The optimal management of tumors metastatic to the spine is controversial. At Memorial Sloan Kettering Cancer (MSKCC), a multidisciplinary team of surgeons, radiation oncologists, physiatrists, and neuroradiologists that make up the spine service assess patients according to neurologic and oncologic symptoms, mechanical stability, and extent of systemic disease (NOMS).

Neurologic considerations are based on the patient’s degree of neurologic compromise. Oncologic factors include tumor histology and radiosensitivity and degree of epidural disease. Mechanical issues concern spinal stability. Systemic evaluation of the overall extent of disease and patient condition must always be factored into the decision-making process.

The NOMS paradigm is a systematic assessment of the clinical situation and is an easily understood system of categorizing patients, regardless of the specialty. A common lexicon for recommending treatment options has proven invaluable to provide patients with the most appropriate options for treatment.

Cancer metastatic to the spine is commonly encountered in clinical practice. Recent advancements in the areas of surgery and radiation therapy have made a significant impact on the management of such patients.

More than 18,000 new cases of spinal metastases are diagnosed in North America each year, affecting more than 100,000 patients each year (1,2). The vast majority of secondary malignancy to the spine is extradural. More than 90% of patients initially have significant pain (3). Motor weakness, paresthesia, and myelopathy are also important problems that often affect patient quality of life. Despite the enormity of the problem, no real consensus exists on the optimal management of spinal metastases.

At MSKCC, patients are evaluated in a multidisciplinary manner, including experts from orthopedics and neurosurgery, radiation oncology, neuroradiology, and physiatry. Consequently, a multidisciplinary paradigm has been developed to evaluate each patient
to guide management and decision making. This paradigm provides a systematic multidisciplinary structure to evaluate each patient in terms of neurologic, oncologic, mechanical, and systemic (NOMS) aspects (4). The pros and cons of each treatment modality are weighed in view of the specific clinical scenario to provide the most effective and appropriate palliation for each patient.

Neurologic status of the patient is of paramount importance. Surgical management is given first consideration for patients who first seen with rapid and recent onset of symptoms, particularly those associated with myelopathy or loss of function (5). Level one evidence, reported by Patchell et al. (6), confirmed the superiority of surgery over radiation therapy alone for patients with high-grade epidural cord compression. In this study, a significant benefit was found in favor of surgery in terms of ambulation, as well as other quality-of-life measures, and the study was stopped before accrual was completed. Radiation therapy may contribute to spinal cord edema in the setting of high-grade epidural cord compression, and should be used cautiously in such settings, keeping in mind the potential for exacerbation of symptoms in such situations. Corticosteroids are routinely used to minimize cord edema.

In situations without rapid escalation of neurologic symptoms or significant epidural disease, or when surgery is contraindicated for medical reasons, radiation therapy may offer good palliation. Both conventional radiation therapy and high-dose image-guided radiation are appropriate considerations. Radiation therapy, much less invasive than surgery, is often an appropriate modality to maintain optimal quality of life in patients with metastases.

Oncologic issues to consider include the histology (radiosensitive or radioresistant) and the extent of the tumor, both the paradural and paraspinal components. Lymphomas, myelomas, and leukemias are likely to respond rapidly to systemic therapy or conventional radiation therapy. Surgery may be indicated if a histologic diagnosis has not been made or if mechanical back pain requiring surgical stabilization is present. In the previously mentioned phase 3 study reported by Patchell et al. (6), the majority of patients had high-grade epidural tumors with relatively radioresistant histologies (non-small cell lung cancer and colorectal carcinoma). These patients will not respond in a timely fashion to radiotherapy, and surgery should be considered. As reported in the study, these patients have significantly worse outcomes when conventional radiotherapy is used, reinforcing the need for surgical decompression in cases of high-grade epidural spinal cord compression.

At MSKCC, epidural disease is classified as 0 (no epidural disease), 1 (mild to minimal epidural disease), 2 (moderate) cerebrospinal fluid (CSF) still seen on T₂

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