Spinal Malignancy
‘’'Original Editor ‘’'- Jess Bell ‘’'Top Contributors’’' - Jess Bell, Lucinda hampton, Kim Jackson, Tarina van der Stockt, Admin, Tony Lowe and Vidya Acharya
Introduction to Spinal Malignancy[edit | edit source]
Between one and five percent of all musculoskeletal presentations in primary care are due to serious pathology and these rates are expected to increase as cancer survival rates improve.[1]
Metastatic bone disease (MBD) is the second most common serious spinal pathology - vertebral fracture is the most common.[1] Metastases are cancers that have spread from a primary cancer to a new site in the body; bone is a common location for metastases.[2]
The spine is often one of the earliest areas affected, particularly in patients who have a history of breast and prostate cancer.[1] The five types of cancer that are most likely to spread to the spine are:
- Breast
- Prostate
- Lung
- Kidney
- Thyroid[3]
It is not entirely understood how MBD spreads, but its predilection for the spine is considered to be due to hematogenous spread via the venous or arterial pathways.[1]
The distribution of metastases in the spine varies:
- 70% occur in the thoracic spine
- 20% occur in the lumbar spine
- 10% occur in the cervical spine[1]
NB while 70% of metastases occur in the thoracic spine, the patient may not describe thoracic pain.[3]
Identifying Spinal Malignancy[edit | edit source]
Despite relatively low presentation rates, serious pathology, including spinal malignancy, should be considered as a differential diagnosis when a patient presents with back pain.[4] However, identifying serious pathology as the cause of musculoskeletal pain is highly complex.[2] Red flags have traditionally been used to help identify these conditions and a “history of cancer” and “strong clinical suspicion” have empirical evidence of high diagnostic accuracy for malignancy.[5] However, red flags generally have poor diagnostic accuracy[6] and there is a lack of consistency in guidelines over which red flags should be used[7] or when health professionals should act.[4] This has led to inconsistency in management of patients when there is suspicion of serious pathology.[2]
It is vital to identify patients with spinal malignancy as early as possible as this results in much better outcomes.[4] This is discussed in more detail here, but it is known that a patient with a single metastasis or just BMD will do better than a patient with multiple metastases.[3] However, if a patient presents to you with signs of Metastatic Spinal Cord Compression (eg paralysis, bladder/bowel changes, band like pain), they will likely have a poor prognosis as this condition indicates late stage metastatic cancer.[3]
The pneumonic RED FLAGS can be used to detect early warning signs of metastatic spinal cord compression.[8]
- R: Referred back pain that is multi-segmental or band like
- E: Escalating pain that responds poorly to treatment including medication
- D: Different character or site to previous symptoms
- F: Funny feelings, odd sensations or heavy legs
- L: Lying flat increases back pain
- A: Agonising pain causing anguish or despair
- G: Gait disturbance, unsteadiness especially on stairs (not just a limp)
- S: Sleep grossly disturbed due to pain being worse at night[8]
- ↑ 1.0 1.1 1.2 1.3 1.4 Finucane L, Greenhalgh S, Selfe J. Which red flags aid the early detection of metastatic bone disease in back pain? Physiotherapy Practice and Research. 2017;38(2): 73-77.
- ↑ 2.0 2.1 2.2 Finucane LM, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM et al. International framework for red flags for potential serious pathologies. J Orthop Sports Phys Ther. 2020; epub: 1-23.
- ↑ 3.0 3.1 3.2 3.3 Finucane L. Spinal Malignancy Course. Physioplus 2020.
- ↑ 4.0 4.1 4.2 Finucane L. An Introduction to Red Flags in Serious Pathology. Physioplus 2020.
- ↑ Verhagen AP, Downie A, Maher CG, Koes BW. Most red flags for malignancy in low back pain guidelines lack empirical support: a systematic review. Pain. 2017;158(10):1860-8.
- ↑ Premkumar A, Godfrey W, Gottschalk MB, Boden SD. Red Flags for Low Back Pain Are Not Always Really Red. J Bone Jt Surg. 2018;100(5):368–74.
- ↑ Verhagen AP, Downie A, Popal N, Maher C, Koes BW. Red flags presented in current low back pain guidelines: a review. European Spine Journal. 2016 Sep 1;25(9):2788-802.
- ↑ 8.0 8.1 The Christie NHS Foundation Trust. The use of red flags to identify serious spinal pathology. Greater Manchester and Cheshire. 2013. Available from https://www.christie.nhs.uk/media/1121/legacymedia-4941-briefing-paper-use-of-red-flags-to-identify-serious-spinal-pathology-updated-jan-2016.pdf (accessed 18 June 2020).