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

What is your differential diagnosis and what investigations would you order to identify the primary tumour?

How do you assess prognosis in metastatic spinal disease? What scoring systems are used?

What is the role of biopsy? How would you obtain tissue for diagnosis?

What are the treatment options for this patient? Discuss the role of surgery, radiotherapy, and systemic therapy.

The patient develops acute worsening of leg weakness (now 2/5 bilaterally). What is your management?

What factors predict neurological recovery after surgery for MSCC? How would you counsel this patient's 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

Identify the primary - CT CAP, tumour markers, protein electrophoresis
Assess prognosis - Tokuhashi, Tomita scores guide treatment intensity
Assess stability - SINS score determines need for stabilisation
Biopsy before treatment - unless known primary with classic pattern
MDT essential - spine surgeon, radiation oncology, medical oncology
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.

Pathological Fractures
Bone Metastases
Myeloma and Spine
Primary Spinal Tumours
Spinal Cord Compression
Tokuhashi and Tomita Scoring

Spinal Metastasis