Key question

How can the delay (patient and physician delay) in diagnosing spinal metastases be reduced?

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Considerations

Balance between desired and undesired effects

Diagnose vertebral metastases as soon as possible; patients with neurological deficits require urgent evaluation

In the literature many studies have attempted to clarify why patients with metastatic spinal disease are so often only identified in the end stage when neurological deficits have already occurred. No clear answer has been found other than that the majority of healthcare professionals taking care of these patients are not spine-experts and are not working in centers of definitive care where most knowledge and expertise is present. In spite of this apparent knowledge gap, the literature is clear on the benefits of identifying and treating patients with metastatic spinal disease before onset of neurological symptoms (van Tol 2019; Debono, 2024). 

Ensure that both patients and healthcare providers (throughout the entire care chain) are familiar with the red flags defined by IKNL, especially the occurrence of new back pain in a patient with a history of cancer

In the absence of a better system than what is currently available, it is suggested to emphasize the importance of actively seeking/finding red flags in patients with (new) back pain with the aim of timely detection of spinal metastases. These red flags (also listed by the IKNL) find their history in the article by Kienstra (2000). At the same time, it may be of interest to reassess the value of the current red flags and identify more objective and poweful (e.g. radiological) red flags. 

Perform imaging of the entire spine using CT, followed by MRI if necessary, in cases of new back pain with an oncological history

Although MRI imaging is the most sensitive and specific modality to detect spinal metastases, it is not the most accessible nor the most convenient/patient-friendly modality. For patients with symptoms related to spinal metastases (reflecting a more advanced stage in the natural course of spinal metastases) CT imaging is usually adequate and can be used for detection of spinal metastases and assessment of stability. For patients with neurological symptoms/deficits an additional MRI examination is still recommended (Harlianto, 2024). 

Do not request conventional X-rays when suspecting vertebral metastases due to their low sensitivity

Conventional radiographs have shown to be inadequate to detect spinal metastases and may therefore lead to false reassurance to both patients and caregivers. Van Tol et al. showed that general practitioners suspecting spinal metastasis and requesting radiographs actually prolonged the diagnostic phase for their patients (van Tol, 2023). 

In case of doubt whether an emergency indication is present, consult a center specialized and experienced in the treatment of vertebral metastases

It is known that the exposure of patients with metastatic spinal disease to non-spine experts is relatively low. Therefore, it is suggested that the knowledge and experience in this non-expert group is relatively limited when it comes to recognizing (pending) emergencies, for example, the occurrence of neurological deficits. Since the clinical outcome of emergency patients is far worse than for elective cases, a low-threshold consultation with a center of definitive care is recommended for all unclear cases (Van Tol, 2019). 

Ensure that there is easy and prompt access within the region to the center where definitive treatment can be provided

Reiterating the above argument, patients with metastatic spinal disease (i.e. spinal metastases with symptoms) often need treatment in specialized centers with spine surgery and radiotherapy available 24/7. Therefore, it is suggested to establish a working relationship with such center and construct a regional pathway for patients with metastatic spinal disease beforehand.

Quality of the evidence

A search was not conducted because it was not anticipated that there would be research available to answer this key question. Therefore, the question has been addressed using expert opinion, the expertise of the working group, and existing agreements regarding the organization of care in the Netherlands.

Values and preferences of patients (and possibly their relatives/caregivers)

Learning the diagnosis spinal metastasis has a profound effect on patients and their family. Depending on the stage in the natural course of spinal metastases, patients can be treated in their local hospital, or they need to be transferred to a center of specialized care, the latter which can cause further stress to patients and their family. Therefore, it is of importance to minimize delays in the diagnostic process as it helps patients receive timelier, and the most appropriate treatments closer to home.

The desired effects on patient-relevant outcomes are very substantial.
See also the dissertation by Tol (2023). The undesired effects on patient-relevant outcomes are minor. One potential undesired effect is that, in order to establish the diagnosis, the patient must undergo radiological imaging (CT or MRI). For patients in whom the diagnosis of vertebral metastases is confirmed, this examination is justified, and the burden for the patient is warranted.

Cost aspects

The intervention (i.e., the timely identification of patients with spinal metastases and the performance of radiological imaging) is less costly compared to the control treatment, because the costs of unnecessary radiological imaging (i.e., overtreatment) are significantly lower than the costs of surgical intervention, rehabilitation, and additional expenses for patients who were not identified in time due to the absence of radiological imaging and were therefore treated too late (van Tol, 2022).

Equity (health equity/equitable)

The intervention may lead to increased health equity, as more patients will receive the right care at the right time in the right place.

Acceptability
Ethical acceptability

The intervention appears to be acceptable to those involved. The working group does not foresee any ethical objections.

Sustainability

The intervention involves the following sustainability aspects. A certain increase in radiological imaging can be expected, which may have a negative impact, for example, on energy consumption. However, this impact is significantly smaller than in the control group, where more urgent surgical and radiotherapeutic interventions are likely to occur, resulting in a larger environmental footprint.

Feasibility

The intervention is feasible and, at least theoretically, already part of standard care. However, widespread implementation of the intervention will require investments in training healthcare professionals to take the appropriate steps in shortening the diagnostic process. Initiatives on this topic are already underway.

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