Research questions

For which patient is which modality and in what order indicated for the treatment of spinal metastases, with the goals of palliation, achieving local control, and maintaining mobility in patients with spinal metastases?

Subquestions:

1. How do you determine the phase the patient is in that indicates a particular treatment?
2. Which treatment is indicated?

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Considerations

Balance between desired and undesired effects

When selecting an appropriate treatment option for patients with spinal metastases it is imperative to have answers available to questions pertaining to the patient’s condition including: the presence of alarm symptoms (e.g. neurological deficits), (mechanical) back pain or radicular pain, oncological status and availability of treatment options, and overall performance status (Tsukamoto, 2021). As neurological alarm symptoms may be indicative of the development of serious and irreversible damage due to ongoing compression of the spinal cord or cauda equina, it is suggested that these symptoms receive the highest priority in terms of allocating time and resources for diagnosis, decision-making and treatment (van der Linden, 2015; Cole, 2008).

Neurological alarm symptoms can often be diagnosed by history taking combined with a relatively basic physical examination (van der Linden, 2015). Imaging studies have great value to indicate the location of the metastatic epidural spinal cord/cauda compression (MESCC) and may even visualize an imminent threat to neurological function in an, otherwise, asymptomatic patient (Cole, 2008; Switlyk, 2012). Once a high-grade MESCC (Bilsky 2/3, see chapter 1.2 pathofysiology) has been visualized in a patient with spinal metastasis, it is critical to record the presence of neurological symptoms (if any) and their progression over time. Rapidly progressing neurological deficits can lead to (irreversible) loss of function in the course of hours to days; while slowly progressing deficits may lead to minimal loss of function and remain stable for days to weeks (Vaishya,2024). As a rule of thumb, rapid progression of neurological deficits warrants an equally rapid response from caregivers to maintain or restore as much function as possible (van Tol, 2020). For patients who are fit for surgery, the presence of neurological symptoms in combination with a high-grade MESCC warrants urgent decompressive surgery, sometimes combined with stabilizing surgery and often followed by radiotherapy for long term tumor control (Amelink, 2025).

For patients with spinal metastasis not displaying alarm symptoms (e.g. neurological deficits and/or high-grade MESCC), it is important to balance the nature and severity of the complaints against the demands and complications of treatments offered. For some patients no specific treatment or intervention is needed due to minor symptoms or limited life expectancy. For other patients symptoms can be moderate to severe warranting further examination and treatment. It is currently believed that different forms of pain exist in patients with spinal metastases each with their optimal treatment modality (Pahuta, 2025). Inflammatory pain has been described as the pain caused by local secretion of inflammation mediators, cytokines etc. by the spinal metastasis (Takemura, 2023). Inflammatory pain typically responds well to palliative radiotherapy (Mercadante, 2007). This type of pain differs from the pain due to weakening of the bone by a locally destructive tumor. With the advent of the SINS score more information has become available on the topic of ‘mechanical instability’ (Versteeg, 2016). Many studies have shown pain caused by mechanical instability to respond best to a form of stabilization, mostly by surgically fixing vertebral segments together to restore stability (Versteeg, 2019). However, patients with pain caused by mechanical instability of spinal metastases should be carefully selected and declared to be fit for surgery, for example based on their performance status (Verlaan, 2016). If patients are not declared fit for surgery, patients with pain form unstable spinal metastases might still benefit from systemic and/or radiotherapy. Generally accepted criteria to briefly assess whether a patient is fit for surgery are a KPS > 50 and a life expectancy of more than 3 months. To select the best treatment for each patient, we advocate a treatment/referral scheme based on the amount of pain, neurological status and performance status of patient with painful spinal metastases. In this scheme we also advocate a timeline for referral for patients with different characteristics in pain and neurological status.

Values and preferences of patients (and possibly their relatives/caregivers)
Timely, systematically organized consultation and treatment within a multidisciplinary team meeting is expected to offer patients personalized, optimal care. During the process of creating a treatment plan, the recommended treatment will be communicated to the patient, including both the advantages and the risks. The values and preferences of patients, and possibly their relatives or caregivers, will be taken into consideration.

Cost aspects
The recommendations in this module are designed to provide patients with the best available and most effective treatment, which is expected to improve patient outcomes and reduce costs compared with less organized approaches.

Equity (health equity / equitable access)
Since the selection of treatment modality is applicable to every patient, the recommendations are not expected to affect health equity.

Acceptability
Ethical acceptability

Ethical acceptability does not play a role in this module.

Sustainability
Sustainability does not play a role in this module.

Feasibility

The working group believe that working through an multidisciplinairy team meeting approach using the NOMS framework is feasible. However, there should be regional consensus on which hospital serves as the referral center in cases of neurological involvement. Such a referral center should provide 24/7 coverage by a spinal surgeon (either an orthopedic surgeon or a neurosurgeon). Therefore, it is highly recommended to establish a clear protocol or care pathway for patients with spinal metastases, specifying which hospital acts as the referral center for spinal surgery. It should also be defined when immediate discussion with the referral center is mandatory and which cases can be discussed later, for example during a multidisciplinairy team meeting.