Essential Concepts for the Management of Metastatic Spine Disease: What the Surgeon Should Know and Practice

Abstract

Study Design: Literature review. Objective: To provide an overview of the recent advances in spinal oncology, emphasizing the key role of the surgeon in the treatment of patients with spinal metastatic tumors. Methods: Literature review. Results: Therapeutic advances led to longer survival times among cancer patients, placing significant emphasis on durable local control, optimization of quality of life, and daily function for patients with spinal metastatic tumors. Recent integration of modern diagnostic tools, precision oncologic treatment, and widespread use of new technologies has transformed the treatment of spinal metastases. Currently, multidisciplinary spinal oncology teams include spinal surgeons, radiation and medical oncologists, pain and rehabilitation specialists, and interventional radiologists. Consistent use of common language facilitates communication, definition of treatment indications and outcomes, alongside comparative clinical research. The main parameters used to characterize patients with spinal metastases include functional status and health-related quality of life, the spinal instability neoplastic score, the epidural spinal cord compression scale, tumor histology, and genomic profile. Conclusions: Stereotactic body radiotherapy revolutionized spinal oncology through delivery of durable local tumor control regardless of tumor histology. Currently, the major surgical indications include mechanical instability and high-grade spinal cord compression, when applicable, with surgery providing notable improvement in the quality of life and functional status for appropriately selected patients. Surgical trends include less invasive surgery with emphasis on durable local control and spinal stabilization.

Separation surgery for metastatic epidural spinal cord compression: A qualitative review

“…Many studies analyzed effectiveness of cEBRT both as primary and adjuvant treatment for MESCC. Historically, cERBT with palliative intent (30 Gy in 10 fractions, 20 Gy in 5 fractions or 8 Gy in one fraction) have been considered the main treatment options for spinal metastases [20] . In a recent review, Barzilai et al underlined the wide range of response duration and recurrence rate after adjuvant cERBT and its strong dependency from tumor histology of primary tumor, with poorly responses in radioresistant tumors [36] , [42] , [51] .…”

“…Considering the systemic nature of MESCC, surgical treatment plays a functional role in preserving or restoring neurological status and spinal stability [6] , [16] , [20] . With the introduction of ablative radiation treatment (SRS or SBRT) in the new paradigms of treatment [16] , surgery for decompression in MESCC has evolved, shifting from aggressive cytoreduction, in order to obtain neurological outcomes improvement and better LC, towards the modern idea of “separation surgery”(SS) [7] .…”

“…Recently, Cofano et al proposed the Neurologic Stability Epidural compression (NSE) score with the aim to translate all these concepts in a practical score evaluating the need for surgery in patients with MESCC, according to the latest evidence and assessing ASA, performance status, neurological status, spine stability and ESCC [28] . In the setting of a more comprehensive approach with SRS as a new and relevant treatment option, SS has carved out a key role in MESCC treatment, creating the adequate conditions for radiations [2] , [6] , [7] , [12] , [20] , [22] , [26] .…”

Minimally Invasive Spine Surgery: Techniques, Technologies, and Indications

“…With technological advancement, MISS for spine metastasis has become feasible, and thus has been considered as a new treatment option over traditional open surgery [ 38 ]. Several studies have reported equivalent functional outcomes and faster recovery with reduced morbidity, such as blood loss and surgical site infection [ 3 , 39 - 42 ].…”

“…In 2019, Barzilai et al [ 39 ] suggested a treatment algorithm for spine metastasis, which consisted of following: patient evaluation using the health-related quality of life questionnaire; cancer-related spinal instability; epidural spinal cord compression; tumor biology; primary or adjuvant radiotherapy; and spinal surgeries such as separation surgery, minimal access surgery, and stabilization. Given the careful patient selection, MISS for spine metastasis significantly reduces surgery-related morbidity and improves patients’ quality of life compared with traditional open surgery.…”