Spinal metastasis: current status and recommended guidelines for management.

An overview of the current status of various aspects of spinal metastasis, including pathology, diagnosis, and management is presented. The cell type of the tumor, particularly with reference to its radiosensitivity, seems to be positively correlated with treatment outcome, regardless of the treatment modality. Because pretreatment neurological status also seems to influence prognosis, early identification of spinal involvement in patients at risk is important; therefore, a high index of suspicion in patients known to have cancer is necessary. The most useful warning of impending spinal cord or nerve root compression is spinal or radicular pain, which usually precedes neurological deficit by days to years. An aggressive diagnostic evaluation of pain symptoms is therefore warranted; this should include plain spine films and, in questionable cases, radioisotope bone scan. Myelography should also be considered in any cancer patient with persistent spinal or radicular pain, even in the absence of neurological deficit and certainly if there is any neurological impairment. Therapeutically, radiation and surgery continue as the mainstays of management, whereas steroids and chemotherapy serve as adjuvants. The guidelines for management recommended in this paper are to be viewed as tentative because the ideal treatment for spinal metastasis has not been established. The proposed guidelines are based on an analysis of retrospective studies that suggest that radiotherapy should be the primary mode of treatment and that surgery should be reserved for situations in which radiotherapy fails or where there is bony compression or spinal instability. Cases are presented to illustrate the application of these guidelines. (Neurosurgery, 5: 726--746, 1979).