Spinal metastasis: diagnosis, management and follow-up

Abstract

Spine metastatic disease is an increasingly common occurrence in cancer patients due to improved patient survival. Close proximity of the bony spinal column to the spinal cord limits many conventional treatments for metastatic disease. In the past decade, we have witnessed dramatic advancements in therapies, with improvements in surgical techniques and recent adoption of spine stereotactic radiotherapy techniques leading to improved patient outcomes. Multidisciplinary approaches to patient evaluation, treatment and follow-up are essential. Imaging plays an ever increasing role in disease detection, pre-treatment planning and assessment of patient outcomes. It is important for the radiologist to be familiar with imaging algorithms, best practices for surgery and/or radiotherapy and imaging findings in the post-treatment period that may indicate disease recurrence. In this review, we present a multidisciplinary discussion of spine metastases, with specific focus on pre-treatment imaging, planning, current treatment approaches, and post-treatment assessment.

Figure 1.

A 59-year-old patient with history of non-small cell lung carcinoma, presenting with right-sided radiculopathy but without neck pain. On sagittal fat-saturated T1 post-contrast image (1a), there is diffuse enhancement throughout the C7 vertebral body (short arrow) representing a metastatic lesion. On axial T1 post-contrast image (1b), the lesion involves >50% of the vertebral body (thick arrows). On axial CT image (1c), the lesion is lytic. SINS for this lesion is shown in 1d. The total score is 5, indicating the lesion is stable and does not require surgical consultation. SINS,Spine Instability Neoplastic Score.

Figure 2.

A 68-year-old with history of lung adenocarcinoma who presents with periodic mid-back pain. Sagittal 3D T₂ weighted image (2a) shows metastatic disease diffusely involving the T10 and T11 vertebral bodies. There is less than 50% collapse of the T10 vertebral body. Axial T₂ weighted image (2b) of the T10 vertebral body shows unilateral involvement of the right pedicle (short arrow). Axial CT image of T10 (2c) shows a lytic lesion involving a majority of the vertebral body. Sclerotic regions within the lesion were thought to represent fragmented bone as opposed to blastic disease. SINS for the T10 vertebral body is shown in 2d. The SINS was 8, indicating potential instability. Surgical consultation is recommended for lesions with SINS greater than or equal to 7. 3D, three-dimensional; SINS,Spine Instability Neoplastic Score.

Figure 3.

A 75-year-old with metastatic breast ductal adenocarcinoma who presents with persistent lower back pain exacerbated by axial loading. Sagittal T₂ weighted image in midline (3a) shows diffuse metastatic involvement of the L5 vertebral body (short arrows) with greater than 50% vertebral height collapse. There is compression of the cauda equine at this level secondary to retropulsion. Left parasagittal (3b) and right parasagittal (3c) T₁ weighted post-contrast images show bilateral posterior element involvement (long arrows). Axial CT image of L5 (3d) shows the lesion to be lytic. SINS is shown in 3e. The L5 lesion had a SINS of 14, which indicates instability. Surgical consultation is recommended for lesions with SINS greater than or equal to 7. SINS,Spine Instability Neoplastic Score.