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Vertebral metastases are secondary malignant deposits in the vertebral column, most commonly resulting from hematogenous spread of cancer.
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Common Primary Tumors:
| Primary Cancers | Appearance |
|---|---|
| Breast | Mixed (lytic + sclerotic) |
| Prostate | Predominantly sclerotic |
| Lung | Lytic and aggressive |
| Kidney | Lytic, vascular, prone to hemorrhage |
| Thyroid | Lytic, expansile |
| Multiple myeloma | Lytic ("punched-out" lesions) |
| Lymphoma | Variable (lytic/sclerotic, soft tissue mass common) |
| Modality | Imaging features |
|---|---|
| XR | • Lytic lesions: Lucent, often with cortical destruction. |
| • Sclerotic lesions: Densely opaque areas (e.g., prostate). | |
| • Mixed lesions: Patchy lucency + sclerosis (e.g., breast). | |
| • Pathologic fractures: Collapse with preserved posterior wall height may suggest benignity, whereas destruction may suggest malignancy. | |
| MR | • T1: Hypointense marrow replacement. |
| • T2/STIR: Hyperintense or heterogeneous. | |
| • Post-contrast: Enhancing soft tissue or epidural mass. | |
| • Epidural extension: Can cause spinal cord compression. | |
| CT | • Defines bony destruction, posterior wall breach, and canal compromise. |
| • Detects sclerotic changes more sensitively than X-ray. | |
| Bone scan | • Detects osteoblastic activity, hence more sensitive for sclerotic metastases. |
| • Lytic lesions (like from renal or thyroid primaries) may be missed. | |
| PET-CT | • High sensitivity for metabolically active lesions (e.g., lung, breast). |
| • Limited for sclerotic lesions unless hypermetabolic. |
A six-grade epidural spinal cord compression (ESCC) grading scale. A grade of 0 indicates bone-only disease; 1a—epidural impingement, without deformation of the thecal sac; 1b—deformation of the thecal sac, without spinal cord abutment; 1c—deformation of the thecal sac with spinal cord abutment, but without cord compression; 2—spinal cord compression, but with CSF visible around the cord; and 3—spinal cord compression, no CSF visible around the cord
Hayashi, K., Tsuchiya, H. The role of surgery in the treatment of metastatic bone tumor. Int J Clin Oncol 27, 1238–1246 (2022). https://doi.org/10.1007/s10147-022-02144-6
ESCC grading scale:
| Grade | Description | Imaging Findings |
|---|---|---|
| 0 | Epidural tumor present, no compression | Normal thecal sac, no deformation |
| 1a | Indentation of the thecal sac, no spinal cord abutment | Tumor near thecal sac, clear CSF around spinal cord |
| 1b | Abutment of the cord, CSF visible | Cord in contact with tumor, but CSF still surrounds it |
| 1c | CSF effaced, cord not deformed | CSF lost circumferentially, but no cord compression |
| 2 | Spinal cord compression, deformed but not displaced | Cord compressed but maintains central position |
| 3 | Severe compression, cord displaced | Cord displaced and flattened; often indistinguishable from tumor on T2 |
Clinical Relevance:
| Grade | Management Consideration |
|---|---|
| 0–1b | May observe or consider radiation if symptomatic |
| 1c–2 | Consider early radiotherapy or steroid therapy |
| Grade 3 | Often requires urgent neurosurgical decompression, especially with neurological symptoms |
Red Flag Features: