The Management of Pain in Metastatic Bone Disease

Sorin Buga, MD; Jose E. Sarria, MD


Cancer Control. 2012;19(2):154-166. 

In This Article

Pain Assessment

The presence of bone metastasis can be determined by recording an accurate history, performing a detailed physical examination, and ordering the appropriate imaging studies.

A pain history should include a description of the pain, its onset, radiation, triggering and relieving factors, as well as the patient's own report of pain intensity, which should be nonjudgmentally assessed by the clinician. Several tools are available to describe pain intensity: the Numerical Rating Scale, which is the most commonly used, the Visual Analog Scale, the Iowa Pain Thermometer Scale, and the Faces Pain Scale.

Several factors can prompt the clinician in the appropriate direction: (1) Metastatic bone pain has a gradual onset, becoming progressively more severe, and it is usually localized and often felt at night and/or on weight bearing. (2) The vast majority of bone metastases originate from cancers of the breast, lung, prostate, thyroid, and kidney. (3) The most common sites of spread in the skeleton include the spine, pelvis, ribs, skull, upper arm, and leg long bones. (4) Even though multilevel involvement occurs in about 80% of metastases to the vertebral bodies, they tend to be more frequently encountered in the thoracic region of the spine, followed by the lumbosacral and cervical regions. (5) Pain located in the occipital or nuchal region radiating to the posterior skull and exacerbated by neck flexion could be related to atlas (C1) bone destruction. (6) Pain referred to the interscapular region could be related to C7–T1 syndrome from tumor invasion of these vertebrae. (7) Pain in the iliac crest or sacroiliac joint could originate at T12 or L1 level, whereas pain in the buttock or posterior thigh that increases when lying down and relieved when standing could be a referred pain from sacral segments. (8) Pain with a rapid crescendo and radiating in a band-like fashion around the chest or abdomen could indicate an epidural compression that represents an oncologic/neurologic emergency. Spinal cord compression is usually accompanied by sensory loss, abnormal reflexes, weakness, and autonomic dysfunction. (9) Pain in the groin or knee could originate in the hip.

The character of the pain in bone metastasis can be somatic (musculoskeletal), neuropathic (with protopathic and/or epicritic features, caused by nerve irritation or damage by the invading tumor) or mixed, which appears to be more common.

Magnetic resonance imaging (MRI) is the most accurate imaging modality in detecting very early skeletal metastases. Computed tomography (CT) scanning can be used for patients who cannot tolerate an MRI or who are not candidates for MRI (such as those having metal implants or using a spinal cord stimulator). Radionuclide bone scan is useful to identify the extent of bone lesions throughout the body.


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