Renal, thyroid, breast, prostate and hepatocellular carcinomas are the most common hypervascular tumors to
metastasize to the vertebrae. 49 For patients with spinal instability, neurologic compromise or severe pain that is not
managed via local radiation or a conservative approach,
surgery for decompression and stabilization remains the best
treatment. However, surgery can be complicated by massive
intraoperative blood loss, usually in the setting of known
vascular pathologies such as renal cell and thyroid cancers.
The vascular supply depends on the anatomic position of the
tumor, but location in the cervical, thoracic or lumbar spine
does not influence vascularity. Cervical spine metastases are
more technically difficult to embolize because of frequent
anastomoses between carotid, vertebral and subclavian arteries. Opting for surgical intervention should be based on the
patient’s prognosis, neurologic symptoms, tumor location,
extent of metastatic disease and overall medical condition.
Diagnostic and therapeutic interventional techniques have
clear roles in the treatment of both primary and secondary
spinal tumors. Guidance of therapy requires careful planning
and diagnostic information in the form of the patient’s history,
physical examination and conventional imaging studies (eg,
CT, MRI, nuclear studies, etc.).
Histologic diagnosis obtained with CT-guided percutaneous needle biopsy with local anesthesia allows for improved
safety, accuracy and a reduction in morbidity. The vascularity of a lesion as well as its regional vascular anatomy can be
determined with diagnostic spinal angiography. If a lesion is
determined to be hypervascular, transarterial embolization
can be implemented to reduce the risk of intraoperative blood
loss, hypotension and stroke. For these reasons, interventional
procedures should be considered when diagnosing and treating neoplastic lesions of the spine.
When considering intra-arterial embolization, it is critical to check for concomitant supply to anterior and posterior
spinal arteries. Visualization of such arteries is reason to
avoid embolization. Selection of the appropriate embolic
agent depends on the indication for its use. If the embolization is preoperative, then particles (Embosphere™ [Biosphere,
France], PVA-particles [Contour™, BSIC and Gelfoam™]) can be
used. If embolism is the treatment plan, Onyx® Liquid Embolic
System (LES)-(EV3) or NBCA-N-butyl cyanoacrylate-lipiodol-mixture can be used.
Ultimately, a multidisciplinary approach is recommended
involving neurointerventionalists, neurosurgeons, orthopedic
spine surgeons, radiation oncologists and medical specialists
with case-specific treatment plans. Embolization, vertebro-plasty/kyphoplasty, various ablation techniques, surgery,
radiation or any combination thereof are all viable options
in the treatment of spinal tumors.
1. Weinstein JN, McLain RF. Primary tumors of the spine. Spine.
1987; 12( 9):843-851.
2. Cooper P, Hida K. Intramedullary spinal cord tumors. In: Spinal
Cord and Spinal Column Tumors. New York, NY: Thieme;
3. Ellman BA, Parkhill BJ, Marcus PB, Curry TS, Peters PC.
Renal ablation with absolute ethanol: mechanism of action.
Investigative Radiology. 1984; 19( 5):416-23.
Figure 1B–D. Three images from spinal angiogram and embolization.
B. Demonstrates microcatheter in T12 spinal artery with vascular
tumor blush. C. Demonstrates microcatheter selecting tumor vessel.
D. Postembolization image from T12 spinal artery injection with
obliteration of tumor vasculature.