General considerations
If applicable, all treatments should aim for the shortest time off systemic therapy. Minimal invasive surgery (MIS) facilitates post-operative wound healing and recovery and is generally the treatment of choice where possible. Larger surgeries should be reserved for specific cases not eligible for less demanding surgery.
T2 through T5 symptomatic metastatic tumors should be treated using a posterior or posterior-lateral approach. The posterior-lateral approach provides greater exposure of the anterior part of the vertebra in order to facilitate anterior decompression and/or stabilization.
The choice between an anterior and posterior approach will be determined by the individual case and preoperative imaging, taking into account the location of the tumor and the destruction of the spine. With the introduction of percutaneous systems, the posterior approach has become the preferred technique.
| Nonoperative treatment | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Patient not fit for surgery due to medical comorbidities or very advanced metastatic disease. |  |
 |
Nonoperative treatment consists of radiotherapy, and if needed, brace stabilization to prevent ranges of motion that cause pain.
| Posterior decompression and stabilization | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Multi- or single-level disease or circumferential tumors |  |
 |
Advantages
- Multilevel osseous fixation
- Avoidance of visceral organ manipulation
Disadvantages
- Extensive paraspinal muscle dissection
- Need for a longer construct compared to stand alone anterior approach
| Posterior decompression and stabilization with corpectomy | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Multi- or single-level disease or circumferential tumors, extensive destruction of the vertebral body requiring anterior reconstruction | |
|
Advantages
- Multilevel osseous fixation
- Avoidance of visceral organ manipulation
Disadvantages
- Extensive paraspinal muscle dissection
- Need for a longer construct compared to stand alone anterior approach
| Posterior MIS | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Multi- or single-level disease or circumferential tumors and no significant neurological deficit | |
|
Advantages
- Less soft tissue-traum
- Decreased risk of wound complications
- Less blood loss
- Earlier rehabilitation
- Multilevel osseous fixation
- Avoidance of visceral organ manipulation
Disadvantages
- Technically demanding
| Anterior corpectomy and stabilization | ||
| Main indication | Skill | Equipment |
|---|---|---|
| T6-L5 Single level vertebral body tumors | |
|
Not recommended for T2-T5.
Contraindications
- Extensive thoracic or abdominal treatment including radiation and prior surgery
Advantages
- Shorter construct length
- Direct anterior column support
Disadvantages
- Risk of visceral or vascular injury
| Combined anterior and posterior | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Anterior or posterior fixation alone does not provide sufficient stability (circumferential tumors) | |
|
Since most cases can be solved by either an anterior or posterior approach, the combined approach is only indicated in rare cases.
Advantages
- Multilevel osseous fixation
Disadvantages
- Extensive paraspinal muscle dissection
- Risk of esophageal or vascular injury
- Need for longer or multistage surgery
- Overall high morbidity
| *Skill | |
|---|---|
|
Basic surgical experience, no specialized skills |
 |
Some specialized surgical experience |
|
Highly experienced and skilled surgeon |
| *Equipment | |
|---|---|
|
Basic equipment only |
 |
Simple surgical and imaging resources |
|
Full specialized surgical and imaging resources |