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Metastatic malignant neoplasm to spinal meninges — Clinical Guidelines

Overview

Metastatic malignant neoplasms involving the spinal meninges often present with pain, neurological deficits, and instability, necessitating multidisciplinary management including surgical, radiation, and pharmacological interventions. 9 10

Diagnosis

Clinical presentation includes back pain, radiculopathy, and spinal cord compression symptoms.

Imaging studies (MRI, CT) are essential for diagnosis, delineating lesion extent and spinal involvement. 9

Neurological examination to assess motor, sensory, and reflex functions is crucial for grading severity. 9

Management

First-line treatments:

- Radiation therapy: Palliative radiotherapy to control pain and stabilize lesions, often using dose conformation techniques like dynamic wedges. 5 - Pharmacotherapy: Analgesics (opioids, NSAIDs) for pain management; corticosteroids for inflammation and edema control. 10

Adjunctive treatments:

- Radiofrequency ablation (RFA): Effective for palliative pain relief, often combined with vertebroplasty. 2 - Vertebroplasty/Percutaneous vertebroplasty (PVP): Provides pain relief and stabilization, particularly useful for osteoblastic lesions. 6 11 - Minimally invasive surgery (MIS): Techniques such as percutaneous pedicle screw fixation (PPSF) and iliac screw fixation for stabilization in unstable lesions. 1 4 - Palliative spinal reconstruction: Using cervical pedicle screws for stabilization in selected cases. 8

Special Populations

Elderly: Minimally invasive techniques are preferred to minimize complications and improve recovery. 1 4

Comorbidities: Tailored treatment plans considering overall health status and functional goals are essential. 7

Key Recommendations

Initiate palliative radiotherapy to control pain and stabilize spinal lesions in patients with metastatic spinal disease. (Evidence: Strong 5)

Consider minimally invasive surgical techniques such as percutaneous pedicle screw fixation for unstable lesions to achieve stabilization without extensive decompression. (Evidence: Moderate 1 4)

Use radiofrequency ablation as an adjunctive therapy for pain relief in patients with painful vertebral metastases, often in combination with vertebroplasty. (Evidence: Moderate 2)

Incorporate vertebroplasty for both osteolytic and osteoblastic lesions to provide pain relief and stabilization, especially when conventional treatments are insufficient. (Evidence: Weak 6 11)

Prioritize patient and family satisfaction in palliative surgical interventions by focusing on quality of life improvements and symptom management. (Evidence: Expert opinion 7)

References

1 Chi JE, Ho CY, Chiu PY, Kao FC, Tsai TT, Lai PL et al.. Minimal invasive fixation following with radiotherapy for radiosensitive unstable metastatic spine. Biomedical journal 2022. link 2 Rosian K, Hawlik K, Piso B. Efficacy Assessment of Radiofrequency Ablation as a Palliative Pain Treatment in Patients with Painful Metastatic Spinal Lesions: A Systematic Review. Pain physician 2018. link 3 Archavlis E, Schwandt E, Kosterhon M, Gutenberg A, Ulrich P, Nimer A et al.. A Modified Microsurgical Endoscopic-Assisted Transpedicular Corpectomy of the Thoracic Spine Based on Virtual 3-Dimensional Planning. World neurosurgery 2016. link 4 Liu G, Hasan MY, Wong HK. Minimally invasive iliac screw fixation in treating painful metastatic lumbosacral deformity: a technique description and clinical results. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2016. link 5 Ormsby MA, Herndon RC, Kaczor JG. Dose conformation to the spine during palliative treatments using dynamic wedges. Medical dosimetry : official journal of the American Association of Medical Dosimetrists 2013. link 6 Chen L, Ni RF, Liu SY, Liu YZ, Jin YH, Zhu XL et al.. Percutaneous vertebroplasty as a treatment for painful osteoblastic metastatic spinal lesions. Journal of vascular and interventional radiology : JVIR 2011. link 7 Fujibayashi S, Neo M, Miyaki K, Nakayama T, Nakamura T. The value of palliative surgery for metastatic spinal disease: satisfaction of patients and their families. The spine journal : official journal of the North American Spine Society 2010. link 8 Oda I, Abumi K, Ito M, Kotani Y, Oya T, Hasegawa K et al.. Palliative spinal reconstruction using cervical pedicle screws for metastatic lesions of the spine: a retrospective analysis of 32 cases. Spine 2006. link 9 Ecker RD, Endo T, Wetjen NM, Krauss WE. Diagnosis and treatment of vertebral column metastases. Mayo Clinic proceedings 2005. link 10 Weinstein SM, Walton O. Management of pain associated with spinal tumor. Neurosurgery clinics of North America 2004. link 11 Pilitsis JG, Rengachary SS. The role of vertebroplasty in metastatic spinal disease. Neurosurgical focus 2001. link

Metastatic malignant neoplasm to spinal meninges