Spinal Metastasis
Spinal metastatic disease causing compression of the spinal canal (Metastatic Epidural Spinal Cord Compression – ESCC/MESCC) is an oncologic emergency in which metastatic lesions exert pressure on the spinal cord and/or nerve roots. The most common initial symptom is back pain, and delayed diagnosis may result in permanent neurological injury.
The key to optimal outcome is immediate recognition, urgent contrast-enhanced MRI, prompt initiation of appropriate therapy (often corticosteroids and radiotherapy) and – in selected cases – extensive surgical decompression with spinal stabilization.
What is spinal cord compression from metastatic disease?
It refers to compression of neural structures (spinal cord/nerve roots) by metastatic disease of the spine, most commonly from a tumor located in the vertebral body that extends into the epidural space.
In MESCC, metastases involve one (or more) vertebrae, causing bone destruction with pathological fractures and/or a mass that enters the spinal canal. This may result in:
- pain (often the first symptom),
- weakness in the legs and/or arms (depending on level),
- numbness/paresthesias,
- gait disturbance,
- bladder/bowel dysfunction (urgent symptomatology).
It is important to emphasize that many patients initially present with pain only, without obvious neurological deficit. Therefore, in any patient with a history of cancer and new spinal pain, the index of suspicion must be high.
How common is it & which cancers most often cause it?
MESCC is one of the most frequent oncologic complications requiring urgent intervention.
In most cases, MESCC occurs in patients with known malignancy, although more rarely a spinal lesion may be the first manifestation of systemic cancer.
Common primary tumors associated with epidural spinal metastases:
- Breast, lung, prostate (a large proportion of cases).
- Lymphoma and multiple myeloma (often highly radiosensitive).
- Renal cell carcinoma, sarcomas, and other solid tumors.
The thoracic spine is the most common site, but MESCC may occur at any spinal level.
Why is it dangerous – what happens to the spinal cord?
Neurological injury results from both “mechanical” compression and secondary vascular compromise. The time to definitive treatment is critical.
Two main mechanisms of injury:
- Direct compression → edema, venous congestion, demyelination. If decompression occurs early, these changes may be partially reversible.
- Prolonged compression → secondary vascular injury with spinal cord ischemia/infarction. At this stage, recovery becomes very limited.
For this reason, when rapid progression of weakness occurs, management must be immediate and coordinated (particularly within the first 24–48 hours).
Which symptoms require immediate attention?
In a patient with known cancer, new or worsening spinal pain should be considered metastatic in origin until proven otherwise.
- Progressive pain in the back/neck, especially if newly developed.
- Pain that awakens the patient at night or worsens in the supine position.
- Weakness in the limbs, paralysis.
- Gait instability, falls.
- Numbness, “band-like” sensation around the trunk, altered or lost sensation.
- Bladder/bowel dysfunction or sudden incontinence.
If any of the above are present, immediate clinical assessment is required, usually with urgent contrast-enhanced MRI.
What type of pain occurs (mechanical, radicular)?
Pain in MESCC has characteristic features that aid diagnosis and often precedes neurological deficits.
1) Local pain – mechanical
Caused by spinal instability due to vertebral destruction. Typically:
- worsens with loading/movement and
- improves with recumbency.
2) Local pain – neoplastic
Caused by infiltration/irritation of the periosteum and its innervation. Often:
- worse at night,
- may worsen in the supine position (some patients must sleep sitting),
- exacerbated by the Valsalva maneuver (coughing/sneezing).
3) Radicular pain
Due to nerve root compression, often radiating along a dermatome (sciatica or intercostal neuralgia).
A careful history (what worsens/relieves pain) is particularly helpful and should be obtained systematically.
How is the diagnosis made – which test is most important?
Contrast-enhanced MRI of the spine is the gold standard: it demonstrates the tumor, the degree of compression, and the condition of the spinal cord.
In practice, evaluation includes:
- Contrast-enhanced MRI (test of choice) – ideally of the symptomatic region and often the entire spine, depending on history and symptoms.
- CT when bony destruction or instability is suspected (for superior bone detail).
- CT myelography when MRI is contraindicated or not feasible.
Neurosurgical assessment integrates imaging with clinical findings (strength, gait, sphincter function), as the time to treatment is critical.
What is the role of biopsy and why is it critical?
Histopathological diagnosis guides treatment. Whenever feasible, CT-guided percutaneous biopsy is preferred before definitive therapy.
Biopsy allows us to:
- confirm that the lesion is a metastasis rather than another pathology (e.g., primary tumor),
- define the tumor type and biological characteristics (radiosensitivity/systemic treatment options),
- design the optimal therapeutic strategy (radiotherapy, surgery, targeted therapies).
Exception: in cases of rapid neurological deterioration (e.g., loss of ambulation/paralysis), priority is immediate decompression, and biopsy may be obtained intraoperatively.
What is the treatment (steroids, radiotherapy, surgery)?
Treatment is multimodal and tailored to neurological status, tumor histology/type, spinal stability, and overall oncologic burden.
A) Corticosteroids
Frequently administered to reduce edema and inflammation of the spinal cord (particularly in the presence of neurological deficit), always with careful medical supervision.
B) Radiotherapy
May be the primary treatment in patients with radiosensitive tumors (e.g., lymphoma, myeloma) or when surgery is not indicated. Often combined with systemic oncologic therapy.
C) Surgical decompression & stabilization
The goal is adequate decompression of the spinal cord/nerve roots and reconstruction/stabilization of the spine, allowing preservation or restoration of ambulation and enabling effective radiotherapy/systemic treatment.
When do we favor surgical decompression + stabilization?
Not all patients are surgical candidates. In selected individuals, surgical decompression followed by radiotherapy can provide clear functional benefit.
Situations where surgery has a strong role include:
- Neurological deficit (weakness, loss of ambulation) with rapid progression.
- Probable or definite instability of the spine (mechanical pain, vertebral collapse, deformity).
- Compression by bone fragments unlikely to respond to radiotherapy.
- Limited disease at a dominant level and a realistic life expectancy where functional recovery is meaningful.
Final treatment is determined using contemporary oncologic frameworks (e.g., NOMS), integrating histology (radiosensitive vs radioresistant), extent of metastatic disease, and the patient’s functional status.
What does “spinal instability” mean in neoplastic disease – SINS score?
Neoplastic spinal instability differs from traumatic instability. We use clinical criteria and tools such as the Spinal Instability Neoplastic Score (SINS) to determine whether surgical stabilization is required.
Simply put, “instability” means that the spine has lost its structural integrity due to tumor involvement, resulting in:
- pain with movement/loading,
- progressive deformity (kyphosis/scoliosis/subluxation),
- and/or risk of neurological compromise under physiological loads.
The SINS incorporates: location, mechanical pain, lesion quality (lytic/mixed/blastic), alignment, degree of vertebral body collapse, and involvement of posterolateral elements. Higher scores → greater likelihood of requiring surgical stabilization with fusion.
Prognosis – what affects the likelihood of recovery?
Outcome depends primarily on neurological status before treatment and the time elapsed since onset of symptoms/spinal cord compression. The earlier decompression occurs, the greater the likelihood of recovery.
Prognostic factors include:
- Preserved ambulation prior to treatment → strong positive predictor.
- Duration and severity of weakness: prolonged complete paralysis has poorer recovery potential.
- Histology: radiosensitivity, tumor biology, and availability of systemic therapies.
- Stability and structural integrity of the spine.
- Total oncologic burden and overall patient condition.
The goal of treatment is not only survival but primarily preservation of independence, mobility, pain control, and a dignified quality of life.
Practical guidance & when to seek a second opinion?
MESCC is a condition where the “right sequence” of actions makes a difference: early imaging, accurate oncologic classification, and an individualized treatment plan.
What is the most important test when MESCC is suspected?
Contrast-enhanced MRI of the spine (at least of the suspected region, often the entire spine) is the examination of choice.
When should I go immediately to the emergency department?
- New or rapidly progressive weakness in the limbs.
- Loss of ambulation or sudden instability.
- Incontinence or inability to urinate/defecate.
- Severe pain with nocturnal worsening in a patient with known cancer.
Why is a multidisciplinary team often necessary?
Because management depends on neurological, oncologic, mechanical, and systemic factors. Optimal care results from collaboration between neurosurgeon, oncologist, radiation oncologist, and radiologist.
At Neuroknife, we provide rapid evaluation (clinical assessment, urgent imaging when required, stability assessment using international criteria such as SINS) and coordinate strategy with the oncology team so that treatment is timely, evidence-based, and function-oriented.
Spinal pain in a patient with a known history of cancer is metastatic until proven otherwise
If you have a history of malignancy and develop new or worsening back pain, particularly with nocturnal exacerbation, or if weakness, gait disturbance, or sphincter dysfunction occurs, seek immediate specialist evaluation.
We offer second opinions, MRI/CT review, stability assessment, and comprehensive discussion of treatment options (radiotherapy, minimally invasive/decompressive techniques, stabilization), always in collaboration with the oncology team.
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