Spine Metastasis

Advancements in cancer detection and screening, systemic therapies, and surgical techniques have led to prolonged patient survival. Now that patients diagnosed with cancer are living longer, there is more time for cancer to spread to the spine.

Metastatic disease to the spine will affect up to 40 percent of cancer patients at some point during their clinical course. Cancers that commonly metastasize to the spine include lung, breast, prostate, melanoma, kidney, and thyroid cancers.  

Symptoms

Spinal metastasis are among the leading causes of cancer pain, leading to frequent visits to the Emergency Department. Metastasis to the spine can lead to significant adverse effects, including numbness/tingling, weakness, pain and incontinence. A significant proportion of patients who develop spinal metastasis will develop one or more of these symptoms.

The symptoms caused by a metastatic spine tumor largely depend on the tumor size and location and vary from patient to patient.

The most common symptoms of spine tumors include:

• Back pain
  • Back pain may result from a tumor that replaces your bone and causes a compression fracture in your vertebra or from a tumor that is compressing a nerve.
  • Back pain may also increase with standing or movement which is a sign that the tumor is causing instability in the bones of the spine.
• Weakness in arms or legs
• Numbness or tingling in arms or legs
• Difficulty walking or balancing
• Sensory problems
• Loss of bowel or bladder control

Diagnosis

A timely and accurate diagnosis of your condition is essential in guiding effective treatment. Determining the exact condition and cancer type often takes a multidisciplinary approach so your physician, oncologist or surgeon may start by asking you a series of questions about your symptoms, perform a physical exam and use a wide range of advanced diagnostic tools to make a full assessment of your spine tumor.

Our highly skilled neuro-radiologists review imaging and provide detailed information about the tumor size, location, and compression of adjacent structures. In many cases, a biopsy is necessary to confirm and refine the diagnosis of a metastatic spine tumor. Having a complete understanding of your condition allows the team at the Duke Center for Brain and Spine Metastasis to begin treatment as quickly as possible.

The Duke Center for Brain and Spine Metastasis uses a comprehensive decision-making framework to help develop a personalized treatment plan consistent with the values and goals of each patient.

Your team of providers further customizes your treatment plan based on your neurologic function, oncologic history, the structure and stability of your spine, and the overall extent of your disease.

Depending on these factors, your treatment team may recommend a combination of treatment therapies to maximize your quality of life. Our goal is to provide a unique treatment plan that effectively fights your cancer while maximizing benefits and minimizing risk.

Minimally Invasive Surgery

When appropriate, the center offers minimally invasive surgical procedures that are intended to relieve pain, reduce spinal deformity, improve neurologic function, and restore mobility. These minimally invasive procedures may reduce recovery time and allow you to get back to systemic treatment faster.

::Vertebroplasty/Kyphoplasty

When fractured or collapsed vertebrae result from a metastatic spine tumor, a surgical bone cement may be injected directly into the collapsed vertebra to provide support and stabilize the spine.

• Vertebroplasty: surgical bone cement is injected directly into the collapsed vertebra
• Kyphoplasty: a balloon-like device is inserted into the vertebra and inflated to create space.  The balloon is removed and surgical cement is injected into the space.

::Spinal Tumor Radiofrequency Ablation

Using image guidance, your doctor places a probe through a small incision into the center of your tumor. The probe then generates radiofrequency energy, which heats and destroys the tumor while minimizing damage to surrounding healthy tissue or bone. After the tumor shrinks, the pressure on the adjacent nerves is relieved thereby reducing your pain.

::Percutaneous Instrumentation

Through limited disruption of tissue, screws are placed into the vertebra using image guidance. The screws act as anchors that can then be connected to rods, which stabilize the spine.

Open Surgical Intervention

Surgery may be necessary to remove your spine tumor and stabilize your spine thereby reducing your pain, preventing, stabilizing or reversing weakness, bowel/bladder dysfunction, difficulty walking or paralysis. The center uses innovative surgical techniques to decompress your spinal cord, stabilize your spine and treat your pain. We also use in surgery technology to monitor your neurologic function in order to reduce the risk of injury to your spinal cord.

::Spinal Cord Decompression and Stabilization

If you have a tumor that is compressing the spinal cord, a surgery to remove the tumor may be necessary. The surgery may include removal of a vertebra and replacement with a prosthesis. Your surgeon may also need to stabilize your spine using rods and screws. Successful decompression of the spinal cord may create adequate space between the tumor and spinal cord to safely receive high-dose radiation.

::Spinal Tumor Embolization

Some tumors have an abnormally high blood supply and reducing the blood supply of a tumor prior to surgery can reduce surgical risks. If indicated, our neurovascular surgeon will locate the tumor’s blood vessels and inject them directly with a material to prevent them from bleeding during surgery.

::Neuroplastics and Reconstructive Surgery

Plastic surgeons are an integral part of the care team who assist in complex back operations and perform closure of the surgical incisions. As experts in wound healing, they frequently employ advanced techniques to reduce complications after spine surgery, such as muscle flaps and negative pressure wound therapy. We offer prophylactic muscle flaps to most patients undergoing spine surgery who are at higher risk for wound healing problems. In this procedure, adjacent muscle tissue is transferred over the spine during closure of the incision, followed by an aesthetic plastic surgery skin closure with dissolvable sutures. Plastic surgeons will perform this at the same time as your spine surgery. This approach leads to a significant reduction in wound healing complications such as infection and opening of the wound, which allows a quicker return to adjuvant therapies such as radiation and chemotherapy.

Radiation therapy is often utilized in the treatment of spinal metastases. Benefits of radiation therapy include:

• Reducing or even eliminating the tumor
• Alleviating pain, relieving spinal cord compression or allowing for easier surgical removal
• Preventing further tumor growth
• Providing a non-invasive, outpatient treatment

Duke radiation oncologists employ a variety of techniques to deliver radiation therapy to the target spine tumor but avoid radiation dose as much as possible to surrounding normal tissues.

Stereotactic radiosurgery (SRS) is the gold standard for radiation care when treating the majority of patients with brain and/or spinal metastases. SRS is a typical front line approach to brain or spine metastases. When surgery is a more appropriate up-front strategy, SRS is still indicated after a surgical procedure to help prevent growth of residual microscopic cancer cells.

SRS precisely delivers high dose radiation to the tumor, but significantly spares healthy tissue/organs, blood vessels, and nerves surrounding the tumor/s. It is more specific and in general offers better disease control and less side effects than whole brain radiation therapy (WBRT) or conventional radiation to the spine. Depending on the size and location of the tumor/s, some patients may only require a single dose of SRS while others may require treatment over three to five sessions.

Although the name suggests SRS involves surgery, SRS is a non-surgical procedure where no incisions are required. The word surgery simply refers to the surgical precision with which the radiation is delivered. WBRT or conventional spine radiation may still be the best treatment in certain situations, however. Our world-class radiation oncologists will explain all treatment options, which are most appropriate, and why.

Our Radiation Oncology Team has several radiation therapy clinical trials open for patients with brain and spine metastases. All patients are screened and considered for clinical trials by the treating team at the time of their initial consultation.

In addition to surgery and radiation therapy, systemic therapies may be recommended by your treatment team to help control tumor growth and prevent further metastases. Systemic therapies for both brain and spinal metastasis include chemotherapy, immunotherapy, targeted therapy, hormone therapy, and/or therapies to protect your bones. Your medical oncologist will help you decide which treatment options are best for you.

The center works closely with interventional pain specialists to ensure your pain remains well controlled throughout the course of your treatment.

Types of interventional pain management treatments include:

• Injections
  • The three most common types of injections include, epidural steroid injections, facet joint injections and trigger point injections. Each injection targets different pain locations in the spine and generally include a numbing agent and a steroid.
• Intrathecal Infusions
  • A pump or reservoir is implanted between the muscle and skin of your abdomen which delivers pain medication via a catheter to your spinal cord and nerves. The pump is specifically programmed to slowly release the right amount of medication for you.    
• Nerve Blocks
  • Nerve blocks are used to interrupt the pain signal that travels from the nerve to the brain. Depending on the type and severity of pain, a nerve block may last hours, days or may be permanent.
• Radiofrequency Ablation
  • This procedure uses an electrical current produced by a radio wave to heat the irritated nerve which then decreases the pain signals from that area.
• Spinal Cord Stimulation
  • Electrical leads inserted in the spinal column apply gentle electrical currents to the source of the pain. These electrical signals block the ability for the brain to perceive pain.

Palliative care, often referred to as supportive care, provides an additional layer of support for people facing serious life-threatening illnesses and their families. It is important to understand that it can be provided together with curative treatment. Research has shown that people with cancer have better outcomes when supportive care forms a regular part of treatment.

This team play a pivotal role within our center at Duke. We work towards ensuring that all patients and their families have the opportunity to meet with a member of the team within their first couple of visits to Duke.

Their expertise in a range of services builds on and complements the care provided by other specialists within our team. These services include:

• Pain management, post-operatively or in a medically complex patients like those living with brain and/or spinal metastasis
• Aggressive symptom management (e.g. fatigue, nausea, depression, anxiety and other symptoms)
• Psychosocial support for patients, caregivers, and families
• Goals of care clarification with patients and families, ensuring cancer care matches up with patients’ priorities and value
• Ensuring clear communication between patients, their families, and the entire care team
• Spiritual care

Advance Care Planning

For more information, go to:

• Five Wishes
• Duke Health