An Overview of Decision Making in the Management of Metastatic Spinal Tumors

Abstract

Introduction: Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern 'separation' surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors.

Methods: A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed.

Discussion: Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment.

Conclusion: The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.

Keywords: Decision-making algorithm; Separation surgery; Spinal metastases; Stereotactic body radiotherapy.

Fig. 1

Bilsky scale for grading Malignant epidural spinal cord compression (MESCC). Grade 0: Intracompartmental osseous lesion without the epidural disease. Grade I: a–c Minimal epidural disease with no spinal cord compression. Grade 2: high-grade MESCC with spinal cord displacement/compression but with visible CSF. Grade 3: high-grade MESCC with spinal cord displacement/compression but no visible CSF. Redrawn from: Bilsky et al. [48]

Fig. 2

T2 weighted sagittal MRI sequence of a metastatic thyroid tumor showing serpiginous vascular flow voids within and around the lesion with intense post-contrast enhancement indicating hypervascularity

Fig. 3

a, b Preoperative MRI images of a 48-year-old lady with metastatic breast cancer resulting in a pathological fracture at L5 with severe back pain. CTPET did not show any other lesions. Although she was neurologically intact, ESCC was grade 3 on Bilsky scale. SIN score was 11 indicating borderline instability. Modified Tokuhashi score was 15, indicating estimated survival of > 12 months. She underwent anterior L5 vertebrectomy and posterior stabilization. 31/2 weeks later, she received cEBRT (c, d) Postoperative X-rays. She survived for 37 months and was pain free and ambulant till the end

Fig. 3

a, b Preoperative MRI images of a 48-year-old lady with metastatic breast cancer resulting in a pathological fracture at L5 with severe back pain. CTPET did not show any other lesions. Although she was neurologically intact, ESCC was grade 3 on Bilsky scale. SIN score was 11 indicating borderline instability. Modified Tokuhashi score was 15, indicating estimated survival of > 12 months. She underwent anterior L5 vertebrectomy and posterior stabilization. 31/2 weeks later, she received cEBRT (c, d) Postoperative X-rays. She survived for 37 months and was pain free and ambulant till the end

Fig. 4

a, b MRI images of a 72 years old lady with a metastatic RCC who presented with progressive paraparesis over 7 days. CT Scans of the chest and abdomen did not reveal any other metastatic lesions. ESCC was grade 3. SIN score was 8. Modified Tokuhashi score was 11, indicating estimated survival of 6–12 months. In view of the progressive neurologic deficit, urgent surgery was planned. Patient was taken up for embolization. Separation surgery was performed along with posterior stabilization. c Postoperative lateral X-ray. 15 days post-surgery, the patient underwent SBRT which was delivered in three fractions. Patient recovered neurology and was ambulant until she died 16 months later