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Vertebral Metastasis:

Vertebral Metastasis Summer Snoek, Steven Solana and Albert Mobley June 16, 2011

General Information:

General Information Metastatic disease is the most common tumor affecting the spinal column. 1 Approximately 70% of all spinal tumors are metastatic in nature. 2 Most vertebral metastases originate from primary carcinoma of the breast, lung, prostate, thyroid gland or intestinal tract. 2,3 The mechanism by which malignant tumors metastasize to and deposit within the bones of the spine is not completely understood. 4

Two types of spinal metastases:

Two types of spinal metastases Osteoclastic / Osteolytic (destruction of bone) Hard and ivory like appearance to the bone. May be mistaken for osteopetrosis , osteoslerotic anemia, Hodgkin’s disease or syphilis. 2 Osteoblastic (formation of bone) Frequently associated with vertebral body collapse. May be mistaken for plasma cell myeloma or Kummell’s disease. 2 Osteolytic destruction is present in 75% of spinal metastases. 5 Both osteolytic and osteoblastic types may be present within the spinal column and even within the same vertebrae. 2

Vertebral Metastases of C56:

Vertebral Metastases of C5 6

Hodgkin disease7:

Hodgkin disease 7

Differential Diagnosis of Ivory Vertebrae:

Differential Diagnosis of Ivory Vertebrae From the previous two radiographs we can observe the similar appearance of the ivory vertebra. Diagnosis is more challenging with standard radiographs

Anatomical Location:

Anatomical Location Thoracic and lumbar spinal segments are the vertebral segments most frequently affected by spinal metastases. 8 The vertebral body is the most frequently affected anatomical site of involvement in cervical spinal metastases. 9


Incidence Typical patient is between 55-60 years of age. 10 A review of 500 cases of men with malignant tumors showed incidence of 19.6% for metastasis to the spine. 2 A review of 500 cases of women with malignant tumors showed incidence of 15.6% for metastasis to the spine. 2 Men: 66.7% of prostatic carcinomas metastasized to the spine. 2 Women: 66.6% of breast carcinomas metastasized to the spine. 2

Signs and Symptoms:

Signs and Symptoms Most common clinical feature of a patient with vertebral metastasis is pain. 3 Approximately 89-93% of patients present with pain. 3 Neurological symptoms may or may not be present depending on the progression of the disease. 3 Possible neurological signs include weakness, sensory loss and sphincter dysfunction. 3 Symptoms of vertebral metastasis may be present for weeks or months and are often misdiagnosed as muscle strains or discogenic in nature. 11

Primary Symptom: Pain:

Primary Symptom: Pain Tumor-related pain: 12 Results from osseous destruction as the tumor infiltrates and stretches the periosteum of the vertebrae. Pain is typically experienced at night or early morning. Described as constant pain that can not be altered with activity or rest. Mechanical pain: 3 Results from structural changes of the vertebral column secondary to the disease process. Pain typically reproduced with movement, thus mimicking musculoskeletal dysfunction.

Diagnosis and Prognosis:

Diagnosis and Prognosis 30-50% osseous destruction must occur before changes are detectable by radiograph. 3 Transverse axial tomography is capable of detecting metastatic disease in the early stage. 13 MRI is the gold standard for evaluation of vertebral metastases. 3 Both sensitive and specific Detects cord and nerve compression, if present Detects pathological changes in the bone marrow

Impact on Function:

Impact on Function Vertebral Metastases may compress the spinal cord leading to acute deterioration 17 95% of patients present with back pain typically worse at night 18 Weakness is the second most common symptomatic manifestation 18-20 Patients with paraparesis will likely become paraplegic if untreated 17 Ambulation: 50-68% of patients are unable to walk at the time of diagnosis secondary to weakness. 18-20 50-60% of patients have bowel or bladder dysfunction at the time of diagnosis. 18-20

Role of Imaging:

Role of Imaging Imaging has a critical role in the recognition, diagnosis, prognosis, treatment planning, and follow-up monitoring of bone metastases 14 In patients with proven non-skeletal tumors, imaging is useful for screening the skeleton to assess metastatic disease and, if it is present, to determine its extent 15,16 Types of Imaging- Conventional Radiographs CT Scans MRI Technetium-99m ( 99m Tc ) bone scintiscanning

Conventional Radiographs21:

Conventional Radiographs 21 Conventional radiography is relatively insensitive to bone metastases. 50% destruction of the bone mineral content is necessary for detection, thus it is not apparent on conventional radiographs the early stages of disease. As a rule, lesions need to be ≥ 2 cm to be detected. Conventional radiography is still the preferred imaging method to determine behavior (i.e.) sclerotic, osteolytic or mixed. Osteolytic metastases can mimic: OA, Subchondral cysts or Schmorl nodes of the spine Sclerotic metastases may mimic other sclerotic bone lesions such as: Tuberous sclerosis, Mastocytosis or Osteopoikilosis

Sclerotic metastases of L221 :

Sclerotic metastases of L2 21 Common signs of spinal metastases found on conventional radiographs include: Destruction of the pedicle Associated soft-tissue mass Angular or irregular deformity of the endplates.


MRI Smoker et al. concluded MRI was the imaging method of choice for evaluating suspected metastatic spinal pathology. 22 Herneth et al. concluded that apparent diffusion coefficient (ADC) values calculated from diffusion-weighted MR images is a reliable factor to distinguish vertebral metastases from normal vertebrae. 23 MRI can also help detect metastatic lesions before changes in bone metabolism make the lesions detectable on bone scintiscans 24-27

Sagittal MR Images27:

Sagittal MR Images 27 Vertebral metastasis at L1 (arrows) Acute compression fractures at T11 and T12 (arrowheads) A. T1 MRI – hypointense fractures B. T2 MRI - hyperintense fractures C/D. Diffusion weighted MRI - hyperintense fractures/metastasis E. Apparent Diffusion Coefficient Map showing both metastasis / fractures


Questions If a patient is referred to your clinic with a diagnosis of mild back ache, what important current and past medical questions must you ask to rule out vertebral metastasis? Can you rule it out? It is vital that we are aware of the symptom behavior of a potential metastasis of the spine. What are the clinical symptoms and how will you differentiate them from a musculoskeletal and/or neuromuscular dysfunction during the examination?


References 1. Van goethem JW, van den Hauwe L, Ozsarlak O, De Schepper AM, Parizel PM. Spinal tumors. Eur J Radiol . 2004; 50: 159-76. 2. Schmorl G, Junghanns H. The Human Spine in Health and Disease 2 nd ed. New York: Grune & Stratton; 1971. 3. Perrin RG, Laxton AW. Metastatic spine disease: epidemiology, pathophysiology , and evaluation of patients. Neurosurg Clin N Am. 2004; 15: 365-73. 4. Roodman GD. Mechanisms of bone metastasis. N Engl J Med. 2004; 350: 1655-64. 5. Taylor JA, Yochum TR. Diagnostic imaging in skeletal metastases. Apple Diagn Imaging. 1990; 2: 1-8. 6. Image. http://neuroradiologyonthenet.blogspot.com/2009/12/ivory-vertebral-body-from-prostate.html 7. Guermazi A, Brice P, Kerviler E. Extranodal hodgkin disease: spectrum of disease. Radiographics . 2001; 21: 161-179. 8. Livingston KE, Perrin RG. Neurosurgical management of spinal metastases. J Neurosurg . 1978; 49: 839-43.

Slide 20:

9. Jenis LG, Dunn EJ, An HS. Metastatic disease of the cervical spine: a review. Clin Orthop Relat Res. 1999; 359: 89-103. 10. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. Cancer J Clin . 2000; 50:7-33. 11. Goodkin R, Carr BI, Perrin RG. Herniated lumbar disc disease in patients with malignancy. J Clin Oncol . 1987; 5: 667-71. 12. Bilsky MH, Lis E, Raizer J, Lee H, Boland P. The diagnosis and treatment of metastatic spinal tumor. Oncologist. 1999; 4: 459-69. 13. Post, MJD. Radiographic Evaluation of the Spine: Current Advances with Emphasis on Computed Tomography . New York: MASSON Publishing USA; 1980. 14. Downey SE, Wilson M, Boggis C, et al. Magnetic resonance imaging of bone metastases: a diagnostic and screening technique. Br J Surg . Aug 1997;84(8):1093-4. 15. Peh WC. Screening for bone metastases. Am J Orthop . May 2000;29(5):405.

Slide 21:

16.Traill ZC, Talbot D, Golding S, Gleeson FV. Magnetic resonance imaging versus radionuclide scintigraphy in screening for bone metastases. Clin Radiol . Jul 1999;54(7):448-51. 17. Meyer SA, Singh H, Jenkins AL. Surgical Treatment of Metastatic Spinal Tumors: Mount Sinai Journal of Medicine. 2010; 77:124–129. DOI: 10.1002/msj.20162. 18. Cole JS, Patchell RA. Metastatic epidural spinal cord compression. Lancet Neurol 2008; 7: 459–466 19. Constans JP, de Divitiis E, Donzelli R, et al. Spinal metastases with neurological manifestations. Review of 600 cases. J Neurosurg 1983; 59: 111–118. 20. Bach F, Larsen BH, Rohde K, et al. Metastatic spinal cord compression. Occurrence, symptoms, clinical presentations and prognosis in 398 patients with spinal cord compression. Acta Neurochir (Wien) 1990; 107: 37–43. 21. Peh WC, Muttarak M, Abdel- Dayem HM, et al. Imaging in bone metastasis. Medscape Reference. 2011. http://emedicine.medscape.com/article/387840-overview#a24

Slide 22:

22. Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol 1978; 3: 40–51. 23. Smoker WR, Godersky JC, Knutzon RK, Keyes WD, Norman D, Bergman W. The role of MR imaging in evaluating metastatic spinal disease; American Journal of Roentgenology . 1987;149(6):1241-1248 24. Kattapuram SV, Khurana JS, Scott JA, el- Khoury GY.Negative scintigraphy with positive magnetic resonance imaging in bone metastases. Skeletal Radiol . 1990;19(2):113-6. 25. Algra PR, Bloem JL, Tissing H, et al. Detection of vertebral metastases: comparison between MR imaging and bone scintigraphy . Radiographics . Mar 1991;11(2):219-32. 26. Frank JA, Ling A, Patronas NJ, et al. Detection of malignant bone tumors: MR imaging vs scintigraphy . AJR Am J Roentgenol . Nov 1990;155(5):1043-8. 27. Herneth AM, Guccione S, Bednarski M. Apparent diffusion coefficient: a quantitative parameter for in vivo tumor characterization. Eur J Radiol . 2003;45(3):208–213