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Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management

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Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management Review Article Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management Abstract Peter S. Rose, MD Spinal metastases are found in most patients who die of cancer. Jacob M. Buchowski, MD, MS The number of patients with symptomatic spinal metastases likely will increase as therapy for the primary disease improves and as cardiovascular mortality decreases. Understanding the epidemiology of metastatic spine disease and its presentation is essential to developing a diagnostic strategy. Treatment may involve chemotherapy, corticosteroids, radiotherapy, surgery, and/or percutaneous procedures (eg, vertebroplasty, kyphoplasty). A rational treatment plan can help improve quality of life, preserve neurologic function, and prolong survival. pinal metastases can present as a with metastatic disease as the result Sprogression of known cancer or as of new treatment modalities will a primary malignancy. They are a likely result in increased incidence of From the Department of source of considerable morbidity in pa- spinal metastases. Orthopaedic Surgery, Mayo Clinic, Rochester, MN (Dr. Rose), and the tients with disseminated malignancies. The skeletal system is the third Department of Orthopaedic Surgery, Early diagnosis is essential in reducing most common organ affected by Washington University, St. Louis, pain, improving or preserving neuro- metastatic cancer, after the lungs and MO (Dr. Buchowski). logic function, and maximizing quality the liver. As many as 70% of patients Dr. Rose or an immediate family of life.1 Spinal metastases are catego- who die of cancer have been shown member serves as a board member, rized as intradural or extradural. Ex- on autopsy to have spinal metasta- owner, officer, or committee member ≤ of the Scoliosis Research Society, tradural lesions account for 90% to ses, and 14% exhibit clinically 2,3 Musculoskeletal Tumor Society, 95% of spinal metastases. Careful symptomatic disease before death. In American Academy of Orthopaedic physical examination and imaging the United States, >20,000 patients Surgeons, and Minnesota studies (eg, radiography, CT, MRI) present with metastatic epidural spi- Orthopaedic Society. Dr. Buchowski 5,6 or an immediate family member aid in making the diagnosis. Treat- nal cord compression annually. serves as a board member, owner, ment must be individualized to each Breast, prostate, lung, renal, and officer, or committee member of the patient and may include nonsurgical hematopoietic tumors are most likely American Academy of Orthopaedic or palliative measures (eg, cortico- to metastasize to the spine. The tho- Surgeons, the North American Spine Society, the Scoliosis Research steroids, radiotherapy) or interven- racic spine is most commonly in- Society, and the Spine Arthroplasty tional treatments (eg, surgery, verte- volved in metastatic disease, possibly Society; and is a member of a broplasty, kyphoplasty). because it contains the greatest vol- speakers’ bureau or has made paid presentations on behalf of and ume of bone marrow for receiving 7 serves as a paid consultant to or is metastatic deposits. an employee of Stryker. Epidemiology J Am Acad Orthop Surg 2011;19: Cancer is the second leading cause of 37-48 Presentation death in the United States, with Copyright 2011 by the American >550,000 cancer-related deaths each Pain is the most common symptom Academy of Orthopaedic Surgeons. year.4 Prolonged survival in patients in approximately 90% of patients January 2011, Vol 19, No 1 37 Metastatic Disease in the Thoracic and Lumbar Spine: Evaluation and Management Table 1 metastatic cancer who presents with spinal metastases requires further Neurologic Impairment Scales9,10 evaluation prior to treatment. Repeat Scale Grade Deficit Below the Level of the Lesion oncologic staging studies are needed, ASIA A Complete: no motor or sensory function including CT scan of the chest, abdo- B Incomplete: sensory function but no motor function men, and pelvis as well as a total C Incomplete: some motor function; most muscle groups body scan (eg, bone, positron emis- grade <3 sion tomography). Typically, biopsy D Incomplete: some motor function; most muscle groups is done to confirm the initial metas- grade ≥3 tasis. Staging studies often reveal E Normal motor and sensory function other lesions that are technically eas- Frankel A Complete motor and sensory loss ier and safer to biopsy than vertebral B Complete motor loss; incomplete sensory loss lesions. For the patient with cancer, C Sensory function useless; some motor function; no the initial diagnosis of metastatic dis- functional strength ease carries significant treatment, D Sensory function useful; weak but useful motor function prognostic, and emotional weight. E Normal motor and sensory function Although restaging and biopsy may seem tedious to the patient, they are ASIA = American Spinal Injury Association essential in determining a treatment plan. with metastatic spine disease.8 Pain is recognition and treatment. Patients with no prior diagnosis of often poorly characterized, and it Compression fractures are com- cancer may present with vertebral le- may be difficult to distinguish from mon in patients with metastatic dis- sions. Spinal metastases are the ini- more typical causes of back pain. ease of the spine, and patient history tial manifestation of malignancy in However, progressive and unrelent- and/or imaging studies typically are approximately 20% of patients who 12 ing pain that is nonmechanical in na- indicative of the presence of a malig- present with vertebral metastases. ture and is present at night is nant lesion. For example, unrecog- The most common histologies that strongly indicative of malignant eti- nized cancer is rare in patients who present in this manner are carcinoma ology. undergo kyphoplasty with biopsy for of unknown origin, carcinoma of the Neurologic signs and symptoms presumed osteoporotic fracture. In lung, multiple myeloma, and lym- are frequently present, but they our experience, metastatic disease in- phoma. An established diagnostic rarely precede axial pain. Eccentri- volving the thoracic and lumbar strategy is required for these pa- cally located tumors may cause rapid spine rarely presents with frankly tients. In a prospective study, biopsy onset of radiculopathy, and neural displaced fractures, whereas lesions alone failed to identify the primary compression resulting from epidural in the cervical spine are more likely tumor in two thirds of patients with 13 extension or fracture can produce to present with such fracture. these histologies. Using a protocol myelopathy or cauda equina syn- that included history and physical drome. Few patients initially present examination, routine laboratory with frank quadriplegia or paraple- Diagnostic Approach studies, technetium Tc-99m phos- gia, but many demonstrate subtle ob- phonate whole-body bone scintigra- jective neurologic deficit that can be Patients who present with spinal me- phy, and plain radiography as well as measured with the American Spinal tastases have either known meta- CT of the chest, abdomen, and pel- Injury Association (ASIA) impair- static disease, history of malignancy vis, Rougraff et al13 identified the ment scale or the Frankel scale9,10 without prior metastases, or no prior primary site of disease in 85% of pa- (Table 1). The median Frankel score diagnosis of cancer. In patients with tients who presented with skeletal in patients with metastatic spine le- established metastatic disease who metastatic disease of unknown ori- sions is D (ie, decreased sensory present with typical imaging find- gin. The addition of biopsy identified function and decreased but useful ings, treatment generally proceeds the diagnosis in an additional 8% of motor function).11 These early neuro- without biopsy unless histologic patients. Many patients without a logic deficits are often mistakenly at- evaluation is expected to affect treat- prior cancer diagnosis who present tributed to other causes (eg, medica- ment decisions. in this manner do not require biopsy. tion side effects), which delays The patient with a history of non- For those who do require biopsy, it 38 Journal of the American Academy of Orthopaedic Surgeons Peter S. Rose, MD, and Jacob M. Buchowski, MD, MS may be possible to obtain a specimen nificant noncontiguous metastases,15 logic signs and symptoms—that in- at a site that is safer for the patient and an unknown number may have creases with axial or rotational load- than the spine. Proper evaluation is undiagnosed intracranial lesions. ing is suggestive of mechanical needed before performing biopsy of Careful assessment of motor insufficiency and local instability. In- any lesion. strength, sensory levels, propriocep- tractable mechanical pain is a strong Image-guided biopsy has sup- tion, and reflexes is critical in guid- indication for surgery in many pa- planted open surgical biopsy as the ing initial management. These find- tients with cancer. first-line invasive tool for the evalua- ings are used later in the evaluation Assessment of overall health status tion of patients with spinal lesions. of the level of response or deteriora- and burden of disease is important in Image-guided biopsy using a large- tion during treatment. New or ab- selecting a treatment modality. A bore needle can be safely performed normal clinical findings (eg, weak- careful approach to treatment is re- in an outpatient setting with sedation ness, sensory loss, hyperreflexia, quired for persons with cachexia, de- or light anesthesia
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