 years than in others. Fortunately, only 10% of these patients are symptomatic, and approximately 94-98% of those patients present with epidural and/or vertebral involvement. Intradural extramedullary and intramedullary seeding of systemic cancer is unusual; they account for 5-6% and 0.5-1% of spinal metastases, respectively.

Metastatic disease to the neuraxis other than the brain parenchyma and the spinal column is uncommon. The incidence of cancer cells invading the leptomeninges is about 8-13%. In autopsy studies, the rate has been estimated to be 25%.

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Pathophysiology

Spread from primary tumors is mainly by the arterial route. Retrograde spread through the Batson plexus during Valsalva maneuver is postulated. Direct invasion through the intervertebral foramina can also occur. Besides the mass effect, an epidural mass can cause cord distortion, resulting in demyelination or axonal destruction. Vascular compromise produces venous congestion and vasogenic edema of the spinal cord, resulting in venous infarction and hemorrhage.

About 70% of symptomatic lesions are found in the thoracic region of the spine, particularly at the level of T4-T7. Of the remainder, 20% are found in the lumbar region and 10% are found in the cervical spine. More than 50% of patients with spinal metastasis have several levels of involvement. About 10-38% of patients have involvement of several noncontiguous segments. Intramural and intramedullary metastases are not as common as those of the vertebral body and the epidural space. Isolated epidural involvement accounts for less than 10% of cases; it is particularly common in lymphoma and renal cell carcinoma. Most of the lesions are localized at the anterior portion of the vertebral body (60%). In 30% of cases, the lesion infiltrates the pedicle or lamina. A few patients have disease in both posterior and anterior parts of the spine.

Primary sources of spinal metastatic disease include the following:

  • Lung - 31%
  • Breast - 24%
  • GI tract - 9%
  • Prostate - 8%
  • Lymphoma - 6%
  • Melanoma - 4%
  • Unknown - 2%
  • Kidney - 1%
  • Others including multiple myeloma - 13%
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Epidemiology

Mortality/Morbidity

See the list below:

  • Median survival of patients with spinal metastatic disease is 10 months.
  • The morbidity of spinal metastatic disease is important, especially in patients with paralysis and/or bowel and bladder involvement. The latter compromises the quality of life of patients with cancer and puts an additional burden on their caregivers. Cord compression is normally seen as preterminal event. Median survival at that stage is about 3 months.
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Contributor Information and Disclosures
Author

Victor Tse, MD, PhD Associate Professor, Department of Neurosurgery, Stanford University Medical Center; Neurosurgeon, Kaiser Neuroscience

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jorge C Kattah, MD Head, Associate Program Director, Professor, Department of Neurology, University of Illinois College of Medicine at Peoria

Jorge C Kattah, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, Phi Beta Kappa

Disclosure: Nothing to disclose.

References
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  2. Wibmer C, Leithner A, Hofmann G, Clar H, Kapitan M, Berghold A, et al. Survival analysis of 254 patients after manifestation of spinal metastases: evaluation of seven preoperative scoring systems. Spine (Phila Pa 1976). 2011 Nov 1. 36(23):1977-86. [Medline].

  3. Dwright et al. Dwright et al. Journal of Neurosurgery Spine. 2012. 17:11-8.

  4. Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010 Oct 15. 35(22):E1221-9. [Medline].

  5. Patil CG, Lad SP, Santarelli J, Boakye M. National inpatient complications and outcomes after surgery for spinal metastasis from 1993-2002. Cancer. 2007 Aug 1. 110(3):625-30. [Medline].

  6. Ibrahim A, Crockard A, Antonietti P, Boriani S, Bünger C, Gasbarrini A, et al. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. J Neurosurg Spine. 2008 Mar. 8(3):271-8. [Medline].

  7. Wilson DA, Fusco DJ, Uschold TD, Spetzler RF, Chang SW. Survival and Functional Outcome After Surgical Resection of Intramedullary Spinal Cord Metastases. World Neurosurg. 2011 Nov 7. [Medline].

  8. Ahmed KA, Stauder MC, Miller RC, Bauer HJ, Rose PS, Olivier KR, et al. Stereotactic Body Radiation Therapy in Spinal Metastases. Int J Radiat Oncol Biol Phys. 2012 Feb 11. [Medline].

  9. Boehling NS, Grosshans DR, Allen PK, McAleer MF, Burton AW, Azeem S, et al. Vertebral compression fracture risk after stereotactic body radiotherapy for spinal metastases. J Neurosurg Spine. 2012 Jan 6. [Medline].

  10. Wang XS, Rhines LD, Shiu AS, Yang JN, Selek U, Gning I, et al. Stereotactic body radiation therapy for management of spinal metastases in patients without spinal cord compression: a phase 1-2 trial. Lancet Oncol. 2012 Jan 26. [Medline].

  11. Weitao Y, Qiqing C, Songtao G, Jiaqiang W. Open vertebroplasty in the treatment of spinal metastatic disease. Clin Neurol Neurosurg. 2011 Nov 14. [Medline].

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