• The spine is the frequent site for metastasis
  • Certain tumors have a unique manifestation in the vertebrae
  • Malignant tumors most common in lumbar spine (lumbar > thoracic > cervical)
  • Malignant tumors more commonly in vertebral body than posterior elements

Metastatic breast cancer


  • Most common tumors of the spine
  • Spread to vertebral body first, then later to pedicles
  • Breast, lung, and prostate cancers are most common

Signs/Symptoms of Metastasis:

  • History of cancer
  • Recent unexplained weight loss
  • Night pain
  • Age > 50 years

Radiographic appearance of Metastasis:

  • Most are osteolytic
  • Prostate cancer is an osteoblastic tumor (osteoid forming tumor)
  • Most not visible on plain radiographs until > 30% of vertebral body destruction

Treatment of Metastasis:

  • Prognosis is poor if neurologic dysfunction, proximal lesions, long duration of symptoms, rapid growth of lesions
  • CT-guided needle biopsy performed when possible, surgery avoided
  • Radiation and Chemotherapy mainstays
  • Prostate and lymphoid tumors are very radiosensitive
  • Breast cancer is 70% radiosensitive, 30% resistant
  • GI and renal cell tumors are usually radioresistant

Surgical indications:

  • Progressive neurologic dysfunction unresponsive to radiation therapy
  • Persistent pain despite radiation
  • Need for diagnostic biopsy
  • Pathologic fracture/dislocation
  • Life expectancy should dictate whether or not surgical treatment is preformed
  • For instability/neurologic deficit, anterior decompression and stabilization often used

Primary Tumors

  • Tumors of the Vertebral Body:
  • Eosinophilic Granuloma
  • Usually seen in children Predilection for thoracic spine
  • Causes progressive back pain
  • Classically causes vertebral flattening, vertebra plana – Calve’s disease, seen on lateral radiograph
  • Treatment:
  • Chemotherapy for systemic histiocytosis
  • Bracing to prevent progressive kyphosis
  • Low-dose radiation may be indicated in presence of neurologic deficit
  • Most symptoms are self-limited
  • 50% reconstitution of vertebral height expected
  • Giant Cell Tumor
  • Most commonly seen in 4th-5th decade of life
  • Expansile destruction of vertebral body
  • Surgical excision and bone grafting recommended treatment
  • High recurrence rate reported
  • Radiation therapy should be avoided due to risk of malignant degeneration

Giant cell tumor of the L3 vertebral body

  • Chordoma
  • Low-grade lytic lesion in midline of sacrum or base of skull
  • May occur in vertebrae
  • Patients present with intra-abdominal complaints and pre-sacral mass
  • Treatment: Radiation and Surgery
  • Surgical excision may include unilateral resection of all sacral nerve roots
  • Bowel and bladder function can be preserved by unilateral root resection
  • High recurrence rates

CT scan of sacrococcygeal chordoma

  • Osteosarcoma
  • Uncommon in spine (all primary malignant skeletal lesions)
  • Poor prognosis
  • Treatment: Radiation and chemotherapy
  • Aggressive surgical excision occasionally performed
  • Hemangioma
  • Usually asymptomatic
  • Small fractures may be present in symptomatic patients over age 40
  • Radiographic appearance:
  • “Jailhouse striations” seen on plain films
  • “Spikes of bone” seen on CT
  • Vertebrae normal sized, not expanded as in Paget’s
  • Treatment
  • Observation unless painful pathologic fracture present
  • Anterior resection and fusion if posterior collapse
  • Massive bleeding frequently encountered
  • Marrow cell tumors: Multiple Myeloma & Plasmacytoma
  • Common in spine
  • Osteopenic, lytic lesions
  • Pain, pathologic fractures and diffuse osteoprosis present
  • Increased serum calcium levels
  • Decrease hematocrit
  • Abnormal protein studies (serum/urine electrophoresis)
  • Treatment mainstay is radiation therapy (3000-4000 cGy +/- chemo)
  • Surgery reserved for instability or refractory neurologic symptoms

Tumors of the Posterior Elements:

  • Osteoblastoma and Osteoid osteoma
  • Common in the spine
  • May present as painful scoliosis in children – lesion is typically at apex of convexity
  • Pain is typically relieved by non-steroidal anti-inflammatory drugs (NSAIDs)
  • Bone scan helps localize
  • Thin-cut CT scan directs surgical intervention
  • Surgery indicated with scoliosis, curve resolves within 18 months of resection in children NSAIDs are mainstay of treatment if no scoliosis present
  • Resection performed if pain uncontrolled by NSAIDs
  • Osteoblastomas common in posterior elements of older patients
  • Neurologic involvement in 50%
  • Resection and posterior fusion typically required

Osteoid osteoma of L3 vertebra in patient 9 years of age with back pain and mild scoliosis. Sclerotic lesion is seen in pedicle of L3 on concave side of curve.

  • Aneurysmal bone cyst
  • Cysts typically detected during second decade of life
  • May represent degeneration of more aggressive tumors
  • Can occur in posterior or anterior elements (vertebral body)
  • Treatment is excision and/or radiation therapy


  • Plain radiographs
  • Radiographic changes include absent pedicle, cortical erosion or expansion, and vertebral collapse
  • MRI also useful: malignant tumors have decreased T1 and increased T2 intensity
  • MR sensitivity increases with use of gadolinium
  • Treatment:
  • Complete resection is difficult
  • Treatment usually comprises tumor debulking with stabilization
  • Adjuvant chemotherapy and radiation are necessary