Intradural-Extramedullary and Intramedullary Spinal Metastases



Metastases to the spinal cord and spinal canal are rare but often life-threatening lesions. A multi-disciplinary evaluation is warranted to determine the ideal management strategy. Often, intradural and intramedullary tumors necessitate surgical intervention and adjuvant radiation therapy. However, this treatment protocol must take into account patient-related factors, such as overall tumor burden, patient functional status, and overall quality of life. This chapter discusses the treatment options for intradural and intramedullary spinal lesions, and provides some evidence-based treatment algorithms for management.


Intradural metastasis Intramedullary metastasis Spinal metastasis, radiation 


  1. 1.
    Constans JP, de Divitiis E, Donzelli R, Spaziante R, Meder JF, Haye C. Spinal metastases with neurological manifestations. Review of 600 cases. J Neurosurg. 1983;59(1):111–8. Scholar
  2. 2.
    Costigan DA, Winkelman MD. Intramedullary spinal cord metastasis. A clinicopathological study of 13 cases. J Neurosurg. 1985;62(2):227–33. Scholar
  3. 3.
    Bartels RH, Feuth T, van der Maazen R, Verbeek AL, Kappelle AC, Andre Grotenhuis J, Leer JW. Development of a model with which to predict the life expectancy of patients with spinal epidural metastasis. Cancer. 2007;110(9):2042–9. Scholar
  4. 4.
    Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 2005;30(19):2186–91.CrossRefGoogle Scholar
  5. 5.
    Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2001;26(3):298–306.CrossRefGoogle Scholar
  6. 6.
    van der Linden YM, Dijkstra SP, Vonk EJ, Marijnen CA, Leer JW, Dutch Bone Metastasis Study G. Prediction of survival in patients with metastases in the spinal column: results based on a randomized trial of radiotherapy. Cancer. 2005;103(2):320–8. Scholar
  7. 7.
    Wong DA, Fornasier VL, MacNab I. Spinal metastases: the obvious, the occult, and the impostors. Spine (Phila Pa 1976). 1990;15(1):1–4.CrossRefGoogle Scholar
  8. 8.
    Hernandez RK, Adhia A, Wade SW, O'Connor E, Arellano J, Francis K, Alvrtsyan H, Million RP, Liede A. Prevalence of bone metastases and bone-targeting agent use among solid tumor patients in the United States. Clin Epidemiol. 2015;7:335–45. Scholar
  9. 9.
    Li S, Peng Y, Weinhandl ED, Blaes AH, Cetin K, Chia VM, Stryker S, Pinzone JJ, Acquavella JF, Arneson TJ. Estimated number of prevalent cases of metastatic bone disease in the US adult population. Clin Epidemiol. 2012;4:87–93. Scholar
  10. 10.
    Perrin RG, Laxton AW. Metastatic spine disease: epidemiology, pathophysiology, and evaluation of patients. Neurosurg Clin N Am. 2004;15(4):365–73. Scholar
  11. 11.
    Connolly ES Jr, Winfree CJ, McCormick PC, Cruz M, Stein BM. Intramedullary spinal cord metastasis: report of three cases and review of the literature. Surg Neurol. 1996;46(4):329–37. discussion 337-328CrossRefGoogle Scholar
  12. 12.
    Halvorson KG, Sevcik MA, Ghilardi JR, Rosol TJ, Mantyh PW. Similarities and differences in tumor growth, skeletal remodeling and pain in an osteolytic and osteoblastic model of bone cancer. Clin J Pain. 2006;22(7):587–600. Scholar
  13. 13.
    Stranjalis G, Torrens MJ. Successful removal of intramedullary spinal cord metastasis: case report. Br J Neurosurg. 1993;7(2):193–5.CrossRefGoogle Scholar
  14. 14.
    Dunne JW, Harper CG, Pamphlett R. Intramedullary spinal cord metastases: a clinical and pathological study of nine cases. Q J Med. 1986;61(235):1003–20.PubMedGoogle Scholar
  15. 15.
    Schiff D, O'Neill BP. Intramedullary spinal cord metastases: clinical features and treatment outcome. Neurology. 1996;47(4):906–12.CrossRefGoogle Scholar
  16. 16.
    Grem JL, Burgess J, Trump DL. Clinical features and natural history of intramedullary spinal cord metastasis. Cancer. 1985;56(9):2305–14.CrossRefGoogle Scholar
  17. 17.
    Jellinger K, Kothbauer P, Sunder-Plassmann E, Weiss R. Intramedullary spinal cord metastases. J Neurol. 1979;220(1):31–41.CrossRefGoogle Scholar
  18. 18.
    Bollen L, van der Linden YM, Pondaag W, Fiocco M, Pattynama BP, Marijnen CA, Nelissen RG, Peul WC, Dijkstra PD. Prognostic factors associated with survival in patients with symptomatic spinal bone metastases: a retrospective cohort study of 1,043 patients. Neuro-Oncology. 2014;16(7):991–8. Scholar
  19. 19.
    Switlyk MD, Kongsgaard U, Skjeldal S, Hald JK, Hole KH, Knutstad K, Zaikova O. Prognostic factors in patients with symptomatic spinal metastases and normal neurological function. Clin Oncol (R Coll Radiol). 2015;27(4):213–21. Scholar
  20. 20.
    Chao ST, Koyfman SA, Woody N, Angelov L, Soeder SL, Reddy CA, Rybicki LA, Djemil T, Suh JH. Recursive partitioning analysis index is predictive for overall survival in patients undergoing spine stereotactic body radiation therapy for spinal metastases. Int J Radiat Oncol Biol Phys. 2012;82(5):1738–43. Scholar
  21. 21.
    Lutz S, Berk L, Chang E, Chow E, Hahn C, Hoskin P, Howell D, Konski A, Kachnic L, Lo S, Sahgal A, Silverman L, von Gunten C, Mendel E, Vassil A, Bruner DW, Hartsell W, American Society for Radiation O. Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;79(4):965–76. Scholar
  22. 22.
    Rades D, Lange M, Veninga T, Stalpers LJ, Bajrovic A, Adamietz IA, Rudat V, Schild SE. Final results of a prospective study comparing the local control of short-course and long-course radiotherapy for metastatic spinal cord compression. Int J Radiat Oncol Biol Phys. 2011;79(2):524–30. Scholar
  23. 23.
    Bauer HC, Wedin R. Survival after surgery for spinal and extremity metastases. Prognostication in 241 patients. Acta Orthop Scand. 1995;66(2):143–6.CrossRefGoogle Scholar
  24. 24.
    Heindel W, Gubitz R, Vieth V, Weckesser M, Schober O, Schafers M. The diagnostic imaging of bone metastases. Dtsch Arztebl Int. 2014;111(44):741–7. Scholar
  25. 25.
    Huysse W, Lecouvet F, Castellucci P, Ost P, Lambrecht V, Artigas C, Denis ML, Man K, Delrue L, Jans L, Bruycker A, Vos F, Meerleer G, Decaestecker K, Fonteyne V, Lambert B. Prospective comparison of F-18 choline PET/CT scan versus axial MRI for detecting bone metastasis in biochemically relapsed prostate Cancer patients. Diagnostics (Basel). 2017;7(4)
  26. 26.
    Lin CY, Chen YW, Chang CC, Yang WC, Huang CJ, Hou MF. Bone metastasis versus bone marrow metastasis? Integration of diagnosis by (18)F-fluorodeoxyglucose positron emission/computed tomography in advanced malignancy with super bone scan: two case reports and literature review. Kaohsiung J Med Sci. 2013;29(4):229–33. Scholar
  27. 27.
    Pandit-Taskar N, O'Donoghue JA, Durack JC, Lyashchenko SK, Cheal SM, Beylergil V, Lefkowitz RA, Carrasquillo JA, Martinez DF, Fung AM, Solomon SB, Gonen M, Heller G, Loda M, Nanus DM, Tagawa ST, Feldman JL, Osborne JR, Lewis JS, Reuter VE, Weber WA, Bander NH, Scher HI, Larson SM, Morris MJ. A phase I/II study for analytic validation of 89Zr-J591 ImmunoPET as a molecular imaging agent for metastatic prostate Cancer. Clin Cancer Res. 2015;21(23):5277–85. Scholar
  28. 28.
    Adams JE. Quantitative computed tomography. Eur J Radiol. 2009;71(3):415–24. Scholar
  29. 29.
    Imai K. Vertebral fracture risk and alendronate effects on osteoporosis assessed by a computed tomography-based nonlinear finite element method. J Bone Miner Metab. 2011;29(6):645–51. Scholar
  30. 30.
    Moore KR. Radiology of metastatic spine cancer. Neurosurg Clin N Am. 2004;15(4):381–9. Scholar
  31. 31.
    Andreula C, Murrone M. Metastatic disease of the spine. Eur Radiol. 2005;15(3):627–32. Scholar
  32. 32.
    Nobauer I, Uffmann M. Differential diagnosis of focal and diffuse neoplastic diseases of bone marrow in MRI. Eur J Radiol. 2005;55(1):2–32. Scholar
  33. 33.
    Van Goethem JW, van den Hauwe L, Ozsarlak O, De Schepper AM, Parizel PM. Spinal tumors. Eur J Radiol. 2004;50(2):159–76. Scholar
  34. 34.
    Baur A, Stabler A, Bruning R, Bartl R, Krodel A, Reiser M, Deimling M. Diffusion-weighted MR imaging of bone marrow: differentiation of benign versus pathologic compression fractures. Radiology. 1998;207(2):349–56. Scholar
  35. 35.
    Spuentrup E, Buecker A, Adam G, van Vaals JJ, Guenther RW. Diffusion-weighted MR imaging for differentiation of benign fracture edema and tumor infiltration of the vertebral body. AJR Am J Roentgenol. 2001;176(2):351–8. Scholar
  36. 36.
    Spratt DE, Beeler WH, de Moraes FY, Rhines LD, Gemmete JJ, Chaudhary N, Shultz DB, Smith SR, Berlin A, Dahele M, Slotman BJ, Younge KC, Bilsky M, Park P, Szerlip NJ. An integrated multidisciplinary algorithm for the management of spinal metastases: an international spine oncology consortium report. Lancet Oncol. 2017;18(12):e720–30. Scholar
  37. 37.
    Paton GR, Frangou E, Fourney DR. Contemporary treatment strategy for spinal metastasis: the "LMNOP" system. Can J Neurol Sci. 2011;38(3):396–403.CrossRefGoogle Scholar
  38. 38.
    Arana E, Kovacs FM, Royuela A, Asenjo B, Perez-Ramirez U, Zamora J, Spanish Back Pain Research Network Task Force for the Improvement of Inter-Disciplinary Management of Spinal M. Spine instability neoplastic score: agreement across different medical and surgical specialties. Spine J. 2016;16(5):591–9. Scholar
  39. 39.
    Campos M, Urrutia J, Zamora T, Roman J, Canessa V, Borghero Y, Palma A, Molina M. The spine instability neoplastic score: an independent reliability and reproducibility analysis. Spine J. 2014;14(8):1466–9. Scholar
  40. 40.
    Versteeg AL, Verlaan JJ, Sahgal A, Mendel E, Quraishi NA, Fourney DR, Fisher CG. The spinal instability neoplastic score: impact on oncologic decision-making. Spine (Phila Pa 1976). 2016;41(Suppl 20):S231–7. Scholar
  41. 41.
    Fourney DR, Frangou EM, Ryken TC, Dipaola CP, Shaffrey CI, Berven SH, Bilsky MH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fisher CG. Spinal instability neoplastic score: an analysis of reliability and validity from the spine oncology study group. J Clin Oncol. 2011;29(22):3072–7. Scholar
  42. 42.
    Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, Vrionis FD, Yamada Y, Gerszten PC, Kuklo TR. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324–8. Scholar
  43. 43.
    Luksanapruksa P, Buchowski JM, Hotchkiss W, Tongsai S, Wilartratsami S, Chotivichit A. Prognostic factors in patients with spinal metastasis: a systematic review and meta-analysis. Spine J. 2017;17(5):689–708. Scholar
  44. 44.
    Moussazadeh N, Laufer I, Yamada Y, Bilsky MH. Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals. Cancer Control. 2014;21(2):168–74. Scholar
  45. 45.
    Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643–8. Scholar
  46. 46.
    Findlay JM, Bernstein M, Vanderlinden RG, Resch L. Microsurgical resection of solitary intramedullary spinal cord metastases. Neurosurgery. 1987;21(6):911–5.CrossRefGoogle Scholar
  47. 47.
    Chow TS, McCutcheon IE. The surgical treatment of metastatic spinal tumors within the intradural extramedullary compartment. J Neurosurg. 1996;85(2):225–30. Scholar
  48. 48.
    Strickland BA, McCutcheon IE, Chakrabarti I, Rhines LD, Weinberg JS. The surgical treatment of metastatic spine tumors within the intramedullary compartment. J Neurosurg Spine. 2018;28(1):79–87. Scholar
  49. 49.
    Edelson RN, Deck MD, Posner JB. Intramedullary spinal cord metastases. Clinical and radiographic findings in nine cases. Neurology. 1972;22(12):1222–31.CrossRefGoogle Scholar
  50. 50.
    Winkelman MD, Adelstein DJ, Karlins NL. Intramedullary spinal cord metastasis. Diagnostic and therapeutic considerations. Arch Neurol. 1987;44(5):526–31.CrossRefGoogle Scholar
  51. 51.
    Guckenberger M, Goebel J, Wilbert J, Baier K, Richter A, Sweeney RA, Bratengeier K, Flentje M. Clinical outcome of dose-escalated image-guided radiotherapy for spinal metastases. Int J Radiat Oncol Biol Phys. 2009;75(3):828–35. Scholar
  52. 52.
    Howell DD, James JL, Hartsell WF, Suntharalingam M, Machtay M, Suh JH, Demas WF, Sandler HM, Kachnic LA, Berk LB. Single-fraction radiotherapy versus multifraction radiotherapy for palliation of painful vertebral bone metastases-equivalent efficacy, less toxicity, more convenient: a subset analysis of radiation therapy oncology group trial 97-14. Cancer. 2013;119(4):888–96. Scholar
  53. 53.
    Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976). 2007;32(2):193–9. Scholar
  54. 54.
    Yamada Y, Bilsky MH, Lovelock DM, Venkatraman ES, Toner S, Johnson J, Zatcky J, Zelefsky MJ, Fuks Z. High-dose, single-fraction image-guided intensity-modulated radiotherapy for metastatic spinal lesions. Int J Radiat Oncol Biol Phys. 2008;71(2):484–90. Scholar
  55. 55.
    Zelefsky MJ, Greco C, Motzer R, Magsanoc JM, Pei X, Lovelock M, Mechalakos J, Zatcky J, Fuks Z, Yamada Y. Tumor control outcomes after hypofractionated and single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases from renal cell carcinoma. Int J Radiat Oncol Biol Phys. 2012;82(5):1744–8. Scholar
  56. 56.
    Azad TD, Esparza R, Chaudhary N, Chang SD. Stereotactic radiosurgery for metastasis to the craniovertebral junction preserves spine stability and offers symptomatic relief. J Neurosurg Spine. 2015;24:1–7. Scholar
  57. 57.
    Monserrate A, Zussman B, Ozpinar A, Niranjan A, Flickinger JC, Gerszten PC. Stereotactic radiosurgery for intradural spine tumors using cone-beam CT image guidance. Neurosurg Focus. 2017;42(1):E11. Scholar
  58. 58.
    Pan J, Ho AL, D'Astous M, Sussman ES, Thompson PA, Tayag AT, Pangilinan L, Soltys SG, Gibbs IC, Chang SD. Image-guided stereotactic radiosurgery for treatment of spinal hemangioblastoma. Neurosurg Focus. 2017;42(1):E12. Scholar
  59. 59.
    Chang EL, Shiu AS, Mendel E, Mathews LA, Mahajan A, Allen PK, Weinberg JS, Brown BW, Wang XS, Woo SY, Cleeland C, Maor MH, Rhines LD. Phase I/II study of stereotactic body radiotherapy for spinal metastasis and its pattern of failure. J Neurosurg Spine. 2007;7(2):151–60. Scholar
  60. 60.
    Chang JH, Shin JH, Yamada YJ, Mesfin A, Fehlings MG, Rhines LD, Sahgal A. Stereotactic body radiotherapy for spinal metastases: what are the risks and how do we minimize them? Spine (Phila Pa 1976). 2016;41(Suppl 20):S238–45. Scholar
  61. 61.
    Hall WA, Stapleford LJ, Hadjipanayis CG, Curran WJ, Crocker I, Shu HK. Stereotactic body radiosurgery for spinal metastatic disease: an evidence-based review. Int J Surg Oncol. 2011;2011:979214–9. Scholar
  62. 62.
    Joaquim AF, Ghizoni E, Tedeschi H, Pereira EB, Giacomini LA. Stereotactic radiosurgery for spinal metastases: a literature review. Einstein (Sao Paulo). 2013;11(2):247–55.CrossRefGoogle Scholar
  63. 63.
    Yamada Y, Katsoulakis E, Laufer I, Lovelock M, Barzilai O, McLaughlin LA, Zhang Z, Schmitt AM, Higginson DS, Lis E, Zelefsky MJ, Mechalakos J, Bilsky MH. The impact of histology and delivered dose on local control of spinal metastases treated with stereotactic radiosurgery. Neurosurg Focus. 2017;42(1):E6. Scholar
  64. 64.
    Shin DA, Huh R, Chung SS, Rock J, Ryu S. Stereotactic spine radiosurgery for intradural and intramedullary metastasis. Neurosurg Focus. 2009;27(6):E10. Scholar
  65. 65.
    Rosenberg SA, Yang JC, Sherry RM, Kammula US, Hughes MS, Phan GQ, Citrin DE, Restifo NP, Robbins PF, Wunderlich JR, Morton KE, Laurencot CM, Steinberg SM, White DE, Dudley ME. Durable complete responses in heavily pretreated patients with metastatic melanoma using T-cell transfer immunotherapy. Clin Cancer Res. 2011;17(13):4550–7. Scholar
  66. 66.
    Topalian SL, Sznol M, McDermott DF, Kluger HM, Carvajal RD, Sharfman WH, Brahmer JR, Lawrence DP, Atkins MB, Powderly JD, Leming PD, Lipson EJ, Puzanov I, Smith DC, Taube JM, Wigginton JM, Kollia GD, Gupta A, Pardoll DM, Sosman JA, Hodi FS. Survival, durable tumor remission, and long-term safety in patients with advanced melanoma receiving nivolumab. J Clin Oncol. 2014;32(10):1020–30. Scholar
  67. 67.
    Raj VS, Lofton L. Rehabilitation and treatment of spinal cord tumors. J Spinal Cord Med. 2013;36(1):4–11. Scholar
  68. 68.
    Pojskic M, Arnautovic KI. Microsurgical resection of lung carcinoma spinal cord metastasis. Oper Neurosurg (Hagerstown). 2018 [Accepted].Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Semmes MurpheyMemphisUSA
  2. 2.Department of NeurosurgeryUniversity of Tennessee Health Science CenterMemphisUSA

Personalised recommendations