Spinal metastases are a secondary malignant lesion of the spinal column that occurs during the migration of tumor cells from a focus located in another organ. They are manifested by pain, impaired sensitivity and movement, paresis, paralysis, pelvic disorders, hypercalcemia and pathological fractures. The diagnosis of “metastases in the spine” is established taking into account anamnesis, general and neurological examination, radiography of the spine, CT of the spine and other diagnostic procedures. Treatment – chemotherapy, radiotherapy, hormone therapy, laminectomy, stabilizing surgery.
Meaning
Spinal metastases are secondary foci of a malignant tumor of another localization, affecting the vertebrae and nearby anatomical structures. They are the most common secondary malignant lesion of the skeleton. They make up 13% of the total number of oncological diseases. Primary neoplasia of the spinal column is more common. In 80% of cases, metastases to the spine are diagnosed with lung cancer, breast cancer and prostate cancer. They are often found in sarcomas and lymphomas. Any part of the spine can be affected. The thoracic and lumbar regions are more often affected, metastases to the spine are relatively rare in the cervical region. The prognosis is unfavorable. The treatment is carried out by specialists in the field of oncology and vertebrology.
Classification
Taking into account the characteristic changes in the bone substance, two types of metastases to the spine are distinguished:
- Osteolytic (osteoclastic) secondary foci – characterized by the predominant activation of osteoclasts that dissolve bone tissue. Accompanied by a decrease in the height of the vertebrae visible on radiographs.
- Osteoblastic (osteosclerotic) metastases in the spine are characterized by uncontrolled proliferation and an increase in bone density. Radiographs show “spotting”, a change in shape and an increase in the volume of the affected bone. Along with the bodies, the arches and processes of the vertebrae can be involved in the process.
The morphological structure of spinal metastases is highly variable and depends on the type of primary neoplasia. In the process of histological examination, high-medium- and low-differentiated and anaplastic carcinomas, squamous cell carcinoma and other types of malignant neoplasms can be detected.
Symptoms
The first manifestation usually becomes a pain syndrome. The pain is more often dull, aching, local or spreading beyond the level of the lesion. Non-intense pain with metastases in the spine may resemble a similar symptom in osteochondrosis, but differ from it in greater resistance and rapid progression. In the early stages, soreness with metastases to the spine may be insignificant, provoked by tapping on the vertebrae, turning the neck or lifting the straightened lower limb.
Subsequently, the pains become permanent, remain at rest. A typical feature of spinal metastases is nocturnal pain. Persistent local soreness is possible, against the background of which there is a feeling of “electric shocks” during movements. The places of the “blows” coincide with the projection of the roots. With metastases to the spine in the neck, pain radiates to the upper extremities, when the thoracic region is affected, the trunk is girdled, when localized in the lumbar or sacral region, it is given to the lower extremities.
With the progression of the process, radicular disorders occur in the form of lumbosacral or cervical-brachial radiculitis. During neurological examination in patients with metastases in the spine, positive symptoms of Neri, Lasega, Minor planting, etc. are detected. In some patients, pain sensitivity disorders are determined by the root type. For root pains with metastases to the spine, a certain cyclicity is characteristic: at the initial stage of the defeat of the next root, the intensity of the pain syndrome increases, after its complete destruction disappears, then reappears when it spreads to the next root.
In patients with metastases to the spine, polyneuropathy are found in the form of paresthesia, decreased sensitivity by the type of stockings and gloves, hyperhidrosis and redness of the distal extremities. Paresis and paralysis with metastases to the spine develop suddenly or gradually. There are disorders of movement and sensitivity in combination with pelvic disorders. The features of the clinical picture are determined by the level of lesion, the rate of progression of compression, the location of metastasis in relation to the spinal cord and the peculiarities of blood supply to the affected area. Brown-Sekara syndrome with metastases to the spine is rare.
With increased bone resorption, hypercalcemia may develop, manifested by drowsiness, lethargy, emotional lability, memory impairment, cognitive disorders, musculoskeletal pain, decreased appetite, digestive disorders, arrhythmia, increased blood pressure, itching and other symptoms. Hypercalcemic disorders aggravate the patient’s condition. Along with the above-listed manifestations caused by metastases to the spine, the patient may have symptoms caused by primary neoplasia and metastases located outside the spinal column.
Diagnostics
The diagnosis is made taking into account the medical history, clinical manifestations and additional examination. When studying the anamnesis, attention is paid to the presence of malignant tumors capable of metastasis to the spinal column. At the same time, oncologists take into account that the symptoms of metastases in the spine can occur both simultaneously or almost simultaneously with the manifestations of primary neoplasia, and several months or even years after its radical treatment. The absence of a history of cancer is not a reason to exclude metastases in the spine. Sometimes it is not possible to determine the localization of the primary process, despite conducting a comprehensive examination of the patient.
The presence of cancer is indicated by a positive blood test for cancer markers. At the initial stage of diagnosis, patients with suspected spinal metastases are prescribed a spine x-ray. In the early stages of metastasis, X-ray signs of vertebral lesions may be absent, therefore, if the study results are negative, patients with suspected spinal metastases are referred for scintigraphy, CT and MRI of the spine. To identify primary neoplasia and secondary foci, ultrasound of the abdominal cavity, chest radiography, mammography and other diagnostic procedures are performed. Differential diagnosis of metastases in the spine is carried out with vascular lesions, the consequences of inflammatory diseases, secondary demyelination and primary neoplasia of the spinal column.
Treatment
The treatment plan is determined by the type and prevalence of the primary neoplasm, the general condition of the patient, the volume and manifestations of metastases in the spine. The main goals of therapy are to reduce pain, prevent or eliminate compression of the spinal cord, improve the quality and increase the life expectancy of patients. In the process of treating metastases in the spine, chemotherapy drugs, diphosphonates, radiation therapy, hormone therapy and surgical interventions are used.
The decision on the need for chemo- and radiotherapy for spinal metastases is made taking into account the sensitivity of the primary tumor. Hormone-dependent neoplasia is treated with hormone therapy. To suppress bone resorption and eliminate hypercalcemia, diphosphonates are prescribed. Surgical interventions for spinal metastases are usually palliative in nature. Indications for surgery are intense pain, progressive compression of the spinal cord, acute radicular syndrome with instability of the spine and pathological fracture of the affected vertebra with compression of the spinal cord. The scope of intervention depends on the condition of the patient with metastases in the spine, the prognosis of the disease, the type of neoplasia and the prevalence of lesions in the spinal column. All operations for spinal metastases can be divided into two groups: decompressive and decompressive-stabilizing.
Decompression operations (laminectomies) are relatively simple and easier to tolerate by patients. Their main disadvantage is the high probability of repeated deterioration of the condition of patients due to the progression of metastases and instability of the spinal column caused by laminectomy. Decompression-stabilizing operations (using fixators, implants, auto- and allografts) allow patients to activate early, provide a long-term effect and significantly improve the quality of life of patients with spinal metastases. The main disadvantages of such interventions are their high traumatism, the impossibility of carrying out in a serious condition and disseminated processes.
Forecast
Metastases to the spine occur at stage IV of the oncological process, which is considered prognostically unfavorable. At the same time, bone metastases proceed quite favorably in comparison with secondary lesions of visceral organs. The average life expectancy for spinal metastases ranges from 1 to 2 years. As unfavorable prognostic factors, the rapid aggressive growth of primary neoplasia, multiple metastatic lesions of various organs, a short period of time between the therapy of the primary neoplasm and the occurrence of metastases in the spine, the large size of the metastatic tumor, the absence of signs of sclerosis on the radiographs of the vertebrae before and after therapy, the serious condition of the patient are considered. Favorable prognostic factors are the slow growth of the primary tumor, the single nature of metastases in the spine, the small size of secondary neoplasia, the presence of signs of sclerosis on radiographs before and after therapy, and the satisfactory condition of the patient.