Spinal Metastases

Descriptors

Several types of presenting groups:

• No history of malignancy, initial presentation with spine lesion, unknown primary
• History of malignancy, initial presentation of metastasis
• History of metastatic disease, initial presentation of spinal metastasis
• History of spinal metastasis s/p radiation or prior intervention

Above all prioritize preservation of neurologic function

NOMS criteria: Neurologic
Bilsky grade (degree of epidural spinal cord compression)

• grade 0: bone-only disease
• grade 1: epidural extension without cord compression
• a: epidural extension only (no deformation of the thecal sac)
• b: deformation of thecal sac, without spinal cord abutment
• c: deformation of the thecal sac, with spinal cord abutment
• grade 2: spinal cord compression, with cerebrospinal fluid (CSF) visible around the cord
• grade 3: spinal cord compression, no CSF visible around the cord
  ASIA scale

Oncologic
- Radiation sensitive or radiation resistant/insensitive?
- Favorable (F): sensitive
- Conventional external beam radiotherapy (cEBRT)
- Unfavorable (U): resistant
- Stereotactic radiosurgery
- Intermediate (I)
- Stereotactic radiosurgery

Mechanical
Estimate of stability / likelihood of pathologic fracture
Spinal Instability Neoplastic Score (SINS) score may be used.

Systemic
Able to tolerate surgery? Estimate of prognosis
Survival predictor

Exam Pearls

Spine exam
ASIA classification
Long tract signs: Hoffman, clonus

Workup

Radiographs: Upright spine films if patient able to tolerate

Other imaging: MRI full spine with and without contrast

Labs: CBC with differential, BMP, LFTs, Coags (INR)

Other:
Consider bilateral LENIS to r/o DVT
EKG

Management

Need for acute intervention:
Progressive neurologic deficit

Weight-bearing and range of motion:
If no neurologic deficit, no instability: activity as tolerated
If new neurologic deficit or instability: bed rest with logroll precautions until reviewed with spine staff

Type of immobilization:
C-collar for cervical spine lesions with instability

Admission or discharge status:
If unknown primary, admit to medicine for oncologic workup (likely tx to oncology once primary identified)

If known primary, admit to oncology

If history of spinal metastasis with no new medical or oncological issues, admit to ortho spine

Radiation oncology consult

Medical oncology consult

Anticoagulation:
No anticoagulation although consider pre-operative workup w/ LENIS

Antibiotics:
None

Surgical Indications

Absolute:
Progressive neurologic deficit

Relative:
Radiation resistant tumor
SINS score
90-day prognosis

Not an indication: New lesion without neurologic deficit, instability or oncologic workup