Every year, almost 500,000 people in Germany are diagnosed with cancer [1]. In the subsequent course, approximately 30 to 40% of those affected develop painful metastases in the spine: spinal metastases [2]. Improving quality of life is at the heart of all therapeutic considerations, with various innovative approaches available.
With the CyberKnife, we offer a state-of-the-art, non-invasive treatment system at the European Radiosurgery Center Munich (ERCM). A technology that combines several medical advances to specifically destroy cancer cells.
Learn more about the benefits of modern radiosurgery. Schedule your initial consultation for a customized treatment plan.
Spinal metastases are metastases from other cancers. The most common primary cancers in which one or more new tumors form in the spine are breast cancer, prostate cancer, and lung cancer (bronchial carcinoma). However, skin cancer, lymph node cancer (lymphoma), and renal cell carcinoma can also spread to the spine. In 3 to 10% of all spinal metastases, the original cancer is unknown [1] .
In many cases, depending on the size and location of the metastases, pain initially develops, but as the disease progresses, movement restrictions and increasing instability of the spine also develop.
If additional pressure is exerted on central nerve structures (compression), further symptoms may occur, such as sensory disturbances and motor deficits [1]. These include decreased strength in the arms and legs and even paralysis.
It's important to us to provide you with comprehensive and understandable information about all possible treatment options – and to provide you with personal support together with our experts and partners. Addressing your individual situation and associated special features is a top priority for us – we want to answer all your questions. In determining your treatment path together, your current situation and your personal wishes play a crucial role.
Metastases, especially in the bone structure of the human body, are often difficult to remove surgically. Alternatives include conventional radiation and chemotherapy. Another particularly gentle and effective form of treatment for some patients is CyberKnife therapy, which we perform at ERCM – this is especially true in cases of recurrence, i.e., recurrent metastases to the spine.
CyberKnife therapy is a very gentle yet precise treatment option that can be used anywhere in the body as an alternative to open surgery. Treatment with this state-of-the-art, high-precision technology is safe and effective for you as a patient. Radiosurgical treatment can also be performed after prior conventional radiotherapy [3].
The CyberKnife is a robotic system that uses photons with submillimeter precision—that is, a precision of less than 1 mm. This is particularly important for the treatment of metastases along the spine, with its delicate structures.
With the help of an integrated image guidance system and the flexibility provided by robot control, treatment can often be carried out painlessly in a single treatment session (single-therapy) – without fixation in a fixed frame, without surgery and without anesthesia [4, 5].
Suspected spinal metastases with suspected bone instability and increasing neurological symptoms should be diagnosed early.
Spinal metastases are most common in lung cancer, followed by prostate cancer – which often spreads to the lumbar spine – and breast cancer with metastases to the thoracic spine.
The average age of patients with spinal metastases is 55 to 60 years [2]. In most cases, spinal metastases are very painful. They can grow outside the spinal cord or within the spinal cord substance. Damage to the nervous system and spinal cord injuries are therefore possible consequences, which, if undetected or untreated, can lead to paraplegia.
In this article we discuss the possibilities of CyberKnife therapy in the treatment of spinal tumors.
In addition to severe spinal pain, which is the primary symptom for most patients, metastases can also cause increasing instability of affected bones and vertebrae [2]. This can subsequently lead to postural disturbances and difficulty walking. Vertebral fractures, for example, are also possible.
In addition to a deteriorating general condition, other symptoms include neurological problems such as paralysis, sensory disturbances, and even bladder and bowel emptying difficulties with urinary or fecal incontinence. Since symptoms can sometimes rapidly develop into a neurological or oncological emergency, rapid treatment is often required [6].
All cancer patients with sudden back pain should be immediately imaging (MRI). If metastases are already pressing on the spinal cord (compression), prompt treatment is essential to prevent further damage
Metastases of other cancers that spread to the spine occur in most cases in the thoracic spine (up to about 70%), followed by the lumbar spine with about 20% and less frequently in the cervical spine (about 10%) [2, 7].
The risk for those affected lies primarily in increasing destruction of bone tissue, accompanied by severe pain and neurological symptoms due to compression of the nerve roots or spinal cord. Approximately 20% of all spinal metastases involve the spinal canal and press on sensitive nerve structures [2].
To make a reliable diagnosis and accurately assess possible metastases in the pelvic and spinal regions, diagnostic imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT) are necessary [8]. This is the only way to determine the location and spread of cancer cells.
In simple terms, this means that images of your body are created layer by layer, which are then combined to create a complete three-dimensional image. This allows the treating experts to draw conclusions about the stage of the cancer in your body.
Additional tests may be required on an individual basis, including laboratory tests. These tests often aim to rule out other possible causes of spinal metastases (e.g., osteoporosis or other bone metabolism disorders) that may be responsible for your symptoms [1].
The individual treatment plan depends on the type, exact location, and extent of the metastases—and thus on the stage of the cancer (staging). Spinal metastases may be confined to the bone. However, they can also be located in the spinal canal, either outside the spinal cord (intraspinal-extramedullary) or already in the spinal cord itself (intraspinal-intramedullary). This distinction is relevant for the precise planning of therapy.
The treatment of spinal metastases is always carried out by a multidisciplinary team of experts. This includes specialists in oncology, radiation therapy, neurosurgery, and radiosurgery. Of particular importance are treatment concepts that effectively stabilize bones and, for example, optimally maintain or regain the ability to walk and thus independence in everyday life.
Due to the complex, often inflammatory pain symptoms, additional drug-based pain therapy is used to quickly and effectively reduce symptoms caused by metastases [1].
For pain (e.g. numbness, discomfort), cortisone or opioids are often used, and if necessary, certain antidepressants or anticonvulsants – these are medications that can be particularly helpful for shooting pains.
The actual treatment of the metastases can then be carried out in combination, e.g. by surgery followed by conventional radiation or chemotherapy.
Another option is modern, robot-guided radiosurgery, which can, in certain situations, specifically destroy cancer cells in the spine. This submillimeter-accurate, high-precision method has also been shown in scientific studies to be a particularly comfortable procedure for patients [3, 5].
Spinal metastases can be treated surgically using both open and percutaneous techniques—percutaneous means through the skin, for example, via a small puncture [1]. Overall, the various surgical options are used individually or in combination, provided that surgery can be performed safely in principle.
The decision to operate and the question of the optimal timing of the procedure depend on various individual factors, such as significant functional limitations or existing or impending instability of the spine.
Especially in cases of rapidly growing metastases, emergency open surgery may be necessary due to time constraints to quickly relieve compression of sensitive nerve structures. However, there are also circumstances that may speak against surgery—primarily the general condition, severe multi-organ involvement, or the prognosis [2]. This also includes the risk associated with surgery and, in particular, the individual wishes of the patient.
In cases of multiple metastases in the spine, conventional radiation therapy is often performed. This treatment must be divided into several sessions, as the spinal cord and nerve roots are within the radiation field. Depending on the individual, between 10 and 25 treatment sessions may be necessary over a period of 2 to 5 weeks. This is intended to minimize damage to healthy tissue.
Even after surgery to decompress metastases or stabilize the spine, radiotherapy can be performed to destroy remaining cancer cells and thus reduce the risk of renewed compression of sensitive nerves.
One of the disadvantages of early radiotherapy after previous surgery is the increased likelihood of complications in postoperative wound healing [1].
Cytotoxic drugs – drugs used as chemotherapy – are intended to influence processes important for cell growth and division. Most chemotherapies therefore affect the metabolic and cell division processes of cancer cells, as well as healthy cells. Chemotherapies are therefore not purely cancer-specific.
Chemotherapy is often combined with other treatments. Cytotoxic drugs can be administered either as tablets or intravenously. Common side effects include nausea, fatigue, or weight loss.
A state-of-the-art alternative for treating metastases in selected situations is radiosurgery using the robot-guided CyberKnife system. This highly precise, submillimeter-accurate radiosurgery using photons can successfully destroy cancer cells with high doses and a focused beam, usually in a single application [9]. Healthy, sensitive tissue in the spine and spinal cord is protected, and the treatment dose is adjusted accordingly.
The photons damage the genetic material of the cancer cells, causing them to die and be degraded by the body over several weeks. This method can also be used to treat metastases located in hard-to-reach areas of the skeleton [5].
Even in cases of recurrence of spinal metastases that occur at the same original site, robot-guided radiosurgery with the CyberKnife is a safe and effective treatment method – even as an alternative to previously performed radiotherapy, as studies have shown [10, 11].
For example, new scientific data have shown that radiosurgical treatment of recurrence can provide relevant pain relief in up to 81% of cases and local tumor control can be up to 90% one year after therapy [11].
Radiosurgical treatment is usually performed in a single session, but depending on the individual initial situation and previous therapy, several sessions may be necessary [12].
In cases of very extensive metastases in the spine, combination therapy may also be appropriate. This involves surgical removal of large portions of the tumor, which can often also compress the spinal cord. This is followed by radiosurgical treatment for metastases that are difficult to access surgically. With CyberKnife therapy, all locations – in all areas of the spine – can be reached and treated with high precision.
The increasing complexity of treatment options means that the decision to undergo therapy should always be made with your individual life situation in mind. It is important to us that you, your family, and those who support and accompany you have a thorough understanding of all aspects of your illness and its treatment options, and are able to make sense of them for yourself.
We support you together with our medical partners and can draw on experts from various, individually required disciplines for both diagnostics and treatment. Our team will ensure that you feel well cared for here at ERCM from the very beginning.
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Spinal metastases can be treated effectively with CyberKnife therapy whenever they occur individually and do not cause immediate compression of the spinal cord.
The robotic system's state-of-the-art technology can compensate for body movements, such as those caused by normal breathing, at any time during therapy through appropriate feedback. This enables highly precise treatment, allowing the treatment of spinal metastases with the CyberKnife without the need for fixation or anesthesia. For you, radiosurgical therapy means a comfortable and painless treatment.
In cases of long-term back pain and a primary oncological diagnosis, imaging should always be performed for safety reasons.
Metastases in the spine grow at a rate of weeks to months, but often they are present for longer periods and without significant growth in the vertebral bodies.
Typically, this results in long-lasting back pain, possibly also radiating pain in the arms or legs.
Metastases are always settlements of a primary tumor in the body.
Metastases are always malignant space-occupying lesions.
After radiosurgery, the chance of success that a recurrence will not occur is very high. However, as with all medical treatments, tumor recurrence is possible over time. In these cases, repeat radiosurgery is often possible.
[1] German Society for Orthopaedics and Trauma Surgery (DGOU) and German Spine Society (DWG): S2k Guideline Spinal Metastases, Version 1.0, 2024; available at:
https://register.awmf.org/de/leitlinien/detail/187-003#anmeldung
[2] Eicker, SO, Mohme, M., Surgical treatment of spinal metastases, The Oncologist 2022;28:371-380.
https://doi.org/10.1007/s00761-021-01074-8
[3] Muacevic, A., Cyberknife radiosurgery: a new treatment method for image-guided and robot-assisted precision radiation. MMW Fortschr Med. 2007;149(7):42-43.
https://www.springermedizin.de/strahlenmesser-laesst-inoperable-tumoren-verschwinden/10315920?fulltextView=true
[4] Muacevic, A., Staehler, M., Drexler, C., Wowra, B., Reiser, M., Tonn, J. C., Technical description, phantom accuracy, and clinical feasibility for fiducial-free frameless real-time image-guided spinal radiosurgery. J Neurosurg Spine. 2006;5(4):303-312.
https://doi.org/10.3171/spi.2006.5.4.303
[5] Muacevic, A., Drexler, C., Kufeld, M., Romanelli, P., Duerr, H. J., Wowra, B., Fiducial-free real-time image-guided robotic radiosurgery for tumors of the sacrum/pelvis. Radiother Oncol. 2009;93(1):37-44.
https://www.thegreenjournal.com/article/S0167-8140(09)00273-4/abstract
[6] Guckenberger, M. Guninski, R. S., Hüllner, M., Kobe, A., Schaser, K. D., Wicki, A., Current concepts for the interdisciplinary treatment of bone metastases, Die Onkologie 2023;29:222-229.
https://doi.org/10.1007/s00761-023-01304-1
[7] Bollen, L., Jacobs, W. C. H., Van der Linden, Y. M., Van der Hel, O., Taal, W., Dijkstra, P. D. S., A systematic review of prognostic factors predicting survival in patients with spinal bone metastases. Eur Spine J. 2018;27(4):799-805.
https://doi.org/10.1007/s00586-017-5320-3
[8] Wessling, M., Pflugmacher, R., Müller, M. C., Kabir, K., Pennekamp, P. H., Basic principles of surgical treatment of bone metastases. Z Orthop Unfall. 2013;151(3):303-315.
https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0032-1328634
[9] Muacevic, A., Kufeld, M., Rist, C., Wowra, B., Stief, C., Staehler, M., Safety and feasibility of image-guided robotic radiosurgery for patients with limited bone metastases of prostate cancer. Urol Oncol. 2013;31(4):455-460.
https://www.sciencedirect.com/science/article/abs/pii/S1078143911000810?via%3Dihub
[10] Ehret, F., Mose, L., Kufeld, M., Fürweger, C., Windisch, P., et al., Image-Guided Robotic Radiosurgery for the Treatment of Same Site Spinal Metastasis Recurrences. Front Oncol. 2021;11:642314.
https://doi.org/10.3389/fonc.2021.642314
[11] Myrehaug, S., Sahgal, A., Hayashi, M., Levivier, M., Ma, L., et al., Reirradiation spine stereotactic body radiation therapy for spinal metastases: systematic review. Journal of neurosurgery. Spine 2017;27(4):428-435.
https://doi.org/10.3171/2017.2.SPINE16976
[12] Sahgal, A., Weinberg, V., Ma, L., Chang, E., Chao, S., Muacevic, A., et al., Probabilities of radiation myelopathy specific to stereotactic body radiation therapy to guide safe practice. Int J Radiat Oncol Biol Phys 2013;85(2):341-347.
https://www.redjournal.org/article/S0360-3016(12)00649-9/fulltext