Incidental with symptoms (depending on size and location)

Moderate/Severe numbness to pain, cold, and heat in upper or lower extremities

Moderate/Severe back pain

Paresthesia in upper body or lower body extremities

Neck/Lower back/hip/lower abdominal/pelvis/buttocks pain and loss of mobility due to the pain

Radiating pain down the arms or radicular pain extending into legs/buttocks/thighs/external genitalia/perineum

Pain in moving shoulders

Muscle weakness in arms or legs (paresis) and potentially paralysis

Inability to conduct fine motor skills with hands

Paraplegia (partial or complete)

Difficulty maintaining balance and walking

Diminished control/dysfunction of bowel/bladder (including urinary retention) and external genitalia (men: problems with erection and ejaculation; women: problems with lubrication)

Spine benign/malignant tumor

CT of spine with and without contrast to assess whether there is bony involvement of tumor

MRI of spine with and without contrast to assess if there is spinal cord, epidural space, or nerve root involvement of tumor

PET scan of body to look for other foci of tumor

CT of chest/abdomen/pelvis to rule out metastatic disease and appendicitis

Biopsy to examine tissue sample to determine whether tumor is benign or malignant, and what cancer type resulted in the tumor if malignancy is determined

Metastatic tumor

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  Breast, prostate, lung, renal cell

Primary tumor

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  Intramedullary (typically reside in cervical or thoracic)

  
  
  
  
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    Astrocytoma

    
    
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    Ependymoma

    
    
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    Hemangioblastoma

    
    
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    Lipoma

  
  
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  Intradural extramedullary

  
  
  
  
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    Meningioma

    
    
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    Schwannoma

    
    
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    Neurofibroma

    
    
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    Ependymoma

  
  
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  Extradural (may reside within intervertebral foramen)

Acute pain control with medications and pain management

If asymptomatic or mildly symptomatic with pain/radiculopathy with small focus of tumor:

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  Radiation treatment (radiation oncology consultation)

  
  
  
  
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    Some metastatic tumors are radioresistant

  
  
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  Chemotherapy (medical oncology consultation)

  
  
  
  
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    Some metastatic tumors are radioresistant

  
  
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  Kyphoplasty (to treat pain)

  
  
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  Surgical instrumentation and fusion (if there is concern for deformity, instability, or cord compression)

If symptomatic with cord compression and myelopathy with large tumor burden:

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  Urgent surgical decompression and fusion of multiple segments with tumor resection if deemed suitable candidate for surgery; may be followed by radiation treatment after resection if considered necessary by the radiation oncologist

  
  
  
  
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    Oncologist will need to determine overall prognosis, Karnofsky performance score, and extent of visceral disease

    
    
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    If poor surgical candidate with poor life expectancy, medical management recommended

    
    
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    Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization

  
  
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  Preoperative embolization may be indicated for select vascular tumors to the spine such as renal cell cancer and thyroid cancer, breast cancer in order to decrease vascularity intraoperatively

  
  
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  Radiosurgery/CyberKnife treatment (primary treatment for metastases):

  
  
  
  
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    The CyberKnife system includes 6-MV compact linear accelerator, two diagonal X-ray cameras, a robotic manipulator, an image detector, a treatment couch, and a treatment planning computer

    
    
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    A fractionated approach (small daily doses given over several weeks) may be used