Spinal tumours

In one minute

A spinal tumour is an abnormal growth in or around the spine. The great majority are metastases, deposits from a cancer that began elsewhere, most often in the breast, prostate or lung. Tumours that start in the spine itself are rare. The first symptom is almost always back pain, and the danger is that a growing deposit collapses the vertebra or presses on the spinal cord. MRI (magnetic resonance imaging) of the whole spine is the test, and it is urgent when there is cancer in the history and more urgent still when the legs are weak. Treatment is decided by a team: surgeons to decompress and stabilise, radiotherapists and oncologists to control the tumour. The aim for a metastasis is to keep you walking, out of pain and stable, and we say so plainly, because that is different from a cure.

What it is

Cancer cells travel in the blood and settle in the bone marrow of the vertebral body, which is rich in blood supply. There they grow, weaken the bone and can extend backward into the canal. Doctors call this a spinal metastasis; when it presses on the cord it is metastatic spinal cord compression (MSCC), and when the weakened vertebra collapses it is a pathological fracture. A 2022 systematic review found that metastases are diagnosed in the spine during life in about 16% of people with a solid cancer, and are present at autopsy in about 30%; roughly two thirds come from breast, prostate or lung cancer, about 1 in 10 people with spinal metastases develop cord compression, and about 1 in 8 a pathological fracture.

Primary tumours are the exception. Benign ones include haemangiomas, which are common and almost always harmless, and osteoid osteoma. Malignant ones include chordoma, chondrosarcoma and myeloma. Tumours inside the canal, such as meningioma, schwannoma and ependymoma, grow from the nerve coverings or the cord. Each has its own treatment, and where a primary bone tumour can be removed whole, that is planned with a tumour surgeon.

Causes and risk factors

The risk factor for a spinal metastasis is a cancer, known or not yet found. Breast, prostate, lung, kidney and thyroid cancers and myeloma spread to bone most readily. Time matters: in the 2022 review, lung cancer reached the spine soonest, after about nine months on average, and breast and prostate cancer after about 15 and 17 months, so a history of cancer, however old, still counts. Some people have no known cancer when the spinal metastasis is found, and the spine lesion is the first sign. For primary spinal tumours, most have no identifiable cause; a few run in families.

How it develops

A metastasis destroys bone from the inside. As the vertebral body weakens it can fracture and collapse, which causes sudden mechanical pain and can push bone backward into the canal. Tumour can also grow directly backward through the wall of the vertebra into the epidural space, where it squeezes the cord from the front. The cord tolerates slow compression for a while and then fails, sometimes over days: first the legs feel heavy, then weak, then bladder and bowel control go. The review data show that about one third of patients with cord compression have a deficit when it is found, and the length of time the cord has been compressed decides how much recovers.

Symptoms

Back pain is the first symptom in almost all cases, in 88 to 94% at diagnosis in the review series. It differs from ordinary back pain: it is constant and progressive, it is often worst at night or when lying flat, it may wrap around the trunk in a band, and it is made worse by coughing, straining or sneezing. The NICE guideline lists these features, and the neurological ones that follow: difficulty walking or unsteadiness, weakness in the legs or arms, numbness or tingling, and bladder or bowel dysfunction. In the review series, unsteadiness was a more common first sign than weakness.

Diagnosis

The examination checks strength, sensation, reflexes, walking and bladder function, and looks for signs of a primary cancer. The NICE guideline sets the timing: a person with spinal pain suggestive of metastases but no neurological symptoms should have an MRI of the whole spine and a treatment plan within one week; a person with neurological symptoms should have it within 24 hours. The whole spine is scanned because deposits are often multiple. CT (computed tomography) shows the bone destruction and is used to plan surgery, and a CT of the chest, abdomen and pelvis or a PET scan (positron emission tomography) looks for the primary and other deposits. Blood tests include markers such as PSA (prostate-specific antigen) and myeloma screening.

If there is no known cancer, a needle biopsy under CT guidance gives the diagnosis before treatment, because the treatment differs by tumour type. The report may describe the level, whether the lesion is lytic (bone destroyed) or blastic (bone thickened), vertebral collapse, epidural extension and the degree of cord compression. For our opinion, send the whole-spine MRI, the CT if any, the reports and your cancer history.

Treatment without surgery

For a metastasis, most of the treatment is not surgical. Corticosteroids are started as soon as cord compression with neurological symptoms is suspected, at a dose the treating doctor sets, to reduce swelling around the cord. Radiotherapy is the main local treatment: conventional radiotherapy for radiosensitive tumours such as myeloma, lymphoma, breast and prostate cancer, and stereotactic radiosurgery, a highly focused high-dose form, for tumours that respond poorly to standard doses. The NICE guideline asks for radiotherapy to start within 24 hours of the decision when surgery is not suitable. Systemic treatment, meaning chemotherapy, hormone therapy, targeted drugs or immunotherapy, is the oncologist's part, and bone-strengthening drugs reduce further fractures. Pain is treated with a proper analgesic ladder, and a brace can ease mechanical pain from a collapsed vertebra while other treatment takes effect.

When surgery is considered

Decisions follow a framework that oncology teams call NOMS: neurological (how much the cord is compressed), oncological (how sensitive the tumour is to radiation), mechanical (whether the spine is stable) and systemic (how fit the person is and what the outlook is). Two scores help. The Spinal Instability Neoplastic Score (SINS) adds the level, the pain, the type of bone lesion, the alignment, the degree of collapse and the involvement of the back of the vertebra into a score from 0 to 18; 0 to 6 is stable, 7 to 12 potentially unstable, 13 to 18 unstable, and 7 or more should bring a spine surgeon into the discussion. The revised Tokuhashi score estimates survival from six factors, with a score of 8 or less predicting under six months and 12 or more a year or longer, and in the original validation matched the actual survival in 86% of patients; a 2022 review warns that survival scores now underestimate how long people live with modern oncology.

Surgery is considered when the cord is compressed and the deficit is new or progressing, when the spine is unstable, and when a tumour keeps growing despite radiotherapy, provided the person is fit enough and expected to live long enough to benefit. A randomised trial published in 2005 assigned 101 patients with cord compression to surgery followed by radiotherapy or radiotherapy alone: 84% versus 57% could walk afterwards, they kept walking for a median of 122 days versus 13, and of those who arrived unable to walk, 62% versus 19% regained it. The NICE guideline asks that surgery intended to halt or reverse neurological decline be done as soon as possible after symptoms begin.

Surgical options

Separation surgery removes the tumour that is pressing on the cord and creates a margin of a few millimetres between the cord and the remaining tumour, then stabilises the spine with screws, so that stereotactic radiosurgery can treat the rest safely. In a series of 186 patients, local progression at one year was 16% overall and about 4% after the high-dose hypofractionated regimen. Decompression and stabilisation with pedicle screws, open or percutaneous, treats instability and cord compression; when the vertebral body has collapsed it may be replaced with a cage. Vertebroplasty or kyphoplasty can relieve the pain of a collapsed vertebra without cord compression; see the vertebroplasty and kyphoplasty page. Complete removal of a vertebra with the tumour inside it, called en bloc resection, is reserved for selected primary tumours and solitary metastases. Fusion is described on the spinal fusion page.

Endoscopic surgery has a limited place here. It can decompress a nerve root in selected cases, but stabilisation and tumour removal need open or percutaneous surgery, and we say so.

How we treat it at spine.uz

A spinal tumour is never treated by a spine surgeon alone. Decisions are made with oncologists, radiotherapists and radiologists, and the surgeon's part is to decompress the cord, stabilise the spine and obtain tissue for diagnosis when that is needed. Not every case needs an operation, and not every operation is endoscopic. We are Tashkent's first endoscopic spine team, five surgeons operating as one, and the team treats the full range of surgical spine pathology, including the decompression and stabilisation that tumours require.

If you would like an opinion on whether a spinal lesion needs surgical treatment, send the MRI and CT images and your cancer history through Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours. The in-person consultation and any operation are paid, and after the consultation you receive a written conclusion from the team that you can share with your oncologist. Across the team's 27,600+ endoscopic and spine operations, our complication rate is well below 1%.

Recovery and outcomes

The honest measure of success for a metastasis is function. In the randomised trial, 84% of the group treated with surgery and radiotherapy could walk after treatment, and they kept walking for a median of 122 days, about four months. Pain from a stabilised spine usually eases within days to weeks. Survival depends on the cancer, not on the spine operation: in the 2022 review, median survival with spinal metastases was about six months overall, longer for breast and prostate cancer (roughly one to three years) and shorter for lung cancer, and paralysis shortened it sharply. The same review notes that survival has improved with modern oncology and that the usual prediction scores now underestimate it.

Recovery after spinal surgery for a tumour is slower than after degenerative surgery because of the illness itself, and radiotherapy is usually given within weeks of the operation. For a primary benign tumour that has been removed completely, recovery is usually full.

Living with it and prevention

There is no way to prevent a spinal metastasis other than treating the cancer. What helps: report new back pain early if you have had cancer, keep active as far as pain allows, take the bone-strengthening drugs your oncologist prescribes, and keep the treating team, oncologist, radiotherapist and surgeon, talking to each other about you.