If you experience sudden spinal pain, be alert to spinal metastases!

Author: Jiang Dongjie, attending physician, Second Affiliated Hospital of Naval Medical University, Doctor of Medicine

Reviewer: Wei Haifeng, Chief Physician and Professor, Second Affiliated Hospital of Naval Medical University

Uncle Wang has been a car mechanic for most of his life. He never had a serious illness when he was young. Apart from smoking, he has no other hobbies. Uncle Wang has been living in the countryside since he retired. He is nearly seventy years old and has always been in good health. Half a year ago, Uncle Wang felt a slight discomfort in his back, but he didn't care. One morning when he got out of bed, his legs became weak and he sat on the ground. Then he suddenly felt severe pain in his back. Soon his legs and feet were completely powerless and he couldn't stand up. The family hurriedly sent Uncle Wang to the local hospital for examination and found that his thoracic vertebrae were fractured. But Uncle Wang had not suffered any trauma, so how could he have a thoracic vertebra fracture? After a series of examinations, it was discovered that Uncle Wang had a tumor on his thoracic vertebrae. This tumor not only eroded the thoracic vertebrae, but also compressed the spinal cord, causing Uncle Wang to have back pain and weakness in his lower limbs. This was the culprit for Uncle Wang's sudden fracture of the thoracic vertebrae. Even more unfortunately, the doctor found that Uncle Wang also had a tumor in his lungs. Combining all the clues together, the truth finally came to light: Uncle Wang had lung cancer, and the cancer cells had metastasized to the spine.

Figure 1 Copyright image, no permission to reprint

Uncle Wang had always been in good health, so how come he suddenly got lung cancer and even had it metastasized to his spine? In fact, there is no such thing as a tumor that "suddenly" grows. Uncle Wang smokes all year round, which is a high-risk factor for lung cancer. In addition, Uncle Wang believes that he has always been healthy, and he thinks that coughs and back discomfort are minor problems caused by aging, so he does not have a physical examination every year, which leads to the failure to discover the lung tumor early, not to mention linking the back discomfort with the spinal tumor. So, in Uncle Wang's case, the tumor has already metastasized to the bones. Can it still be treated? Should it be treated? Today, let's talk about spinal metastases.

1. What is spinal metastasis?

Spinal metastasis refers to a disease in which a malignant tumor originating outside the bone tissue metastasizes to the spine through the blood or lymphatic system, thereby destroying the bone, compressing the spinal cord, and causing symptoms such as pain and impaired nerve function.

According to statistics from the National Cancer Center [1], there are more than 4 million new cancer cases in my country each year, and the top five cancers in terms of incidence are: lung cancer, colorectal cancer, thyroid cancer, liver cancer, and gastric cancer. Among them, the top five cancers that are most common in men are lung cancer, colorectal cancer, liver cancer, gastric cancer, and esophageal cancer, and the top five cancers that are most common in women are lung cancer, breast cancer, thyroid cancer, colorectal cancer, and cervical cancer. So, which ones are more likely to metastasize to the spine? The answer is that 30% to 70% of patients with the above-mentioned high-incidence cancers may develop spinal metastasis in the middle and late stages [2,3].

2. What are the hazards of spinal metastases? How can we detect the presence of spinal metastases in time?

Common symptoms of patients with spinal metastases include back pain, local swelling, and limited movement. If spinal cord compression is caused, there will often be weakness and numbness in the limbs. If not treated in time, the condition will further deteriorate. Once a pathological fracture occurs, severe pain will occur, and even symptoms such as paralysis and incontinence will occur. It may even affect the respiratory center and endanger life. Therefore, patients with a history of malignant tumors who suddenly experience local swelling and pain in the back, weakness and numbness in the hands and feet, and incontinence need to consider the possibility of spinal metastases. Even if there is no history of malignant tumors, if the above symptoms occur and cannot be relieved repeatedly, you should be vigilant and seek medical attention in time. In clinical practice, there are indeed many patients like Grandpa Wang who have symptoms of spinal metastases as the first symptom.

3. Can spinal metastases be cured?

Let me first state the conclusion. All patients with tumor metastasis are worth treating and should receive scientific treatment. Admittedly, most people still regard tumor metastasis as "the coming of death", especially the patients themselves. After experiencing painful initial treatment, they suddenly receive the bad news that the tumor has metastasized, and they often have the idea of ​​"not wanting to be treated anymore". So, if the tumor has metastasized, especially to the spine, is it really worthless to treat it?

Strictly speaking, according to tumor grading, tumors with distant metastasis are indeed classified as stage IV, which is what we often call the late stage, but the late stage does not mean the terminal stage. The most critical treatment for all malignant tumors is to control the progression of the tumor. Like the primary tumor, spinal metastasis can also be controlled through systemic treatments such as chemotherapy, targeted therapy, immunotherapy, and endocrine therapy.

Many spinal metastatic lesions discovered in the early stage often have not yet caused obvious bone destruction, and patients do not experience severe back pain, pathological spinal fractures, or symptoms of spinal cord compression. At this time, surgical intervention is not required. By using bone-modifying drugs [4], including bisphosphonates and RANKL (NF-κB receptor activating protein ligand) inhibitors, the degree of bone destruction can be slowed down as much as possible, the progression of the disease can be controlled, and the patient's survival can be prolonged. In addition, external radiation therapy can also effectively relieve local pain and slow down the progression of the tumor to a certain extent.

If the patient has already developed pathological spinal fractures or symptoms of spinal cord compression, then different surgical plans can be adopted for surgical treatment, provided that the patient's physical condition meets the surgical conditions, so as to achieve the purpose of relieving symptoms and improving the quality of life. At the same time, the nature of the pathology can be further clarified, providing a basis for systemic anti-tumor treatment, and ultimately achieving the purpose of prolonging the patient's life.

Figure 2 Copyright image, no permission to reprint

In short, the treatment of spinal metastases is a multidisciplinary comprehensive treatment, which is not only the treatment of the primary tumor, but also the treatment of the spinal metastasis lesions. It is necessary to combine the advantages of oncology, orthopedics, radiotherapy, and pain medicine, and formulate a personalized treatment plan according to the specific situation of the patient, so as to improve the treatment effect and the patient's quality of life. Through cooperation and communication between different disciplines, we can have a more comprehensive understanding of the patient's condition, timely detect and deal with complications, and ensure the smooth progress of the treatment process.

The journey of fighting cancer is never smooth. Both patients and their families should maintain a good attitude and living habits, pay attention to physical changes at any time, diagnose as early as possible, and actively treat. Even if spinal metastases occur, they may only be a temporary storm in the direction of progress, and the other side of life is still farther ahead.

【References】

[1] Zheng Rongshou, Chen Ru, Han Bingfeng, et al. Analysis of the prevalence of malignant tumors in China in 2022[J]. Chinese Journal of Oncology, 2024, 46(3): 221-231.

[2] SCHOENFELD AJ, FERRONE ML, SCHWAB JH, et al. Prospective validation of a clinical prediction score for survival in patients with spinal metastases: the New England Spinal Metastasis Score[J]. Spine J, 2021, 21(1): 28-36.

[3] Bone Tumor Group of the Orthopedic Branch of the Chinese Medical Association. Guidelines for surgical treatment of spinal metastases[J]. Chinese Journal of Orthopaedics, 2019, 39(12): 717-726.

[4] Breast Cancer Group of the Oncology Branch of the Chinese Medical Doctor Association, International Medical Exchange Branch of the Chinese Anti-Cancer Association. Consensus on the safety of bone-modifying drugs for the treatment of bone metastases of malignant tumors (2024 edition) [J]. Chinese Journal of Oncology, 2024, 46(6): 517-525.