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Vertebral Metastasis

Summary

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  • Vertebral metastases are secondary malignant lesions in the spine from distant primary tumours
  • Common primaries include breast, lung, prostate, thyroid, and renal cell carcinomas

Pathophysiology

  • Metastatic spread to vertebrae occurs via:
    • Haematogenous dissemination
    • Direct extension from paravertebral masses
    • Lymphatic spread (less common)
  • Tumour cells colonise bone marrow and induce osteoclastic or osteoblastic activity
  • Lesions can be:
    • Osteolytic (bone destruction)
    • Osteoblastic (new bone formation)
    • Mixed

Demographics

  • Most common in adults aged 40-65 years
  • Slightly more prevalent in males
  • Incidence increases with age
  • Accounts for approximately 70% of all osseous metastases
  • Thoracic spine most commonly affected (60-70%), followed by lumbar (20%) and cervical (10%) regions

Diagnosis

  • Clinical presentation:
    • Back pain (often worse at night or when recumbent)
    • Neurological deficits (radiculopathy, myelopathy)
    • Pathological fractures
    • Spinal cord compression (in advanced cases)
  • Laboratory tests:
    • Elevated tumour markers (e.g., PSA, CA 15-3)
    • Increased alkaline phosphatase
    • Hypercalcaemia
  • Biopsy:
    • CT-guided or open biopsy for definitive diagnosis and primary tumour identification

Imaging

  • Plain radiographs:
    • Limited sensitivity (50-70%)
    • May show lytic or blastic lesions, vertebral collapse, or pedicle erosion
  • CT:
    • Higher sensitivity than radiographs
    • Better visualisation of bone destruction and cortical integrity
    • Useful for assessing stability and fracture risk
  • MRI:
    • Gold standard for detecting vertebral metastases
    • T1-weighted images: hypointense lesions
    • T2-weighted images: hyperintense lesions
    • Contrast-enhanced sequences improve lesion detection
    • Whole-body MRI useful for staging
  • Bone scintigraphy:
    • High sensitivity but low specificity
    • Useful for whole-body screening
  • PET/CT:
    • High sensitivity and specificity
    • Allows for detection of both osseous and extra-osseous metastases

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  • 60-year-old patient with breast cancer presented with acute back pain.
  • CT showed a compression fracture of L3, a lucent region, and bulging of the posterior cortex into the vertebral canal.
  • MRI showed abnormal signal in the whole vertebral body.

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  • 60-year-old patient with lung cancer presented with back pain.
  • MRI shows lesions in the T12 (causing a compression fracture) and L2 vertebral bodies that were STIR hyperintense and T2 and T1 hypointense.

Treatment

  • Multidisciplinary approach involving oncology, radiology, and orthopaedics
  • Pain management:
    • Analgesics (NSAIDs, opioids)
    • Bisphosphonates or denosumab for bone pain
  • Radiotherapy:
    • External beam radiation for localised pain relief
    • Stereotactic body radiotherapy for oligometastatic disease
  • Surgery:
    • Spinal stabilisation for impending or actual pathological fractures
    • Decompression for spinal cord compression
  • Minimally invasive procedures:
    • Vertebroplasty or kyphoplasty for painful osteolytic lesions
    • Radiofrequency ablation for small, localised lesions
  • Systemic therapy:
    • Chemotherapy, hormonal therapy, or targeted therapies based on primary tumour type
  • Immunotherapy:
    • Emerging option for certain tumour types (e.g., melanoma, renal cell carcinoma)

Differential diagnosis

Differential Diagnosis Differentiating Feature
Osteoporotic fracture Lack of focal lesion, diffuse osteopenia
Degenerative disc disease Preserved vertebral body height, disc space narrowing
Osteomyelitis Contiguous disc space and end-plate involvement; paraspinal soft tissue; T1 hypointense and STIR hyperintense crossing disc
Multiple myeloma Diffuse osteopenia; punched-out lytic lesions; T1 hypointense and STIR hyperintense; may show diffuse marrow involvement
Primary bone tumour Typically single lesion; posterior element involvement common; chondroid or osteoid matrix on CT
Paget's disease Increased bone density with bone enlargement and cortical thickening; "picture frame" or "ivory vertebra" appearance
Tuberculosis of spine Disc space involvement with end-plate erosion; gibbus deformity; paraspinal and psoas abscess with rim enhancement
Hemangioma Characteristic "polka-dot" appearance on CT; high T1 and T2 signal; no destructive bone changes
Lymphoma Preservation of disc space with permeative infiltration; soft tissue mass; homogeneous on MRI
Aneurysmal bone cyst Expansile lytic lesion with multiple fluid-fluid levels on MRI; thin cortical shell