# CIM Case: Spinal Metastasis ## Clinical Scenario **Patient:** 78-year-old female **Presentation:** 15-year history of chronic mechanical back pain, 3-month history of new-onset right thigh pain radiating to knee, associated with new-onset difficulty walking and progressive weakness, unintentional 8kg weight loss **Relevant history:** No known prior malignancy, 30-pack-year smoking history (ceased 10 years ago), no previous spinal surgery **Examination findings:** - Thin, cachectic appearance - Point tenderness L2-L3 region - Decreased ROM lumbar spine due to pain - Right hip flexion and knee extension weakness (4/5) - Left lower limb normal power - Absent right knee jerk, left normal - Sensation intact bilateral - No bladder or bowel dysfunction - Rectal examination: normal tone --- ## Investigations Provided ### Laboratory Results | Test | Result | Normal Range | Interpretation | |------|--------|--------------|----------------| | Haemoglobin | 98 g/L | 120-160 | Anaemia of chronic disease | | WCC | 8.2 × 10⁹/L | 4-11 | Normal | | Platelets | 345 × 10⁹/L | 150-400 | Normal | | ESR | 78 mm/hr | 0-20 | Elevated - malignancy/inflammation | | CRP | 45 mg/L | <5 | Elevated | | Sodium | 141 mmol/L | 135-145 | Normal | | Potassium | 4.2 mmol/L | 3.5-5.0 | Normal | | Creatinine | 95 μmol/L | 60-110 | Normal | | Calcium (corrected) | 2.85 mmol/L | 2.15-2.55 | **Hypercalcaemia** | | Albumin | 28 g/L | 35-50 | Low (malnutrition/chronic disease) | | ALP | 245 U/L | 30-120 | **Elevated** - bone/liver | | LDH | 380 U/L | 120-250 | Elevated | | PSA | N/A | - | Not applicable (female) | | CA 15-3 | 145 U/mL | <30 | **Elevated** (breast marker) | | CEA | 8.5 ng/mL | <5 | Mildly elevated | | Protein electrophoresis | No paraprotein | - | Myeloma excluded | ### Imaging **Image 1: Plain Radiograph Lumbar Spine - AP and Lateral** **Radiological features:** - Collapse of L2 vertebral body (50% height loss) - Loss of left pedicle "winking owl" sign - Soft tissue mass extending into left paraspinal region - Osteopaenic appearance generally **Image 2: MRI Whole Spine with Gadolinium** **MRI findings:** - L2 pathological fracture with complete replacement of marrow signal (T1 low, T2 heterogeneous, enhances with Gd) - Epidural soft tissue extension causing moderate thecal sac compression - Cord terminates at L1 - no cord signal change - Additional lesions at T8, T11 (marrow replacement, no collapse) - No leptomeningeal disease **Image 3: CT Chest/Abdomen/Pelvis** **CT staging findings:** - 2.5cm spiculated left upper lobe mass - Mediastinal lymphadenopathy - Multiple hepatic lesions (metastases) - Lytic lesions bilateral iliac bones - No pelvic visceral lesion ## Questions & Model Answers **Differential Diagnosis for Metastatic Spinal Disease:** This patient has a destructive spinal lesion with systemic features strongly suggesting malignancy. The primary task is identifying the source. **Most Common Primaries Metastasising to Spine:** | Primary | Frequency | Clues in This Patient | |---------|-----------|----------------------| | **Lung** | 30-40% | 30 pack-year smoking, LUL mass on CT | | **Breast** | 20-30% | Female, elevated CA 15-3 | | **Prostate** | 15-20% | Not applicable (female) | | **Renal** | 10-15% | No renal mass on CT | | **Thyroid** | 5-10% | Not evident | | **Myeloma** | 5-10% | Protein electrophoresis negative | | **Unknown primary** | 5-10% | Must be excluded | **This Patient:** Likely lung primary given smoking history and LUL mass. However, elevated CA 15-3 raises breast as possibility. **Workup for Unknown Primary:** **Step 1: Basic Bloods (done)** | Test | Purpose | |------|---------| | FBC | Anaemia (chronic disease, marrow infiltration) | | EUC | Renal function, hypercalcaemia effect | | LFTs | Liver metastases, ALP (bone) | | Calcium | Hypercalcaemia of malignancy | | LDH | Tumour burden marker | **Step 2: Tumour Markers** | Marker | Primary Tumour | |--------|----------------| | PSA | Prostate | | CA 15-3 | Breast | | CEA | GI, lung | | AFP | HCC, germ cell | | CA 125 | Ovarian | | CA 19-9 | Pancreatic, biliary | | Thyroglobulin | Thyroid | | Chromogranin A | Neuroendocrine | | Protein electrophoresis | Myeloma | **Step 3: Imaging** | Imaging | Purpose | |---------|---------| | CT CAP | Primary identification, staging | | Bone scan or PET | Extent of skeletal disease | | MRI whole spine | All spinal lesions, cord compression | | Mammogram (female) | Occult breast primary | **This Patient's Primary:** CT shows lung mass - most likely primary lung carcinoma with bone metastases. > **Consultant Tip:** Always consider the common primaries (lung, breast, prostate, kidney, thyroid, myeloma). CT CAP is the workhorse for primary identification. **Prognostic Scoring Systems:** Prognosis determines treatment intensity - from conservative care to aggressive surgery. **1. Tokuhashi Revised Score (2005):** | Parameter | Score 0 | Score 1 | Score 2 | This Patient | |-----------|---------|---------|---------|--------------| | **General condition (KPS)** | Poor (10-40%) | Moderate (50-70%) | Good (80-100%) | Moderate = **1** | | **Extraspinal bone metastases** | ≥3 | 1-2 | 0 | ≥3 (iliac bones) = **0** | | **Vertebral metastases** | ≥3 | 2 | 1 | 3 (L2, T8, T11) = **0** | | **Visceral metastases** | Unresectable | Resectable | None | Liver mets = **0** | | **Primary tumour site** | Lung, stomach, etc. | Kidney, uterus, etc. | Breast, thyroid, etc. | Lung = **0** | | **Spinal cord palsy** | Complete | Incomplete | None | Incomplete (L3) = **1** | | **TOTAL** | | | | **2/15** | **Tokuhashi Interpretation:** | Score | Predicted Survival | Recommended Treatment | |-------|-------------------|----------------------| | 0-8 | <6 months | Palliative (conservative or simple surgery) | | 9-11 | ≥6 months | Palliative or excisional surgery | | 12-15 | ≥12 months | Excisional surgery | **This Patient:** Tokuhashi 2 = poor prognosis (<6 months). **2. Tomita Score:** | Parameter | Score | |-----------|-------| | **Primary tumour growth rate** | | | - Slow (breast, thyroid, prostate) | 1 | | - Moderate (kidney, uterus) | 2 | | - Rapid (lung, stomach, liver, unknown) | 4 | | **Visceral metastases** | | | - None | 0 | | - Treatable | 2 | | - Untreatable | 4 | | **Bone metastases** | | | - Solitary or isolated | 1 | | - Multiple | 2 | **This Patient:** Primary = Lung (4) + Visceral = Yes/untreatable (4) + Bone = Multiple (2) = **10** **Tomita Interpretation:** | Score | Strategy | Surgery | |-------|----------|---------| | 2-3 | Long-term control | Wide excision | | 4-5 | Mid-term control | Marginal excision | | 6-7 | Short-term palliation | Palliative surgery | | 8-10 | Terminal care | Supportive only | **This Patient:** Tomita 10 = terminal care, supportive only. **3. SINS (Spinal Instability Neoplastic Score):** | Component | Score | This Patient | |-----------|-------|--------------| | **Location** | | | | - Junctional (O-C2, C7-T2, T11-L1, L5-S1) | 3 | | | - Mobile spine (C3-6, L2-4) | 2 | L2 = **2** | | - Semi-rigid (T3-10) | 1 | | | - Rigid (S2-S5) | 0 | | | **Pain** | | | | - Mechanical | 3 | Mechanical = **3** | | - Non-mechanical | 1 | | | - None | 0 | | | **Bone lesion type** | | | | - Lytic | 2 | Lytic = **2** | | - Mixed | 1 | | | - Blastic | 0 | | | **Alignment** | | | | - Subluxation/translation | 4 | | | - Kyphosis/scoliosis | 2 | Some kyphosis = **2** | | - Normal | 0 | | | **Vertebral body collapse** | | | | - >50% | 3 | 50% = **3** | | - <50% | 2 | | | - None | 1 | | | - Posterior elements only | 0 | | | **Bilateral posterior element involvement** | | | | - Yes | 3 | | | - No | 0 | Left only = **0** | | **TOTAL** | | **12** | **SINS Interpretation:** | Score | Stability | Recommendation | |-------|-----------|----------------| | 0-6 | Stable | Likely non-surgical | | 7-12 | Indeterminate | Surgical consultation | | 13-18 | Unstable | Surgical stabilisation | **This Patient:** SINS 12 = indeterminate, surgical consultation warranted. > **Consultant Tip:** Tokuhashi guides overall management intensity. SINS determines if spine is unstable and needs stabilisation. Poor prognosis doesn't preclude surgery for pain/function. **Tissue Diagnosis in Spinal Metastasis:** Histological confirmation is essential before treatment unless: - Known primary with classic metastatic pattern - Patient too unwell for any intervention - Urgent decompression required (can biopsy intraoperatively) **Biopsy Considerations:** **When Biopsy is Essential:** | Situation | Rationale | |-----------|-----------| | Unknown primary | Must identify for systemic treatment | | Atypical presentation | Could be primary bone tumour, infection | | Solitary lesion | May be primary, different prognosis | | Young patient | Must exclude primary bone malignancy | | Inconsistent with known malignancy | New primary possible | **Biopsy Options:** **Option 1: CT-guided Percutaneous Biopsy (Preferred)** | Aspect | Details | |--------|---------| | **Approach** | Transpedicular or posterolateral | | **Guidance** | CT fluoroscopy | | **Cores** | Multiple cores for histology | | **Diagnostic yield** | 80-95% | | **Advantages** | Minimally invasive, outpatient | | **Risks** | Bleeding, infection, neurological (<1%) | **Transpedicular Approach:** | Advantage | Consideration | |-----------|--------------| | Contained tract | Reduces tumour seeding | | Access to body and posterior elements | Versatile | | Minimal paraspinal contamination | If later resection planned | **Option 2: Biopsy of Most Accessible Lesion** | Site | Advantage | |------|-----------| | Lung mass | Bronchoscopy or CT-guided | | Liver | CT-guided, good yield | | Lymph node | Ultrasound-guided | | Iliac bone | May be easier access | **This Patient:** Could biopsy lung mass (likely primary) OR spinal lesion (if lung biopsy non-diagnostic). **Option 3: Open Surgical Biopsy** | Indication | Situation | |------------|-----------| | Percutaneous non-diagnostic | Need open sample | | Surgery planned anyway | Biopsy at time of decompression | | Suspicion of infection | Need more tissue | **Biopsy Planning Principles:** | Principle | Rationale | |-----------|-----------| | Biopsy tract through planned surgical approach | If resection considered | | Avoid contaminating compartments | Oncological principle | | Send for culture also | Infection differential | | Fresh tissue for molecular | Targeted therapy testing | **Expected Histology - Lung Carcinoma:** | Feature | Finding | |---------|---------| | **Morphology** | Adenocarcinoma or squamous | | **Markers** | TTF-1+, Napsin A+ (adenocarcinoma) | | **Molecular** | EGFR, ALK, ROS1, PD-L1 | > **Consultant Tip:** In an unknown primary, biopsy the most accessible lesion with highest yield. For solitary spine lesion without known primary, always biopsy before treatment. **Treatment Strategy for Metastatic Spinal Disease:** Treatment is multidisciplinary - orthopaedic/spinal surgeon, radiation oncologist, medical oncologist, palliative care. **Goals of Treatment:** | Goal | Priority | |------|----------| | **Pain control** | Primary | | **Preserve/restore neurological function** | Critical | | **Maintain/restore spinal stability** | Important | | **Local tumour control** | Secondary | **Treatment Options:** **1. Non-operative Management** | Treatment | Indication | |-----------|------------| | **Analgesia** | All patients - WHO ladder | | **Steroids** | Cord compression, reduces oedema | | **Bracing** | Unstable spine, poor surgical candidate | | **Radiotherapy** | Radiosensitive tumours, pain control | **2. Radiotherapy - Conventional External Beam (EBRT)** | Aspect | Details | |--------|---------| | **Regimen** | 20-30 Gy in 5-10 fractions | | **Pain relief** | 60-80% achieve some relief | | **Onset** | Takes 2-4 weeks | | **Radiosensitive** | Myeloma, lymphoma, breast, prostate | | **Radioresistant** | RCC, melanoma, lung | **This Patient:** Lung primary - relatively radioresistant. **3. Stereotactic Body Radiotherapy (SBRT)** | Advantage | Details | |-----------|---------| | **Precision** | High dose to tumour, spares cord | | **Dose** | 16-24 Gy single fraction or hypofractionated | | **Indication** | Radioresistant tumours, post-operative | | **Contraindication** | Significant cord compression | **4. Surgery** **Indications for Surgery (NOMS Framework):** | N - Neurological | O - Oncological | M - Mechanical | S - Systemic | |------------------|-----------------|----------------|--------------| | Cord compression | Radioresistant | SINS instability | Life expectancy | | Myelopathy | Tumour control | Pathological fracture | Fitness for surgery | | Rapid decline | Post-XRT recurrence | Deformity | Systemic disease | **Surgical Options:** **Option A: Decompression + Stabilisation (Palliative)** | Approach | Details | |----------|---------| | **Posterior** | Laminectomy + pedicle screw fixation | | **Levels** | 2 above, 2 below involved level | | **Indication** | Cord compression, instability | | **Advantages** | Familiar, rapid decompression | **Option B: Separation Surgery + SBRT (Modern Approach)** | Step | Purpose | |------|---------| | 1. Posterior decompression | Create space between tumour and cord | | 2. Circumferential epidural decompression | Remove epidural tumour | | 3. Stabilisation | Pedicle screws 2 levels above/below | | 4. SBRT post-op | High-dose radiation to residual tumour | **Advantage:** Allows SBRT for radioresistant tumours by creating separation. **Option C: En Bloc Resection** | Indication | Requirement | |------------|-------------| | Solitary metastasis | No other disease | | Good prognosis | Tokuhashi ≥9 | | Radioresistant primary | RCC, thyroid | | Contained lesion | Surgically resectable | **This Patient:** Not a candidate for en bloc (multiple metastases, poor prognosis). **5. Vertebral Augmentation** | Technique | Indication | |-----------|------------| | **Vertebroplasty** | Painful collapse, no canal compromise | | **Kyphoplasty** | Better height restoration | | **Contraindication** | Epidural extension, posterior wall breach | > **Consultant Tip:** For this patient with poor prognosis (Tokuhashi 2), palliative decompression + stabilisation if symptomatic cord compression. Otherwise, radiotherapy + systemic therapy. **Metastatic Spinal Cord Compression (MSCC) - Emergency Management:** Acute deterioration in neurological status is a surgical emergency requiring rapid decision-making. **Immediate Assessment:** | Action | Purpose | |--------|---------| | Full neurological exam | Document level and severity | | ASIA score | A (complete) to E (normal) | | Bladder function | Catheterise, check residual | | Rectal exam | Tone, sensation | **This Patient Now:** - Bilateral LE weakness 2/5 (was 4/5 right, 5/5 left) - Rapid deterioration suggests acute cord compression **Immediate Medical Management:** **Dexamethasone Protocol:** | Phase | Dose | |-------|------| | **Loading dose** | 16-100 mg IV bolus (controversy on exact dose) | | **Maintenance** | 16 mg daily in divided doses | | **Duration** | Until definitive treatment | | **Adjuncts** | PPI for GI prophylaxis | **Imaging:** | Study | Urgency | |-------|---------| | Urgent MRI whole spine | Within hours | | Assess compression severity | Level of block | | Other levels | May have multiple levels of compression | **Decision: Surgery vs Radiotherapy** **Patchell Criteria for Surgery (Landmark RCT 2005):** | Finding | Recommendation | |---------|----------------| | Direct epidural compression | Surgery + RT superior to RT alone | | Ambulatory patients | Maintain ambulation - surgery | | Recently non-ambulatory | May regain function with surgery | | Complete paraplegia >48 hours | Poor prognosis for recovery | **Surgery is Indicated If:** | Criterion | This Patient | |-----------|--------------| | Single level compression | L2 primarily | | Unknown primary needing tissue | Lung identified, but could still biopsy | | Radioresistant tumour | Lung is moderately resistant | | Instability present | SINS 12 | | Good surgical candidate | Assess comorbidities | | Life expectancy >3 months | Possibly | **Surgical Approach for MSCC:** **Posterior Decompression + Stabilisation:** | Step | Details | |------|---------| | 1 | Prone positioning | | 2 | Pedicle screw insertion T12-L4 | | 3 | L2 laminectomy ± partial L1, L3 | | 4 | Circumferential epidural decompression | | 5 | Tumour debulking (if safe) | | 6 | Rod placement and compression/distraction | | 7 | Consider cement augmentation of screws | **When to Avoid Surgery:** | Factor | Consideration | |--------|---------------| | Very poor prognosis | Tokuhashi <5 with rapid decline | | Complete paraplegia >48 hours | Unlikely to recover | | Medically unfit | ASA IV, severe comorbidities | | Widespread unstable disease | Would not survive surgery | **Post-operative Care:** | Component | Details | |-----------|---------| | Radiotherapy | Usually within 2-4 weeks post-op | | Rehabilitation | Early mobilisation | | DVT prophylaxis | LMWH, IPC | | Bowel/bladder | Catheter care, bowel regime | > **Consultant Tip:** Acute cord compression = surgical emergency. Dexamethasone immediately. Surgery for acute deterioration with salvageable neurology even with poor oncological prognosis - quality of remaining life matters. **Prognostic Factors for Neurological Recovery:** **Pre-operative Factors Predicting Recovery:** | Factor | Better Prognosis | Worse Prognosis | |--------|------------------|-----------------| | **Pre-op motor function** | Ambulatory | Complete paraplegia | | **Duration of deficit** | <24-48 hours | >48 hours | | **Speed of onset** | Gradual | Sudden/rapid | | **Bowel/bladder** | Intact | Involved (worse) | | **Number of levels** | Single | Multiple | | **Tumour type** | Slow-growing | Aggressive | **Key Evidence - Timing and Outcomes:** | Finding | Source | |---------|--------| | Ambulatory pre-op → 90% remain ambulatory | Patchell 2005 | | Surgery within 48 hours → better outcomes | Multiple studies | | Complete paralysis >48 hours → poor recovery | Rades et al | | Partial deficits → best chance of improvement | Consensus | **This Patient's Prognosis:** - Acute deterioration (rapid onset) - concerning - Still has some motor function (2/5) - not complete - If operated within 24 hours - reasonable chance of improvement - Complete recovery unlikely given tumour biology **Expected Outcomes After Surgery:** | Pre-op Status | Likelihood of Walking Post-op | |---------------|------------------------------| | Ambulatory | 80-90% | | Paraparetic (motor function present) | 50-60% | | Paraplegic <48 hours | 20-30% | | Paraplegic >48 hours | <10% | **Family Counselling Points:** **1. Honest Prognosis Discussion:** | Topic | Message | |-------|---------| | **Underlying disease** | Advanced lung cancer with spread to spine, liver, bones | | **Prognosis** | Expected survival months, not years | | **Surgery purpose** | Not curative - aimed at preserving function and quality of life | **2. Goals of Surgery:** | Goal | Expectation | |------|-------------| | **Pain relief** | Good chance of improvement | | **Preserve walking** | Possible but not guaranteed (50-60% if done urgently) | | **Avoid complete paralysis** | Primary aim | | **Independence** | May maintain self-care ability | **3. Surgical Risks:** | Risk | Approximate Rate | |------|------------------| | Wound complication | 10-15% (higher in cancer patients) | | Neurological worsening | 5-10% | | DVT/PE | 10-20% | | Infection | 5-10% | | Death (30-day) | 5-10% | **4. If Surgery Declined:** | Course | Expectation | |--------|-------------| | Radiotherapy | May stabilise, unlikely to improve | | Progression | Likely complete paralysis | | Survival | Similar but worse quality of life | **5. Holistic Care:** | Component | Discussion | |-----------|------------| | Palliative care | Early involvement | | Goals of care | What matters most to patient/family | | Advanced care planning | Preferred place of death, resuscitation | | Family support | Counselling, social work | **Key Message to Family:** "Your mother has advanced cancer that has spread to her spine. The tumour is pressing on her spinal nerves causing weakness in her legs. Without surgery, she will likely become completely paralysed. Surgery gives her the best chance of maintaining some leg function, but we cannot guarantee she will walk again. The surgery is major and carries risks. Whether or not she has surgery, we expect her survival to be limited to months. We want to help her have the best quality of life in that time." > **Consultant Tip:** Be honest about prognosis. Surgery in MSCC is about quality not quantity of life. Include palliative care early and have goals of care discussions with family. --- ## Key Teaching Points ### Pattern Recognition **This pattern suggests Metastatic Spinal Disease:** - Older patient with constitutional symptoms (weight loss) - New or changed back pain pattern - Radicular symptoms (L3 distribution = thigh pain) - Risk factors (smoking for lung, female for breast) - Laboratory abnormalities (hypercalcaemia, elevated ALP, anaemia) **Comparison - Primary vs Metastatic Spinal Tumour:** | Feature | Primary Tumour | Metastatic | |---------|---------------|------------| | Age | Often younger | Usually >50 | | History of cancer | No | Often yes | | Number of lesions | Usually single | Often multiple | | Systemic symptoms | Less common | Common | | Visceral disease | No | Often present | | Treatment intent | Often curative | Usually palliative | ### Critical Management Points 1. **Identify the primary** - CT CAP, tumour markers, protein electrophoresis 2. **Assess prognosis** - Tokuhashi, Tomita scores guide treatment intensity 3. **Assess stability** - SINS score determines need for stabilisation 4. **Biopsy before treatment** - unless known primary with classic pattern 5. **MDT essential** - spine surgeon, radiation oncology, medical oncology 6. **MSCC is emergency** - dexamethasone, urgent MRI, consider surgery --- ## Common Examiner Follow-ups **Q: "What is the difference between Tokuhashi and Tomita scores?"** | Aspect | Tokuhashi | Tomita | |--------|-----------|--------| | **Focus** | Survival prediction | Treatment strategy | | **Factors** | 6 parameters | 3 parameters | | **Primary** | Specific types listed | Grouped by growth rate | | **Output** | Predicted survival | Treatment recommendation | | **Use** | Deciding treatment intensity | Surgical planning | --- **Q: "What is 'separation surgery'?"** | Concept | Description | |---------|-------------| | **Goal** | Create 2-3mm gap between tumour and spinal cord | | **Technique** | Posterior decompression, epidural tumour removal | | **Purpose** | Allow high-dose SBRT without cord injury | | **Indication** | Radioresistant tumours (RCC, melanoma, lung) | | **Outcome** | Better local control than RT alone | --- **Q: "When would you consider en bloc resection for spinal metastasis?"** | Criterion | Requirement | |-----------|-------------| | **Solitary metastasis** | Only spinal lesion | | **No visceral disease** | Or completely resected | | **Good prognosis** | Tokuhashi ≥9, life expectancy >12 months | | **Radioresistant primary** | RCC, thyroid, where RT less effective | | **Technically feasible** | Contained lesion, experienced team | En bloc is rarely performed - most patients have disseminated disease. --- ## Related Topics - Pathological Fractures - Bone Metastases - Myeloma and Spine - Primary Spinal Tumours - Spinal Cord Compression - Tokuhashi and Tomita Scoring