Vertebral Metastases – Causes, Symptoms, Diagnosis, Treatment

Vertebral metastases represent the secondary involvement of the vertebral spine by hematogenously-disseminated metastatic cells. They must be included in any differential diagnosis of a spinal bone lesion in a patient older than 40 years.
Metastases to the spine can involve the bone, epidural space, leptomeninges, and spinal cord. The spine is the third most common site for metastatic disease, following the lung and the liver [] and the most common osseous site [] . These are more commonly found as bone metastasis and may present with symptoms of spinal canal invasion and cord compression

This  will focus only on the metastasis involving the bony structures of the spine; please refer to the specific articles for other spinal metastatic diseases:

  • intradural extramedullary metastases
  • intramedullary metastases

Symptoms of Vertebral Metastases

Vertebral lesions are very frequently asymptomatic in the setting of widespread metastatic disease and are thus often found incidentally when imaging is performed for other reasons (e.g. staging).

Lesions may become symptomatic due to bone pain, pathological compression fractures, or extension into the spinal canal with cord compression and ensuing neurological deficits.  The most common primary malignancies to involve the vertebrae include:

  • breast cancer
  • lung cancer
  • prostate cancer
  • lymphoma
  • renal cell carcinoma
  • gastrointestinal tract malignancies
  • melanoma
  • pancreatic cancer
  • thyroid carcinoma 
  • carcinoid

Metastases are either osteoblastic or osteolytic, however, osteoid formation and mineralization is of limited help in determining the primary tumor as some metastases may secrete osteoblast- and osteoclast-stimulating factors at the same time. The new bone formation may also occur after chemotherapy or radiation therapy. Having said that some primaries more frequently result in sclerosis than others.

Primaries with predominantly osteoblastic metastases (sclerotic extradural bone lesions) include:

  • prostate carcinoma
  • osteosarcoma
  • medullary thyroid carcinoma

Primaries with predominantly osteolytic metastases, that may rarely become osteoblastic (mixed sclerotic and lytic extradural bone lesions) include:

  • breast cancer
  • lymphoma
  • urothelial carcinoma
  • lung cancer
  • gastrointestinal tract cancers
  • renal cell carcinoma
  • malignant melanoma
  • multiple myeloma

Diagnosis of Vertebral Metastases

The vertebra is the most common site affected, followed by the femur, pelvis, ribs, sternum, proximal humerus, and skull. Bone metastases may be asymptomatic or manifest in a variety of ways termed skeletal-related events (SRE) as a result of the destruction of normal bone architecture. The following further describes SRE:

  • Bone pain – Pain associated with bone metastasis is a frequent symptom. It is typically gradual in onset and described as a dull, boring pain that is worse at night.
  • Nerve root or spinal cord compression – Bone metastases causing nerve root compression can present as radicular pain different from mechanical pain.
  • Spinal cord compression – As the vertebra is the most common site of metastasis, a significant complication includes spinal cord compression, which is an oncologic emergency. Metastatic spinal cord compression occurs either through pathological vertebral collapse or direct epidural extension. Patients may present initially with back pain. Limb weakness is the second most common symptom of cord compression. Sensory symptoms include paresthesias and numbness at and below the level of cord compression. Autonomic dysfunction, including bowel and bladder incontinence and impotence, is typically a late presentation. Early recognition, workup, and prompt surgical consultation are pertinent to prevent permanent neurological damage with resultant paraplegia.
  • Hypercalcemia – In the setting of malignancy, this can be multifactorial and confers a poor prognosis overall. Osteolytic bone metastases are associated with 20% of the cases of hypercalcemia of malignancy. In osteolytic metastases, enhanced osteoclastic bone resorption occurs as a result of the release of humoral factors by tumor cells that in turn stimulate osteoclasts and lead to unchecked bone resorption and hypercalcemia. Symptoms of hypercalcemia include nausea, anorexia, abdominal pain, constipation, and mental status changes. Immediate treatment for hypercalcemia includes IV hydration
  • Pathological fractures – Bone metastases cause bone destruction, leading to complete or impending fracture at the site of pathology either spontaneously or with minimal trauma. The presentation is dependent on the site of the fracture; however, constant pain is a prevalent symptom. Fractures of the thoracic and lumbar spine present with pain characteristically worse with sitting or standing. Pathologic fractures result in significant morbidities resulting from pain, radiculopathy (e.g., sciatica with pelvic fracture), deformities, and immobility.
  • Myelophthisis – Symptomatic anemia resulting from infiltration of the bone marrow with metastatic tumor cells. Pancytopenia may also be present in late stages.

Imaging

It is pertinent to identify bone metastasis early, both types of staging and prognostication as well as the implementation of prophylactic and treatment strategies which may lead to decreased morbidity and mortality. Bone metastases can be characterized as osteolytic, sclerotic, or mixed on imaging studies.

Plain Radiograph

  • X-rays – or plain radiograph is the initial imaging of choice in patients presenting with bone pain. Plain films are used to assess abnormal radionuclide uptake or to detect pathological fractures.  Metastatic lesions can have virtually any appearance. They can mimic a benign lesion or an aggressive primary bone tumor. It can be difficult, if not impossible, to judge the origin of the tumor from the appearance of the metastatic focus, although some appearances are fairly characteristic.
  • Plain radiography – best detects osteolytic lesions, but they may not be apparent until they are greater than 1 to 2 centimeters and with loss of 50% of the bone mineral content at the site of disease. Osteolytic lesions are seen as thinning of trabeculae and ill-defined margins on radiographs, while sclerotic lesions appear nodular and well-circumscribed as a result of thickened trabeculae. Plain films tend to be insensitive, especially in detecting bone metastases and with asymptomatic and subtle lesions. Progression of disease and response to therapy can be monitored with plain films and further correlation with other modalities. Sclerosis or new bone formation in osteolytic metastatic lesions is demonstrated by the sclerotic rim of reactive bone, which starts at the periphery and eventually involves the center with continued healing. Purely sclerotic lesions are more difficult to assess. Major disadvantages of plain radiographs include poor sensitivity.
  • Computed Tomography – Computed tomography (CT) is more sensitive (74%) than plain radiographs. It is useful in the evaluation of cortical and trabecular bone as well as in the assessment of the osteolytic and sclerotic lesions. CT scan is advantageous as it can determine staging and treatment response of other organs in addition to bone and objectively assess reactive sclerosis by calculating the change in Hounsfield units. Ribs are better evaluated with CT due to the high cortex to marrow ratio.  The appearance of CT will depend on the degree of mineralization of the metastasis. The more common lytic metastases appear as regions of soft-tissue attenuation with irregular margins. The mass may breach the cortex and result in a compromise of the spinal canal.  Histopathology of bone metastases is only employed for diagnostic purposes in patients of primary unknown cancers or in the presence of multiple cancers.
  • MRI – In the detection of bone metastasis, MRI demonstrates a sensitivity of 95% and specificity 90%. MRI is also more advantageous than a bone scan as it can detect marrow involvement before the development of osteoblastic lesions. It can be used with women who are pregnant and used to detect spinal cord compression. Bone metastases manifest as low T1 signal and high intensity on the T2 weighted sequence. Whole-body MRI requires 40 to 45 minutes to perform and involves short-tau inversion recovery (STIR) and/or T1-weighted sequences.
  • Nuclear Medicine  – Nuclear medicine scans also are used to detect bone metastases using osteotropic radioisotopes; these include skeletal scintigraphy, SPECT, and PET scan.
  • Skeletal scintigraphy – or bone scan is the most commonly used radionuclide imaging which uses 99mTc-MDP employed in the detection of skeletal metastases. Radioisotopic imaging methods depict bone metastatic lesions as areas of increased tracer uptake.
  • Bone scan – provides the advantage of scanning the whole skeleton and has a high sensitivity (78%) therefore resulting in early diagnosis. When osteoblastic activity is prominent, the lesions are readily detected using radionuclide bone scanning. However, bone scans have low specificity for differentiating between benign and malignant bone lesions and for the detection of predominantly osteolytic lesions. Bone scans can be used to monitor the progression of disease and response to treatment.
  • SPECT uses 99mTc-MDP radioisotopes  – uptake to detect bone lesions; however, images are acquired in cross-sectional rather than a planar fashion. SPECT has a higher specificity of 91% compared to skeletal scintigraphy.
  • PET – is a nuclear medicine technique that uses the radiotracers 18F FDG or 18FNaF for the detection of skeletal metastases. 18F FDG PET scan identifies bone metastases based on a high glucose metabolism exhibited by neoplastic cells. PET has a better spatial resolution compared to skeletal scintigraphy. 18F NaF-PET is proven to be substantially more sensitive and specific than bone scan and SPECT for the detection of bone metastases. Combining imaging techniques and modalities allows for improved visualization both anatomically and functionally, leading to increased diagnostic accuracy. One example of this is the 18F-Sodium fluoride (18F-NaF) PET/CT bone scanning which has significantly greater sensitivity (100%) and specificity (97%). Other hybrid imaging techniques include SPECT/CT, PET/CT, and PET/MRI.
  • Bone scintigraphy – is an effective means of assessing the metabolic activity of the spine, while plain radiographs can only demonstrate lesions with a loss of 30%–50% of bone mineral content[rx, rx]. Technetium‐99m (99m Tc) planar bone scintiscans detect metastatic bone deposits through increased osteoblastic activity, considered to be an indirect marker of an oncological process. For this reason, it is considered to be the most efficient modality for screening the whole body for metastasis[rx, rx]. 18F‐fluoro‐deoxy‐D‐glucose positron emission tomography (18FDG PET) offers superior spatial resolution and improved sensitivity, which is superior to bone scintigraphy in the detection of osteolytic metastases, while osteoblastic metastases show lower metabolic activity and are frequently undetectable by PET[rx, rx].
  • Blood tests – can aid in supporting the diagnosis of bone metastases. Complete blood count and a comprehensive metabolic panel should be obtained routinely. CBC may reveal anemia, thrombocytopenia, or pancytopenia in late stages. Serum calcium and alkaline phosphatase may be elevated due to ongoing osteolysis. Bone turnover markers are still being studied as indicators of bone resorption. Tartrate-resistant acid phosphatase has been proven to elevated in patients with breast and prostate cancer with bone metastases. Objective scoring models such as the Mirel classification system for long bones and assessment of spinal stability in addition to imaging criteria are used to determine the surgical necessity for impending pathological fractures.
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Treatment of Vertebral Metastases

The therapeutic approach to bone metastases should be a multidisciplinary approach targeted at preserving the quality of life, including pain control, minimizing SREs, and achieving local tumor control. It is pertinent to consider a multitude of factors including the extent of disease spread, performance status, impending fracture, and side effects when creating the initial approach for the treatment of bone metastases. 

  • NSAIDs  – A major aspect of treating bone metastases is analgesia/pain control for the debilitating pain that occurs with bone metastases. Pain control can be initiated with NSAIDs and titrated up to or in conjunction with narcotics as needed for symptom relief. Glucocorticoids may also be useful for additional pain control.
  • Osteoclast inhibitors – (bisphosphonates and denosumab) decrease morbidity and mortality associated with bone metastases as they reduce skeletal-related events and can be used for analgesia to some extent.
  • Local radiation for symptomatic bone metastases – is a significant component of the palliative approach in providing analgesia. It is also used postoperatively to consolidate continued bone healing. External beam radiation is the standard approach for painful bone metastases and is beneficial in reducing pain by up to 50% to 80%. Several studies have proven that a single 8 Gy fraction compared to more prolonged or fractionated radiation is non-inferior; however, it may carry a higher need for pretreatment (20 % vs. 8%). Stereotactic body radiation therapy spares the normal tissue while delivering highly conformal radiation to the affected area. There are no clear guidelines on stereotactic body radiotherapy (SBRT) use however it may be indicated over external beam radiation therapy (EBRT) in specific instances of bone metastases specifically vertebral from certain radio-resistant neoplasms.
  • Bone-targeted radiopharmaceutical therapy – (e.g., beta-emitting agents strontium-89, alpha-emitting radium-223) provides the specific advantage of treatment of diffuse pain associated with osteoblastic bone metastases. It is typically used in bowel movement associated with prostate and breast cancer or for analgesia in radiation therapy for refractory pain.  Systemic chemotherapy when amenable, aimed at the primary tumor can also provide analgesia by reduction of tumor size and control of tumor spread.
  • Surgery is indicated – for impending or complete fracture, mechanical stability, and spinal cord compression. In cases where the spread of the primary cancer is limited to a single bone lesion, en bloc resection of the metastasis can be done by means of local tumor control.

Local ablation via radiofrequency ablation (RFA), cryoablation, and focused ultrasound (FUS) should be considered for patients with persistent pain following radiation therapy or patients with recurrent pain

National Institute for Health and Care Excellence clinical guideline for the management of spinal cord compression

In November 2018, NICE issued a clinical guideline for the diagnosis and management of adults at risk of or with MSCC.The guidelines contained treatment algorithms for patients with symptoms suggestive of spinal metastases. The guideline proposed the patient treatment pathways shown in. Treatment of patients with spinal metastases and MSCC can be broadly divided into three pathways.

Treatment of patients with spinal metastases and prevention of metastatic spinal cord compression

Patients with painful spinal metastases should be offered conventional analgesics, i.e. non-steroidal anti-inflammatory drugs. Those patients with intractable pain should be considered for specialist pain care that includes invasive procedures and neurosurgical interventions. Patients with spinal metastases from breast and prostate cancer should be offered bisphosphonates to alleviate pain and reduce the risk of pathological fracture/collapse of the spine. Those patients with non-mechanical spinal pain should be given single-fraction palliative radiotherapy. This should also be considered in those who are completely paralyzed. In asymptomatic patients, radiotherapy should not be administered.

Two vertebral augmentation techniques, vertebroplasty, and kyphoplasty should be considered in those with mechanical spinal pain resistant to conventional analgesics and no evidence of MSCC or spinal instability.

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Surgery should be preferred when there is evidence of progressive disease mainly to prevent MSCC. It should also be considered in those with spinal metastases and mechanical pain resistant to conventional analgesics and in those with evidence of spinal instability.

Treatment of threatened spinal cord in patients with metastatic spinal cord compression

In patients with severe mechanical pain suggestive of spinal instability or those with neurological symptoms or signs suggestive of MSCC, the spine should be stabilized. Patients should be monitored regularly, especially during sitting from supine to 60 degrees. If patients continue to deteriorate, then they should revert back to the lying position or to the position in which there is minimal pain/neurological symptoms. In those patients not suitable for definitive treatment, the aim of the treatment should be to help the patient to achieve a comfortable position and mobilization. This is usually achieved by using orthoses.

Corticosteroids should be given to all patients with MSCC unless contraindicated. Dexamethasone at 16 mg as a loading dose should be given followed by a short course of 16 mg dexamethasone daily until definitive treatment is employed. After definitive treatment, the dose of dexamethasone should be reduced gradually over 5–7 days and then stopped. In those patients in whom symptoms have deteriorated, the dose of dexamethasone can be increased temporarily.

Definitive treatment of metastatic spinal cord compression

The definitive treatment should be given as early as possible, ideally within 24 hours of the diagnosis of MSCC. Before this, a diagnosis of the primary location of the tumor should be made. In addition, an attempt should be made to study the extent of the disease. A scoring system such as the Tokuhashi scoring system and the American Society of Anesthesiologists grading for the overall patient condition should be used to assess whether surgery is appropriate.

Radiotherapy

Patients unsuitable for surgery should receive radiotherapy within 24 hours, 7 days a week. Fractionated radiotherapy is the definitive treatment of choice for patients with epidural tumor without neurological dysfunction, mechanical pain or spinal instability. It is also an appropriate first-line treatment for patients with a good prognosis. Radiotherapy should not be given to patients with MSCC who are waiting for surgery but fractionated radiotherapy should be offered to all patients postoperatively once their wound has healed.

Supportive care and rehabilitation

Supportive care includes thromboprophylaxis, management of pressure ulcers, bladder and bowel continence, circulatory and respiratory functions, and access to specialist rehabilitation care at home.

Radiation

The aim of radiation is to alleviate pain and to prevent recurrence and tumor growth. It is indicated when the spine is stable, if the tumor is radiosensitive and the patient’s neurological condition is stable, or if the patient is in poor medical condition or has a life expectancy < 3–6 months and has had complete paraplegia for > 24 hours.[

Recently, new approaches, such as intensity-modulated radiotherapy (IMRT), or stereotactic body radiotherapy, have been suggested for the treatment of vertebral metastases.

Systemic therapies

Corticosteroids

Intravenous or oral corticosteroids have been found to provide improvement or resolution of neurological symptoms and pain in patients with epidural spinal metastases. It should be noted that there is no standard dosage regimen for corticosteroids. They are often used before surgery.

In patients with MSCC undergoing surgical decompression, corticosteroids are often used in combination with radiotherapy.

Bisphosphonates and denosumab

Bisphosphonates are known to impair osteoclastic activity and so they reduce tumor-related resorption of bone., Currently, bisphosphonates are used to alleviate metastatic bone pain and to reduce SREs such as pathological fractures, hypercalcemia, and MSCC. Bisphosphonates are also used to reduce the frequency of surgery and radiation therapy., Bisphosphonates such as pamidronate (Aredia®; Novartis Pharmaceuticals Corporation), clodronate (Bonefos®, Clasteon®, Loron®; Bayer), ibandronate (Bondronat®; F. Hoffmann-La Roche Ltd), alendronate (Fosamax®; Merck Sharp & Dohme Corporation) and zoledronate (Aclasta®; Novartis) have all been found to be effective in the treatment of hypercalcemia. Although radiotherapy is the main treatment for reducing bone pain, bisphosphonates can be used as an alternative therapy, which in turn will considerably reduce the frequency of radiotherapy., The effect of bisphosphonates on pain is not dependent on the nature or type of the tumor (i.e. sclerotic or lytic). The efficacy of these drugs has been seen in breast cancer, multiple myeloma, and other osteolytic metastases. Although bisphosphonates have been found to be effective in preventing skeletal-related complications, they are not so effective in reducing pain in patients with prostate cancer.

Recently, monoclonal antibody therapy with denosumab, a specific inhibitor of RANKL, has been found to be effective in delaying and preventing SREs.

Chemotherapy

The benefits of chemotherapy are limited in spinal metastases, as patients are usually at a late stage of disease. Chemotherapy can be given on its own or in combination with surgery and hormonal therapy.

Radioisotopes

Radioisotopes are administered systematically and act as local radiation therapy to the spine. Radioisotopes include strontium-89 and rhenium-186. Although radioisotopes are found to reduce pain in patients with spinal metastases, these can cause irreversible bone marrow suppression and, for this reason, they are recommended for use in those with good marrow function and in whom no other treatment is available.

Hormonal therapies

Hormonal therapies are a major treatment modality for metastatic breast and prostate cancer. As an example, a new drug, abiraterone (Zytiga®; Janssen), has recently been developed which has improved outcomes in men with metastatic castration-resistant prostate cancer.,

Surgery

The main aims of surgery are to remove the tumor, achieve spinal stability, and reconstruct the vertebral column. Surgery may also help with diagnosing the origin of the tumor and in relieving neurological symptoms. In those with solitary renal cell carcinoma metastases, surgery can increase disease-free survival. Current indications for surgery are (1) radioresistant tumor such as renal or colon carcinoma, (2) evidence of neurological function deterioration or tumor progression despite radiotherapy, (3) radiological images showing fragments of bone in the spinal canal, (4) spine instability due to fracture and causing pain and neurological deficit, (5) neurological deficit for > 24 hours, or significant MSCC, and (6) life expectancy of at least 3 months.,

Surgery should be considered only if it would increase the patient’s survival by > 3 months. The aim of this treatment is to decompress the spinal cord and stabilize the spine. Posterior decompression alone should be used only in cases of isolated epidural tumor or neural arch metastases without bony instability. In those in whom metastasis involves the vertebral body and who are therefore at increased risk of spinal instability, posterior decompression by internal fixation, with or without bone grafting, should be carried out. Reconstruction of the vertebral body should be carried out in patients with MSCC and vertebral body involvement who are expected to survive < 1 year, whereas in those expected to survive > 1 year, reconstruction of the vertebral body with anterior bone graft should be undertaken. In rare circumstances such as solitary renal or thyroid metastasis following complete staging, en bloc excisional surgery should be carried out.

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Vertebral augmentation

Two techniques, percutaneous vertebroplasty and kyphoplasty, initially developed for the treatment of painful vertebral haemangiomas, are now used effectively in treating painful pathological fractures caused by metastatic spinal disease. Vertebroplasty involves an injection of polymethylmethacrylate (PMMA) into the compression fracture whereas in kyphoplasty an inflatable balloon is placed in the vertebral body and PMMA is injected., Although these interventions can lead to significant pain reduction and greater mobility,, are contraindicated in SCC because of pathological fractures as they do not relieve cord compression. Complications of these techniques include leakage of PMMA, misplacement of PMMA, and hematogenous embolization of PMMA to the lungs.

Non‐operative Measures

Oral analgesia as titrated by the World Health Organization Analgesic Ladder is considered the first line in the treatment of bony pain. Morphine is the most commonly used opioid for moderate to severe pain and may be combined with adjuvant medications such as tricyclic antidepressants and corticosteroids. Side effects of medications can limit opioid dosage and cause significant morbidity. These include delirium, constipation, pruritus, nausea, vomiting, sedation, myoclonus, and respiratory depression[rx], [rx], [rx]. Other non‐invasive methods of pain relief include cutaneous stimulation, continuous repositioning, spine cryoablation, and regional nerve blocks[rx], [rx], [rxx].

Monthly infusions of bisphosphonates like zoledronic acid to patients with bone metastases reduce the frequency and delays the onset of skeletal‐related events[rx]. Their administration also provides significant improvements in bone pain and quality of life[rx]. Bisphosphonate use in patients with spinal metastases has increased in the past decade. Their use has decreased bone pain scores and reduced skeletal‐related events such as the need for local radiotherapy, hypocalcemia, pathologic fracture, and spinal cord compression[rx, rx]. Once injected, bisphosphonates are internalized by osteoclasts. This leads to a decrease in osteoclast activity and viability[rx]. Complications of bisphosphonate therapy include renal impairment and mandibular osteonecrosis[rx, rx]. Bisphosphonate demonstrates maximal effectiveness and safety when combined with either single or multiple fraction radiotherapy[rx, rx]. This synergism is due to the fact that radiotherapy is believed to reduce numbers of tumor‐produced osteoclast activating factors[rx]. The American Society of Clinical Oncology guidelines and the International Expert Panel guidelines recommend starting bisphosphonates when the first radiographic indication of metastatic deposits in the spine is noted[rx, rx].

Denosumab, a fully human monoclonal antibody to RANK‐L, has demonstrated in clinical trials inhibition of osteoclast‐mediated bone destruction in breast, prostate, and myeloma tumors, and is considered non‐inferior to zoledronic acid[rx], [rx]. A meta‐analysis performed by Lipton et al. compared the efficacy of denosumab to zoledronic acid in preventing skeletal‐related events in people with prostate cancer, breast cancer, solid tumors, or multiple myeloma. Denosumab increased the time to the first on‐study skeletal‐related event by 8.21 months and reduced the risk of a first skeletal‐related event by 17%[rx].

Chemotherapy is very seldom considered in the targeted treatment of metastatic spinal tumors due to its systemic nature and also owing to the fact that it requires an extended course of administration prior to pain relief[rx]. Complications are the source of morbidity and fear for the patient and include pain, gastrointestinal abnormalities, hematological disturbances, immunosuppression, and biopsychosocial sequelae (alopecia and infertility)[rx].

Pain caused by bone metastases has multiple causes, including periosteal elevation and inflammation[rx]. Radiopharmaceuticals may be used in the palliation of bony pain. Ethylenediamine tetramethylene phosphonic acid is an IV radioisotope that preferentially binds to osteoplastic metastases and osteosarcomas, and a significant analgesic effect may be achieved in 83%–93% of patients[rx]. Strontium‐89 chloride infusions have also been trialed as a similar treatment. Response rates vary in the published literature from minimal to up to 77%[rx]. Corticosteroids produce effects that include mood elevation, an anti‐inflammatory effect, and reduction of spinal cord edema in bony metastases[rx]. There is good evidence supporting the use of high-dose dexamethasone (64 mg/day) in the treatment of pain from spinal metastases, particularly if epidural compression is present. It is associated with significant pain relief and the ability to remain ambulatory in up to 81% of patients[rx].

Psychiatry

Involvement of psychiatric services may be necessary in patients with a diagnosis of metastatic spinal disease. Psychological complications in this instance usually manifest as anxiety, depression, adjustment disorder, and loss of self‐esteem[rx, rx]. Studies have shown that up to 50% of such patients may experience psychological issues following such a diagnosis[rx, rx]. Early involvement and assessment of this cohort of patients by psychiatric services is essential in the multidisciplinary management and treatment of spinal metastases.

Nutrition

Nutritional support is another consideration in the approach to metastatic spinal disease[rx]. The goals of nutrition support include preventing or reversing nutrient deficiencies, maximizing quality of life, aiding immunologic function, and preserving lean body mass.

This cohort is at risk of anorexia and cachexia[rx]. Important considerations include dysphagia after radiation, oesophagitis, and reduced motility owing to pain medications[rx]. Anorexia has been noted to be an almost universal side effect in individuals with widely metastatic disease[rx]. The multidisciplinary team must also consider decreased caloric intake as a result of diminished appetite and malaise and tumor competition for nutrients. Constipation may be secondary to opiate analgesia or spinal cord involvement by tumors causing an upper motor neuron lesion. Malnutrition may also exacerbate this. The addition of dietary calcium and vitamin D for bone health in the patients at risk of therapy‐associated fractures is warranted.

Screening and nutrition assessment should be interdisciplinary. Physicians, nurses, dietitians, and social workers (as members of the health‐care team) should all participate in nutritional management throughout the continuum of the management of the metastatic spinal disease. Such screening tests include the prognostic nutrition index[rx].

Suggestions for appetite improvement include keeping a daily menu, snacking between meals, eating small and frequent meals, and adding extra protein to meals[rx, rx]. Progestational agents such as megestrol acetate and medroxyprogesterone can lead to appetite stimulation and subsequent weight gain[rx]. The preferred method of nutritional support is via the oral route. If the GI tract is rendered dysfunctional, TPN may be indicated[rx].

Physiotherapy

Physiotherapists play a central role in the multidisciplinary approach to spinal metastasis. Their role is to maximize the quality of life by maintaining patient mobility and facilitating their capacity to perform activities of daily living[rx, rx]. Pain reduction therapies may also be employed, such as hot/cold packs, massage, and electrical stimulation. Assistive devices or orthotics, such as frames, canes, and thoracolumbosacral orthosis (TLSO), are provided by the physiotherapy department to patients with spinal metastasis when required[rx].

References