Management of patients with metastasis to the vertebrae: recommendations from the Italian Orthopaedic Society (SIOT) Bone Metastasis Study Group

Abstract

The purpose of this article is to outline the current approach to patients affected by metastasis to the spine and to present a clinical and surgical algorithm available for clinicians and for future research. A modern approach to the patients affected by spinal metastasis in fact requires a multidisciplinary contest where oncologists, radiotherapists, surgeons and physical therapists cooperate with shared vision to provide the best possible integrated treatments available. The authors of this article constitute the Bone Metastasis Study Group of the Italian Orthopaedic Society (SIOT): a national group of orthopedic tumor surgeons who are dedicated to studying the approach, techniques and outcomes of surgery for metastatic tumors of the musculoskeletal system.

Keywords::

• algorithm
• metastasis
• palliative therapy
• spine
• surgical treatment

Acknowledgements

Hereby it is acknowledged that A Piccioli is the Coordinator of the Italian Orthopaedic Society Bone Metastasis Study Group, and is the Senior author of the current manuscript.

Financial & competing interests disclosure

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The indication for surgical treatment of a patient with vertebral bone metastases must be the result of a multidisciplinary assessment and the data to take into account are: the patient’s general conditions, the characteristics of the primary tumor and of the vertebral metastases in terms of spinal involvement, mechanical characteristics and risk of fracture.

• Surgical approach to a patient affected by spinal metastases depends on several factors: the general health status and the life expectancy; the chance to restore the neurological function and to reduce pain and the chance to achieve a local control of the metastatic disease in an integrated approach with chemotherapy and radiotherapy treatment, as determined by the oncologists.

• The vast majority of patients with spinal metastasis can be managed non-operatively, since these respond well to conservative orthopedic/orthotic treatment and radiotherapy.

• Indications for surgery in patients affected by spinal metastasis are: intractable pain, the onset of neurological deficits, the mechanical instability of the spinal segment affected by the metastasis and a failure of the previous therapy.

• The surgical procedures employed in the treatment of vertebral metastasis can be classified as palliative (aimed at patient’s symptoms and to the prevention of potential complications), adjuvant (where the aim is the treatment of metastases itself with partial or complete intra-lesion removal of the metastasis with stabilization and spine reconstruction) and therapeutic, performed by local removal of the metastasis through a complete resection of the lesion with stabilization and eventual reconstruction of the removed bone.

• An algorithm has been recently proposed to guide in the treatment of vertebral metastases, in which the parameters vary according to the time when these are considered.

• Parameters taken into account for the algorithm are the patient’s general condition expressed according to the ASA score; the histological sensitivity to adjuvant treatments; the extent of neurological compromise; the instability of the spine and the risk of pathological fracture; oncologic staging in terms of the skeletal and visceral dissemination of the disease.

Notes