Spinal Metastases: Diagnosis and Management

  • Vincenzo Denaro
  • Alberto Di MartinoEmail author


The management of the patient affected by spinal metastases requires an integrated multidisciplinary approach. Surgery and radiotherapy being the mainstay of the treatment of these fragile patients, clinical and surgical trials are required to determine which patients will benefit most from these treatments when affected by metastatic epidural spinal cord compression. In recent years, a newer and more important role for radiotherapy is emerging for these patients; in particular, stereotactic radiosurgery is used as an adjuvant to the decompressive surgery for management of these patients.


Spinal metastases Surgery Radiation therapy Separation surgery IONM 


  1. 1.
    Tubiana-Hulin M. Incidence, prevalence and distribution of bone metastases. Bone. 1991;12(Suppl 1):S9–10.CrossRefPubMedGoogle Scholar
  2. 2.
    Durr HR, Maier M, Pfahler M, Baur A, Refior HJ. Surgical treatment of osseous metastases in patients with renal cell carcinoma. Clin Orthop Relat Res. 1999;367:283–90.Google Scholar
  3. 3.
    Sundaresan N, Digiacinto GV, Hughes JE. Surgical treatment of spinal metastases. Clin Neurosurg. 1986;33:503–22.PubMedGoogle Scholar
  4. 4.
    Fornasier VL, Horne JG. Metastases to the vertebral column. Cancer. 1975;36:590–4.CrossRefPubMedGoogle Scholar
  5. 5.
    Schuster JM, Grady MS. Medical management and adjuvant therapies in spinal metastatic disease. Neurosurg Focus. 2001;11(6):e3.CrossRefPubMedGoogle Scholar
  6. 6.
    Raque GH Jr, Vitaz TW, Shields CB. Treatment of neoplastic diseases of the sacrum. J Surg Oncol. 2001;76:301–7.CrossRefPubMedGoogle Scholar
  7. 7.
    Gasbarrini A, Boriani S, Capanna R, Casadei R, Di Martino A, Spinelli MS, Papapietro N, Piccioli A, The Italian Orthopaedic Society Bone Metastasis Study Group. Management of patients with metastasis to the vertebrae: recommendations from the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group. Expert Rev Anticancer Ther. 2014;14:143–50.CrossRefPubMedGoogle Scholar
  8. 8.
    Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12(20 Pt 2):6243s–9s.CrossRefPubMedGoogle Scholar
  9. 9.
    Coleman RE. Skeletal complications of malignancy. Cancer. 1997;80(8 Suppl):1588–94.CrossRefPubMedGoogle Scholar
  10. 10.
    Vrionis FD, Miguel R. Management of spinal metastases. Semin Pain Med. 2003;11:25–33.CrossRefGoogle Scholar
  11. 11.
    Dewald RL, Bridwell KH, Prodromas C, Rodts MF. Reconstructive spinal surgery as palliation for metastatic malignancies of the spine. Spine. 1985;10:21–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Galasko CSB. Spinal instability secondary to metastatic cancer. J Bone Joint Surg. 1991;73B:104–8.CrossRefGoogle Scholar
  13. 13.
    Brihaye J, Ectors P, Lemort M, Van Houtte P. The management of spinal epidural metastases. Adv Tech Stand Neurosurg. 1988;16:121–76.CrossRefPubMedGoogle Scholar
  14. 14.
    Denaro V, Di Martino A, Papalia R, Denaro L. Patients with cervical metastasis and neoplastic pachymeningitis are less likely to improve neurologically after surgery. Clin Orthop Relat Res. 2011;469:708–14.CrossRefPubMedGoogle Scholar
  15. 15.
    Di Martino A, Vincenzi B, Denaro L, Barnaba SA, Papalia R, Santini D, Tonini G, Denaro V. ‘Internal bracing’ surgery in the management of solid tumor metastases of the thoracic and lumbar spine. Oncol Rep. 2009;21:431–5.PubMedGoogle Scholar
  16. 16.
    Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamuru T. Surgical strategy for spinal metastases. Spine. 2001;26(3):298–306.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Sundaresan N, Steinberger AA, Moore F, et al. Indications and results of combined anterior-posterior approaches for spine tumor surgery. J Neurosurg. 1996;85(3):438–46.CrossRefPubMedGoogle Scholar
  18. 18.
    Damron TA, Sim FH. Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. Instr Course Lect. 2000;49:461–70.PubMedGoogle Scholar
  19. 19.
    Vecht CJ, Haaxma-Reiche H, van Putten WLJ, et al. Initial bouls of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology. 1989;39:1255–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Helweg-Larsen S, Mouridsen H, et al. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomized trial. Eur J Cancer. 1994;30A:22–7.PubMedGoogle Scholar
  21. 21.
    Bauer H. Posterior decompression and stabilization for spinal metastases: analysis of sixty-seven consecutive patients. J Bone Joint Surg Am. 1997;79A:514–22.CrossRefGoogle Scholar
  22. 22.
    Bilsky MH, Boakye M, Collignon F, Kraus D, Boland P. Operative management of metastatic and malignant primary subaxial cervical tumors. J Neurosurg Spine. 2005;2:256–64.CrossRefPubMedGoogle Scholar
  23. 23.
    Denaro V, Denaro L, Papalia R, Marinozzi A, Di Martino A. Surgical management of cervical spine osteoblastomas. Clin Orthop Relat Res. 2007;455:190–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Denaro V, Gulino G, Papapietro N, Denaro L. Treatment of metastasis of the cervical spine. Chir Organi Mov. 1998;83:127–37.PubMedGoogle Scholar
  25. 25.
    Ghogawalw Z, Mansfield FL, Borges LF. Spinal radiation before surgical decompression adversely affects outcomes of surgery for symptomatic metastatic spinal cord compression. Spine. 2001;26:818–24.CrossRefGoogle Scholar
  26. 26.
    Ibrahim A, Crockard A, Antonietti P, 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. J Neurosurg Spine. 2008;8:271–8.CrossRefPubMedGoogle Scholar
  27. 27.
    Sundaresan N, Digiacinto GV, Hughes JE, Cafferty M, Vallejo A. Treatment of neoplastic spinal cord compression: results of a prospective study. Neurosurgery. 1991;29(5):645–50.CrossRefPubMedGoogle Scholar
  28. 28.
    Sundaresan N, Rosen G, Boriani S. Primary malignant tumors of the spine. Orthop Clin N Am. 2009;40:21–36.CrossRefGoogle Scholar
  29. 29.
    Vieweg U, Meyer B, Schramm J. Tumour surgery of the upper cervical spine – a retrospective study of 13 cases. Acta Neurochir. 2001;143:217–25.CrossRefPubMedGoogle Scholar
  30. 30.
    Bauer HCF, Wedin R. Survival after surgery for spinal and extradural metastases. Prognostication in 241 patients. Acta Orthop Scand. 1995;66:143–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Landreneau RJ, Weigelt JA, Meier DE, et al. The anterior operative approach to the cervical vertebral artery. J Am Coll Surg. 1995;180:475–80.PubMedGoogle Scholar
  32. 32.
    McPhee IB, Williams RP, Swanson CE. Factors influencing wound healing after surgery for metastatic disease of the spine. Spine. 1998;23:726–32.CrossRefPubMedGoogle Scholar
  33. 33.
    Kitchel SH, Eismont FJ, Green BA. Closet subarachnoid drainage for management of cerebrospinal fluid leakage after an operation to the spine. J Bone Joint Surg Am. 1989;71:984–7.CrossRefPubMedGoogle Scholar
  34. 34.
    Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomized trial. Lancet. 2005;366:643–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Riew DK, Khanna N. Treatment of cerebrospinal fluid leaks. In: Vaccaro AR, Betz RR, Zeidman SM, editors. Principles and practice of spine surgery. St. Louis: C.V. Mosby; 2002. p. 727–43.Google Scholar
  36. 36.
    Sorenson PS, Helweg-Larsen S, Mouridsen H, et al. Effect of high-dose dexamethasone in carcinomatous metastatic spinal cord compression treated with radiotherapy: a randomized trial. Eur J Cancer. 1994;30A:22–7.CrossRefGoogle Scholar
  37. 37.
    Weigel B, Maghsudi M, Neumann C, et al. Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine. 1999;24:2240–6.CrossRefPubMedGoogle Scholar
  38. 38.
    Zheng GZ, Chang B, Lin FX, Xie D, Hu QX, Yu GY, Du SX, Li XD. Meta-analysis comparing denosumab and zoledronic acid for treatment of bone metastases in patients with advanced solid tumours. Eur J Cancer Care (Engl). 2016. [Epub ahead of print].
  39. 39.
    Ecker RD, Endo T, Wetjen NM, Krauss WE. Diagnosis and treatment of vertebral column metastasis. Mayo Clin Proc. 2005;80(9):1177–86.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Bilsky MH, Lis E, Raizer J, Lee H, Boland P. The diagnosis and treatment of metastatic spinal tumor. Oncologist. 1999;4:459–69.PubMedGoogle Scholar
  41. 41.
    Liu T, Xu JY, Xu W, Bai YR, Yan WL, Yang HL. Fluorine-18 deoxyglucose positron emission tomography, magnetic resonance imaging and bone scintigraphy for the diagnosis of bone metastases in patients with lung cancer: which one is the best? A meta-analysis. Clin Oncol (R Coll Radiol). 2011;23:350–8.CrossRefGoogle Scholar
  42. 42.
    Maralani PJ, Lo SS, Redmond K, Soliman H, Myrehaug S, Husain ZA, Heyn C, Kapadia A, Chan A, Sahgal A. Spinal metastases: multimodality imaging in diagnosis and stereotactic body radiation therapy planning. Future Oncol. 2017;13:77–91. Scholar
  43. 43.
    O’Sullivan GJ, Carty FL, Cronin CG. Imaging of bone metastasis: an update. World J Radiol. 2015;7(8):202–11.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Bastawrous S, Bhargava P, Behnia F, Djang DSW, Haseley DR. Newer PET application with an old tracer: role of 18F-NaF skeletal PET/CT in oncologic practice. Radiographics. 2014;34:1295–316. Scholar
  45. 45.
    Denaro L, Di Martino A, et al. Cervical spine bone tumor surgery. Berlin Heidelberg: Springer; 2010. p. 165–74.Google Scholar
  46. 46.
    Gasbarrini A, Casadei R, Papapietro N. Il trattamento delle metastasi vertebrali. GIOT. 2012;38:188–93.Google Scholar
  47. 47.
    Denaro V. Stenosis of the cervical spine. Berlin: Springer; 1994.Google Scholar
  48. 48.
    Denaro V, Denaro L, Albo E, Papapietro N, Piccioli A, Di Martino A. Surgical management of spinal fractures and neurological involvement in patients with myeloma. Injury. 2016;47(Suppl 4):S49–53. Epub 2016 Aug 6.CrossRefPubMedGoogle Scholar
  49. 49.
    Chen B, Xiao S, et al. Comparison of the therapeutic efficacy of surgery with or without adjuvant radiotherapy versus radiotherapy alone for metastatic spinal cord compression: a meta-analysis. World Neurosurg. 2015;6:1066–73.CrossRefGoogle Scholar
  50. 50.
    Agabegi SS, Asghar FA, Herkowitz HN. Spinal orthoses. J Am Acad Orthop Surg. 2010;18(11):657–67.CrossRefPubMedGoogle Scholar
  51. 51.
    Di Martino A, Caldaria A, De Vivo V, Denaro V. Metastatic epidural spinal cord compression. Expert Rev Anticancer Ther. 2016;12:1–10.Google Scholar
  52. 52.
    Zairi F, Marinho P, Bouras A, Allaoui M, Assaker R. Recent concepts in the management of thoracolumbar spine metastasis. J Neurosurg Sci. 2013;57(1):45–54.PubMedGoogle Scholar
  53. 53.
    Denaro V, Di Martino A. Cervical spine surgery: an historical perspective. Clin Orthop Relat Res. 2011;469(3):639–48. Scholar
  54. 54.
    Roy-Camille R, Judet TH, Saillant G, Mamoudy P, Denaro V. Tumeurs du rachis. Encicl med-Chir Techniquee Chirurgicales. Orthopedie. 1982;11:44–165.Google Scholar
  55. 55.
    Denaro V. Treatment of metastases and systemic tumors of the cervical spine. Neuroorthopedics. 1988;6:101–10.Google Scholar
  56. 56.
    Shimizu K, Shikata J, Iida H, Iwasaki R, Yoshikawa J, Yamamuro T. Posterior decompression and stabilization for multiple metastatic tumors of the spine. Spine. 1992;17:1400–4.CrossRefPubMedGoogle Scholar
  57. 57.
    Cappuccio M, Gasbarrini A, et al. Vertebroplasty in the treatment of vertebral metastases: clinical cases and review of the literature. Eur Rev Med Pharmacol Sci. 2007;11(2):91–100.PubMedGoogle Scholar
  58. 58.
    Luksanapruksa P, Buchowski JM, Zebala LP, Kepler CK, Singhatanadgige W, Bumpass DB. Perioperative complications of spinal metastases surgery. Clin Spine Surg. 2017;30(1):4–13.CrossRefPubMedGoogle Scholar
  59. 59.
    Scibilia A, Terranova C, Rizzo V, Raffa G, Morelli A, Esposito F, Mallamace R, Buda G, Conti A, Quartarone A, Germanò A. Intraoperative neurophysiological mapping and monitoring in spinal tumor surgery: sirens or indispensable tools? Neurosurg Focus. 2016;41(2):E18. Scholar
  60. 60.
    Laufer I, Iorgulescu JB, Chapman T, Lis E, Shi W, Zhang Z, et al. Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or highdose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine. 2013;18:207–14.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Orthopaedics and Trauma SurgeryUniversity Campus Bio-Medico of RomeRomeItaly

Personalised recommendations