Radiation is the main treatment for a cancer deposit in the spine. It relieves pain in six patients in ten, protects the spinal cord, and in its stereotactic form can abolish pain outright in a third of patients within two sessions. This page explains the emergency of cord compression and when surgery comes first, how conventional and stereotactic radiation compare, who qualifies for each, the course and its side effects, and how patients from abroad arrange treatment in Istanbul.
About This Department
Radiation oncology
A cancer deposit in the spine hurts, weakens the bone and threatens the spinal cord. Radiation answers all three, and in two sessions it can now abolish the pain outright in a third of patients. Timing is what decides the outcome.
Cancer spreads to the spine more often than to any other bone, and radiation remains the treatment nearly every patient with a painful spinal deposit receives. Conventional radiation over one to ten sessions relieves pain in about six patients in ten (Chow and colleagues, Clinical Oncology, 2012). Stereotactic body radiation therapy, which delivers a much higher dose in two sessions with millimeter precision, produced a complete pain response at three months in 35 percent of patients against 14 percent with the conventional course in the randomized SC.24 trial (Sahgal and colleagues, Lancet Oncology, 2021). When the deposit presses on the spinal cord, surgery followed by radiation kept 84 percent of patients walking against 57 percent with radiation alone (Patchell and colleagues, Lancet, 2005). This page explains what radiation does for spine metastases, the emergency of cord compression, how conventional radiation, stereotactic radiation and surgery compare, who qualifies for each, what the course involves, and how patients from abroad arrange it at Biruni Hospital in Istanbul.
35
Percent of patients with no pain at all three months after two-session stereotactic radiation, against 14 percent after conventional radiation
84
Percent able to walk after surgery plus radiation for cord compression, against 57 percent with radiation alone
60
Percent pain response after a single session of conventional radiation, the same as after multiple sessions
Free
Review of your MRI, scans and pain and neurological status
Cancer reaches the spine through the blood, most often from the breast, the prostate, the lung, the kidney and the thyroid, and from myeloma. A deposit in a vertebra does three things. It hurts, with a deep ache that is worse at night and on lying flat. It weakens the bone, which can collapse. And it can grow backward into the canal that carries the spinal cord. Radiation addresses each.
Pain. Radiation kills the tumor cells that inflame the bone and stretch its lining, and pain begins to ease within one to two weeks. Six in ten respond. Two to three in ten become pain free after a conventional course. Stereotactic treatment raises the pain-free proportion.
Cord and nerve protection. A deposit that has begun to press on the spinal cord or the nerve roots is treated within days, with steroids started at once, to preserve walking, bladder control and sensation. Radiation stops the tumor growing further and shrinks it over weeks.
Tumor control. In a patient with a few metastases and a cancer otherwise controlled, a high dose to each spinal deposit aims to destroy it rather than to soothe it, and local control at one year exceeds 85 percent in most stereotactic series.
Cord compression, the one emergency in radiation oncology
New weakness in the legs, numbness rising from the feet, difficulty passing urine or a band of pain around the chest or abdomen in a patient known to have cancer signals possible compression of the spinal cord. Same-day treatment. Every hour of delay costs nerve fibers that do not return.
Surgery first, when it is possible
The randomized trial of 101 patients with cord compression from a single site compared surgery to remove the tumor from the canal, followed by radiation, with radiation alone. After treatment 84 percent of the surgery group could walk against 57 percent, they stayed walking for a median of 122 days against 13, and of the patients who arrived unable to walk, 62 percent regained it after surgery against 19 percent (Patchell and colleagues, 2005). The trial was stopped early because the difference was so large.
The result applies to a patient with one site of compression, a life expectancy of at least three months, and a spine and a general condition that can withstand an operation. A patient with compression at several levels, a very radiosensitive tumor such as lymphoma or myeloma, or a prognosis of weeks receives radiation alone, started within 24 hours, with dexamethasone. The spine surgeon and the radiation oncologist decide together, on the day, with the MRI in front of them. Both see the patient before the sun sets. For the patient who is far from a hospital when the weakness begins, the practical advice is simple and worth stating plainly. Take the steroid the local doctor prescribes, lie flat rather than sit, do not wait for a scheduled appointment, and get to any emergency department with an MRI scanner, because the treatment that saves walking is the one given within a day, wherever it is given, and the transfer to a center abroad can follow once the cord is safe.
Conventional, stereotactic or surgery
Three tools, chosen by what the deposit is doing and what the patient needs from the next months.
Conventional radiation delivers a moderate dose in one to ten sessions through simple fields. It is quick to plan, available anywhere, and relieves pain in most patients. Stereotactic body radiation therapy, SBRT, delivers two to three times the biological dose in one to three sessions, shaped around the spinal cord to within a couple of millimeters, and aims to kill the deposit rather than to calm it. Surgery decompresses the cord and stabilizes a spine that has become unstable, and is followed by radiation of one kind or the other.
Side by side
The three approaches
Question
Conventional radiation
Stereotactic radiation
Sessions
1, 5 or 10
1 to 3
Planning time
Same day to two days
Five to seven days, with MRI fusion
Pain relief
About 60 percent respond, 20 to 25 percent pain free
Same response rate, 35 percent pain free at three months
Tumor control at one year
Modest, retreatment common
Above 85 percent in most series
Best for
Widespread disease, short prognosis, emergency compression
Few metastases, controlled cancer, previous radiation to the same spot, radioresistant tumors such as kidney, melanoma and sarcoma
Main risk
Retreatment need, 2.6 times higher after a single session
Vertebral fracture in about one in ten, pain flare in the first days
Is one session as good as ten?
For pain, yes. A meta-analysis of 25 randomized trials with more than 5,000 patients found the same response rate, 60 percent against 61 percent, and the same complete response rate, 23 against 24 percent, after a single session of 8 Gy or a longer course. The difference lay in the need for repeat treatment, 2.6 times higher after the single session, and in a trend toward more cord compression events after single fractions that did not reach significance (Chow and colleagues, 2012). For a patient with a short prognosis or a long journey, one session is the honest choice. For a patient expected to live years, a longer course or a stereotactic course lasts longer.
What the trials show
Decades ago, the trials settled pain relief. Two questions remained. Whether surgery adds to radiation when the cord is compressed, answered above. And whether the higher stereotactic dose does anything conventional radiation cannot.
What did the SC.24 trial find?
229 patients with painful spinal metastases at 18 hospitals in Canada and Australia were randomized to stereotactic radiation of 24 Gy in two sessions or conventional radiation of 20 Gy in five. At three months, 35 percent of the stereotactic group had a complete response, meaning no pain and no increase in painkillers, against 14 percent of the conventional group. The difference held at six months. Serious side effects were the same in both groups, five patients in each with severe pain, and there were no treatment-related deaths. The authors concluded that stereotactic dose escalation is appropriate for symptom control in selected patients with painful spinal metastases (Sahgal and colleagues, 2021). Selected is the operative word. The trial excluded patients with cord compression causing symptoms, unstable spines and deposits spanning more than three vertebrae.
Who gets stereotactic treatment
The patient who will live long enough to benefit from a treatment that lasts.
Eligible patients had painful MRI-confirmed spinal metastasis, no more than three consecutive vertebral segments in the treatment volume, a performance status of 0 to 2, a spinal instability score of less than 12, and no neurologically symptomatic spinal cord or cauda equina compression (Sahgal and colleagues, 2021).
What is the spinal instability score?
A score from 0 to 18, called SINS, that grades the location of the deposit, whether the pain is mechanical, the type of bone destruction, the alignment of the spine, how much of the vertebral body has collapsed and whether the side elements are involved. Below 7 the spine is stable and radiation alone is safe. From 7 to 12 a surgeon is asked whether the spine needs fixing first. Above 12 it does, with screws and rods or cement, before or instead of radiation. Every patient referred for spinal radiation is scored.
Suitability for SBRT
Favors SBRT
Favors conventional radiation
Needs surgery first
One to three vertebrae involved
Many vertebrae or diffuse disease
Unstable spine, SINS above 12
Cancer controlled elsewhere, prognosis over six months
Pathological fracture with collapse over 50 percent
Tumor more than 3 millimeters from the cord
Tumor touching or displacing the cord
Progressive deficit despite steroids
Cord compression with symptoms rules SBRT out because the dose the cord can take is the same dose that would leave the tumor against it undertreated, and surgery to separate them comes first.
A prognosis of weeks rules it out because the benefit of stereotactic treatment appears over months, and a single conventional session relieves pain just as fast.
The gap between tumor and cord is the whole question in stereotactic planning. The oncologist outlines the cord on a fused MRI and sets a hard limit on the dose it receives, and the plan carves the high-dose region around it. Where the tumor sits against the cord, a surgeon can remove the part that touches it in a procedure called separation surgery, and the stereotactic dose follows a week or two later to what remains.
The course
Fast for conventional treatment. A week of preparation for stereotactic.
Assessment. Pain score, neurological examination, MRI of the whole spine with contrast, the instability score, and a review of the cancer's state elsewhere and of any previous radiation to the same region, which changes the dose that can be given.
Planning. For conventional radiation, a CT in the treatment position on the same day and treatment the same day or the next. For SBRT, a CT in a body mold with the MRI fused to it, outlining of the tumor and the cord, a plan checked by a physicist and delivered to a phantom before the patient, which takes five to seven days.
Treatment. Conventional sessions take ten minutes. Stereotactic sessions take thirty to forty-five minutes, most of it imaging, with a cone beam CT before the beam and sometimes during it, and the patient still in the mold throughout.
Afterward. Steroids for a few days around stereotactic treatment to prevent pain flare. A review at four to six weeks. MRI at three months and then every three to six months for stereotactic patients.
Pain relief begins within a week for the majority and reaches its fullest at four to six weeks. A pain flare, a temporary worsening in the first three days, occurs in about a third of stereotactic patients and settles with dexamethasone.
Side effects
Tiredness. Nausea when the stomach or bowel lies in front of the treated vertebra, prevented with a tablet before each session. A sore throat for treatment of the neck. A temporary flare of pain. Later, a fracture of the treated vertebra in about one in ten stereotactic patients, more often when the vertebra was already partly collapsed, which is the reason the instability score is checked before treatment and a cement injection is sometimes done first. Injury to the spinal cord itself, the complication every plan is built to avoid, occurs in well under one percent when dose limits are respected.
1
Vertebroplasty or kyphoplasty
Cement injected into a collapsed vertebra under X-ray guidance, on the same admission, relieves mechanical pain that radiation does not and stabilizes the bone for the radiation to follow.
2
Systemic treatment
Bone-strengthening drugs, denosumab or zoledronic acid, are started or continued, and the oncologist reviews whether the cancer's drug treatment needs changing, since a new spinal deposit often signals that it does.
Coming from abroad
Two kinds of patients travel. One has a painful deposit and a cancer under control, and comes for stereotactic treatment planned in advance. The other has developed weakness and needs surgery and radiation within days, and is brought by air ambulance or on the first flight with a doctor's clearance. The length of stay is a week for a stereotactic course and two to three weeks when surgery comes first. Two days after the last session, patients are fit to fly. After spinal surgery the wait is ten to fourteen days, with the surgeon's clearance, and the coordinator books the return flight only once that clearance has been given, because an airline will refuse a patient with a fresh spinal wound without a medical certificate and the certificate is written after the wound check on the tenth day.
One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number once you are back home. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages. It arranges the visa invitation letter, airport transfers, a stretcher or wheelchair transfer where needed, daily transport and accommodation near the hospital. The kitchen prepares halal, vegetarian and diabetic meals, a prayer room is on site, and a request for a female physician is met wherever the rota allows.
What to send, and what happens when
The visit
Day
Stereotactic course
Surgery then radiation
Before travel
Whole-spine MRI, recent CT or PET, pain and neurological status, previous radiation record with doses, medicines. Free file review within a few working days
The same, sent the same day, with a phone call to the coordinator. A patient with new weakness is told to go to the nearest emergency department first
Day 1 to 2
Consultation, examination, instability score, planning CT and MRI fusion
Consultation, surgery within 24 to 48 hours of arrival
Day 3 to 7
Plan built and checked, steroid started, first session
Recovery, mobilization with physiotherapy, planning CT once the wound allows
Day 8 to 14
Second session if planned, review, flight home
Radiation over one to ten sessions, wound check
After
Report and dose record for the oncologist at home, MRI at three months reviewed by the same team
The same, plus a rehabilitation plan and a follow-up with the spine surgeon by video
Cost
An estimate follows the file review and depends on whether the course is conventional or stereotactic, the number of levels and sessions, and whether surgery or a cement injection comes first. Hospitals in this market quote spinal radiation as a package for the course, with surgery, the hospital stay and rehabilitation priced separately when they are needed, and a patient who is likely to need both the operation and the radiation should ask for a single figure that covers the whole admission rather than two estimates from two departments, since the second is easier to compare with quotes from elsewhere and leaves less room for items that appear on the final bill unannounced.
Confirm what the figure includes and whether the three-month MRI review is part of it.
References
Sahgal A, Myrehaug SD, Siva S, et al. Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases. An open-label, multicentre, randomised, controlled, phase 2/3 trial. Lancet Oncol. 2021;22(7):1023-1033.
Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer. A randomised trial. Lancet. 2005;366(9486):643-648.
Chow E, Zeng L, Salvo N, Dennis K, Tsao M, Lutz S. Update on the systematic review of palliative radiotherapy trials for bone metastases. Clin Oncol (R Coll Radiol). 2012;24(2):112-124.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Özcan YILDIZ, Medical Oncology.
