Spine

Spinal metastases are the most common malignant tumours affecting the spine and represent an important clinical problem in patients with systemic cancer. They may cause severe pain, spinal instability, neurological impairment, and a marked reduction in quality of life. Since complications such as epidural spinal cord compression can progress rapidly and lead to permanent disability, early recognition and timely management are essential.

Metastatic spread to the spine usually occurs through the bloodstream. The thoracic spine is most commonly involved, followed by the lumbar and cervical regions. Breast, prostate, lung, kidney, and thyroid cancers account for many cases, although almost any malignant tumour can spread to the spine. Metastatic lesions often affect the vertebral bodies, where they may weaken bone, cause vertebral collapse, produce mechanical instability, and compress nearby neural structures.

The clinical presentation of spinal metastases varies, but pain is usually the earliest and most common symptom. Mechanical pain, which worsens with movement or weight bearing, may suggest spinal instability. Constant or night pain can indicate tumour infiltration, while radicular pain may occur when a nerve root is compressed. As the disease progresses, patients may develop weakness, numbness, gait disturbance, or bowel and bladder dysfunction due to compression of the spinal cord or cauda equina. Systemic symptoms such as weight loss, fatigue, or features related to the primary cancer may also be present. New severe back pain in a patient with known cancer, atypical persistent pain, or progressive neurological symptoms should therefore be treated as red flags requiring urgent assessment. 

Diagnosis begins with careful clinical assessment. A detailed history should identify the type of primary cancer, the duration and pattern of symptoms, previous treatments, and the patient’s overall functional status. Physical examination should include a neurological assessment, evaluation of gait, and inspection for spinal tenderness or deformity. In some patients, examination of organs such as the breast, thyroid, prostate, or kidney region may provide clues to the primary malignancy when it is not already known.

Imaging plays a central role in confirming diagnosis and planning treatment. Magnetic resonance imaging is the gold standard because it shows bone marrow involvement, epidural disease, nerve compression, and spinal cord compromise in detail (Figure 1). Plain X-rays are less sensitive but are quick, inexpensive, and widely available, and they may help identify obvious bony lysis, collapse, or deformity (Figure 2). Bone scans and PET/CT can help evaluate the overall burden of metastatic diseases and detect additional sites of spread. When primary cancer is unknown or the diagnosis remains uncertain, biopsy may be necessary. Blood tests, including calcium, alkaline phosphatase, tumour markers, inflammatory markers, and routine preoperative investigations, may provide supportive information and help assess the patient’s general condition.

The management of spinal metastases should be individualised. The main goals are to relieve pain, preserve or restore neurological functions, maintain spinal stability, and control local and systemic diseases. Treatment decisions depend on the patient’s general condition, cancer type, disease stage, severity of symptoms, expected survival, and personal goals. For this reason, multidisciplinary input is often essential.

Medical treatment includes appropriate analgesia, such as non-steroidal anti-inflammatory drugs, opioids, and neuropathic pain agents. Corticosteroids, such as dexamethasone, may be used when spinal cord compression is suspected, as they may slow down neurological deterioration while definitive treatment is arranged. Systemic therapy, including chemotherapy, hormonal therapy, targeted therapy, or immunotherapy, is selected according to tumour biology and guided by oncology input.

Local treatment commonly involves radiotherapy, surgery, or a combination of both. Conventional external beam radiotherapy is effective for pain relief and local tumour control in many patients. Stereotactic body radiotherapy allows high-dose, highly focused treatment and may be especially useful for radioresistant tumours or limited metastatic diseases. Surgery is considered when there is progressive neurological deficit, mechanical instability, high-grade epidural spinal cord compression, intractable pain, deformity, or when separating the tumour from spinal cord is needed to improve the effectiveness of radiotherapy. Surgical procedures may include decompression, stabilisation, and tumour debulking, often followed by postoperative radiotherapy. In rare cases, total en bloc vertebrectomy may be a better method of local cancer control, and in very rare cases, curative resection can be achieved (Figure 3).

In conclusion, spinal metastases require prompt diagnosis and a coordinated, patient-centred approach. By integrating clinical assessment, modern imaging, systemic cancer therapy, radiotherapy, surgery, rehabilitation, and supportive care, clinicians can reduce pain, protect neurological function, maintain spinal stability, and improve quality of life for patients living with metastatic cancer.