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JAMA Patient Page
June 16, 2020

Spinal Metastases

Author Affiliations
  • 1Department of Neurosurgery, University of Illinois Hospital and Clinics, Chicago, Illinois
JAMA. 2020;323(23):2438. doi:10.1001/jama.2020.0716

Spinal metastases occur when cancer tumors spread to the spinal column from a different location where they started.

The spine is made up of the spinal cord, a large bundle of nerves and nerve cells traveling from the brain down the back that control movement and sensation, surrounded by covering membranes (meninges) and protective bones (vertebrae). Cancers from other body areas spreading to vertebrae can cause deep, aching back pain that is usually worse at night. If these metastases invade beyond the bone into the spinal cord itself, or if tumor-filled vertebrae fracture or collapse, cord compression can occur, causing weakness or paralysis in parts of the body such as the legs, decreased or unusual sensations (paresthesia), or problems with urination or bowel function.

Diagnosis

Diagnosing spinal metastases begins with physical examination to look for signs of spinal cord compression. Scans such as computed tomography (CT) or magnetic resonance imaging (MRI) are then often done to visualize the metastases. The most common cancers that spread to the spine are lung, breast, prostate, kidney, and colon. Biopsies are often done to confirm tumor type.

Treatment

Spinal metastases can be treated by surgery, radiation, and chemotherapy, in addition to pain medications. These strategies are often combined and rarely used alone. Studies have shown that combination treatments increase patients’ ability to walk, urinate/defecate, and survive longer. Doctors weigh several considerations when recommending treatments: patient characteristics (age, other medical conditions), tumor type, number of metastases, and whether there is spinal cord compression (with resulting weakness and/or sensory abnormalities).

Older patients and those with many long-standing medical conditions may not be able to tolerate surgery due to its invasiveness. Patients with widespread disease typically also should not undergo surgery because their life expectancy even after operation is limited. Some patients with spinal cord compression are better surgical candidates as rapid decompression is often required to restore movement and sensation. Patients whose metastases are limited to the vertebrae with no spinal cord involvement or significant symptoms are typically treated nonsurgically with pain medication and steroids as needed, chemotherapy, and radiation. Minimally invasive vertebroplasty (filling vertebrae with cement) is performed if there is significant weakening of the bones.

Certain types of cancers, such as multiple myeloma, small cell lung cancer, and lymphoma, respond better to radiation than surgery. Other cancers such as breast and prostate respond better to hormone treatments, placing greater emphasis on chemotherapy. Radiation and chemotherapy are less invasive options than surgery but still have risks. Both typically cause nausea, and because radiation and drugs target both cancer and normal cells in the body, complications include hair loss, bone weakness (leading to fractures), and a weakened immune system, which may lead to infections.

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Article Information

Conflict of Interest Disclosures: None reported.

Sources: Hoskin PJ, Hopkins K, Misra V, et al. Effect of single-fraction vs multifraction radiotherapy on ambulatory status among patients with spinal canal compression from metastatic cancer. JAMA. 2019;322(21):2084-2094.

Barzilai O, Fisher CG, Bilsky MH. State of the art treatment of spinal metastatic disease. Neurosurgery. 2018;82(6):757-769.

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