Primary Bone Tumours of the Spine

A primary bone tumour is one that originates in the cells of the bone, cartilage or marrow of the spine itself. This sets it apart from a metastasis, which is a deposit that has travelled to the spine from a cancer that started elsewhere. Metastases are far more common than primary bone tumours in the adult spine, and the two groups are approached quite differently.

Within the primary group there is a second, equally important division: between benign tumours and malignant ones. Primary tumours of the spinal column make up only around five in every hundred of all primary skeletal tumours, and within the spine the majority of primary lesions are benign, with the malignant forms comprising roughly a fifth. The benign tumours are, broadly, growths that stay local, although some can still be locally troublesome by pressing on nerves or weakening bone. The malignant tumours are true cancers with the capacity, if untreated, to grow destructively and in some cases to spread.

Many benign bone lesions of the spine cause no symptoms at all and are discovered incidentally. Vertebral haemangiomas, the commonest benign vertebral lesions of all, are usually silent. Other tumours announce themselves through pain, and the character of that pain can itself be informative. The classic example is the osteoid osteoma, a small benign tumour whose hallmark is pain that is often worse at night and that is characteristically eased by anti-inflammatory medication. More aggressive or malignant lesions tend to produce pain that is more persistent, less predictable, and not relieved in this neat way.

As a broad tendency, tumours arising in the vertebral body are more often malignant, while tumours arising in the posterior elements are more often benign. Figures frequently quoted suggest around three-quarters of vertebral-body tumours prove malignant, whereas only about a third of posterior-element tumours do. Osteoid osteoma and osteoblastoma have a strong predilection for the posterior elements; aneurysmal bone cysts also favour the posterior elements. By contrast, chordoma, chondrosarcoma and the plasma-cell tumours tend to involve the vertebral body. These are tendencies rather than rules.

Osteoid osteoma is a small benign bone-forming tumour, typically less than two centimetres across, with a central nidus surrounded by reactive bone. It favours the posterior elements and characteristically causes night pain eased by anti-inflammatories.

Osteoblastoma is closely related but larger and tends to behave more actively. It too favours the posterior elements, although it can extend forward into the vertebral body.

Aneurysmal bone cyst is a benign but expansile, blood-filled lesion that can balloon the bone outward, with a particular tendency for the posterior elements in younger people.

Giant cell tumour of bone is classed as benign but is genuinely locally aggressive, with a recognised tendency to recur. In the spine above the sacrum it is uncommon and tends to involve the vertebral body. Denosumab has become part of the modern picture in specialist settings.

Osteochondroma is a cartilage-capped bony outgrowth, common overall but rare in the spine. It may be solitary or part of an inherited condition (hereditary multiple exostoses). The risk of malignant transformation into chondrosarcoma is small for solitary lesions and somewhat higher in the inherited multiple form.

Chordoma is a rare, slow-growing but locally destructive cancer arising from remnants of the notochord. It has a strong predilection for the sacrum and the clivus at the skull base, tends to involve the midline vertebral body, and has a well-documented tendency to recur locally if not completely removed.

Chondrosarcoma is a cancer of cartilage-forming cells and is characteristically resistant to both chemotherapy and radiotherapy, which is why complete surgical removal is so central to its management.

Osteosarcoma is an aggressive bone-forming cancer; in the spine it frequently involves the posterior elements with vertebral-body extension. Management is multimodal.

Ewing sarcoma occurs chiefly in children and young adults and only rarely in the spine. Unlike chondrosarcoma it is sensitive to chemotherapy and radiotherapy, and its management is firmly multimodal.

A solitary plasmacytoma is a single focus of abnormal plasma cells in bone, most often in a vertebral body, while multiple myeloma is the same cell type present diffusely throughout the marrow. A solitary spinal plasmacytoma is widely regarded as a lesion that may precede or evolve into myeloma. Because these are tumours of the blood and marrow rather than true bone tumours, their assessment and management are led by haematology.

Plain X-rays, computed tomography and magnetic resonance imaging each contribute: CT defines the bony architecture, while MRI shows the soft-tissue extent and the relationship to the spinal cord and nerves. The Enneking system, developed for limb tumours, grades a tumour by whether it is benign or malignant, how aggressive it appears, and whether it has spread. The Weinstein-Boriani-Biagini (WBB) system is specific to the spine: it maps the tumour onto a clock-face of twelve radiating zones around the vertebra and into concentric layers, in order to plan complete removal. Both are tools used by specialist teams.

When a primary bone tumour is suspected, the biopsy is best planned and performed at the specialist centre that would go on to treat the tumour. For an aggressive or malignant tumour the biopsy track is regarded as potentially seeded with tumour cells; at the time of definitive surgery, that track must be removed along with the tumour. If the biopsy has been placed without knowledge of the eventual surgical plan, it can compromise the chance of a clean, complete removal and has been associated with a higher rate of complications and local recurrence. The sequence of referral, then biopsy, then treatment, in the same expert hands, is strongly emphasised.

Management is led by a specialist multidisciplinary team bringing together spinal and orthopaedic oncology surgeons, musculoskeletal radiologists, specialist bone pathologists and oncologists. For many benign lesions, the appropriate course ranges from simple observation through to targeted treatment of a painful one; osteoid osteoma, for instance, may be managed with anti-inflammatories or image-guided radiofrequency ablation. For chordoma and chondrosarcoma the governing principle is complete, en-bloc removal with a margin of healthy tissue, since both respond poorly to chemotherapy and radiotherapy. Techniques such as total en-bloc spondylectomy are described for this purpose. For chemo- and radio-sensitive cancers such as Ewing sarcoma, and for osteosarcoma, management is multimodal.

For the benign lesions, the outlook is generally good, although some — such as giant cell tumour and aneurysmal bone cyst — have a recognised tendency to recur and require follow-up. For the primary cancers, the evidence repeatedly links outcome to the completeness of that first treatment. In chordoma, en-bloc resection offers the best chance of preventing local recurrence. In chondrosarcoma, where surgery is the mainstay, completeness of removal again dominates. In Ewing sarcoma, responsiveness to chemotherapy and radiotherapy means that multimodal treatment achieves meaningful long-term survival in localised disease.

Primary bone tumours of the spine are uncommon, diverse, and best understood through a few organising ideas: the distinction between primary tumours and metastases; the importance of location (posterior-element lesions tend towards the benign, vertebral-body lesions towards the malignant); and that the pathway itself — recognition, referral to a specialist team, biopsy planned within that team, and treatment built around complete first removal for the primary cancers — shapes the outcome more than almost anything else.

This page is general medical education and is not a substitute for individual advice. New or worsening weakness, numbness, saddle numbness, or any disturbance of bladder or bowel control requires urgent assessment.

• —Zileli M et al. Primary Benign Neoplasms of the Spine. Diagnostics 2023;13(12):2006 (PMC10297602)
• —Primary Osseous Malignancies of the Spine (PMC10217758)
• —Noronha C et al. Osteoid Osteoma: An Updated Review. In Vivo 2021;35(4):1929–1938 (PMC8286494)
• —Osteoblastomas of the spine: a comprehensive review. Neurosurg Focus 2016;41(2):E4
• —Aneurysmal bone cysts of the spine (PMC3585636)
• —Denosumab Treatment for Giant Cell Tumor of the Spine (PMC7864639)
• —D'Amore T et al. Chordoma of the mobile spine and sacrum (PMC6261773)
• —Chondrosarcoma of the Mobile Spine and Sacrum (PMC3061278)
• —Treatment Outcomes of Primary Spinal Ewing Sarcoma (PMC6603090)
• —Chan P et al. Reliability of the Enneking and WBB classifications. Spine 2009
• —Total en bloc spondylectomy for spinal tumors. J Orthop Sci 2006
• —Biopsy in Musculoskeletal Tumors (PMC4225013)
• —Strauss SJ et al. Bone sarcomas: ESMO–EURACAN Clinical Practice Guideline. Ann Oncol 2021

This information is for general patient education and is not a substitute for an individual consultation. Always seek personalised advice from a qualified spinal specialist.