====== Spinal metastases surgery ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1x_POZXjwvk5sbr7ygqQ-xe7T29zrOF3eyLsDf6LytWtkYhga9/?limit=15&utm_campaign=pubmed-2&fc=20250313184325}} ---- ---- ===== Vertebral Resection Techniques: En Bloc Spondylectomy vs. Posterior Vertebral Column Resection vs. Separation Surgery ===== ==== Definitions ==== **En Bloc Spondylectomy (EBS):** Surgical removal of an entire vertebra in one piece (en bloc), including vertebral body, pedicles, and posterior elements, to achieve oncologic margins. Used primarily for primary or isolated metastatic spine tumors. **Posterior Vertebral Column Resection (pVCR):** Piecemeal removal of vertebral segments via a posterior-only approach. Main goal is spinal deformity correction (e.g. kyphosis, scoliosis). **Separation Surgery:** A palliative procedure for metastatic epidural spinal cord compression. The goal is **circumferential decompression of the spinal cord** and **creation of a safe margin** between tumor and dura to allow high-dose **stereotactic radiosurgery (SRS)**. It does **not aim to remove the entire tumor**. ---- ==== Comparison Table ==== ^ Feature ^ En Bloc Spondylectomy ^ Posterior Vertebral Column Resection ^ Separation Surgery ^ | **Main Goal** | Oncologic resection with margins | Correction of severe deformity | Cord decompression for radiotherapy | | **Type of Resection** | One-piece (en bloc) | Fragmented (piecemeal) | Limited debulking with circumferential decompression | | **Tumor Removal** | Complete, with wide margins | Not applicable | Partial (only decompression) | | **Indications** | Primary or solitary metastatic tumors| Severe kyphosis or scoliosis | Metastatic epidural spinal cord compression | | **Surgical Approach** | Anterior, posterior, or combined | Posterior-only | Posterior-only | | **Oncologic Intent** | Curative | No | Palliative + adjunct to SRS | | **Radiation Planning** | Not typically required | Not applicable | Integral to high-dose SRS planning | ---- ==== Key Distinctions ==== * **EBS** seeks curative tumor resection in one piece. * **pVCR** corrects spinal deformities with complete vertebral removal, often piecemeal. * **Separation Surgery** is a *palliative* oncologic procedure focused on **spinal cord decompression**, facilitating high-dose **radiosurgery** by separating tumor and dura. ---- ==== Conclusion ==== These three procedures, though all involving vertebral resection or manipulation, serve **very different purposes**: * **Curative (EBS)** * **Deformity correction (pVCR)** * **Palliative decompression (Separation Surgery)** Understanding the goal behind each is key to choosing the appropriate technique in spinal surgery. ---- The analyses performed in a study demonstrated key factors affecting intraoperative [[blood loss]] and showed that a simple preoperative [[checklist]] including these factors can be used to identify patients undergoing surgery for metastatic spine tumors who are at risk for increased intraoperative blood loss ((Mohme M, Mende KC, Pantel T, Viezens L, Westphal M, Eicker SO, Dreimann M, Krätzig T, Stangenberg M. Intraoperative [[blood loss]] in oncological [[spine surgery]]. Neurosurg Focus. 2021 May 1;50(5). doi: 10.3171/2021.2.FOCUS201117. PMID: 34003622.)). ---- see also [[Vertebral metastases surgery]]. Although the [[spinal metastases treatment]] paradigms have changed and separation surgery followed by [[stereotactic radiosurgery]] is considered the best strategy, there are still cases in which [[spinal metastases surgery]] by 360° [[decompression]] with [[stabilization]] is indicated. ===== En Bloc Spondylectomy ===== [[En Bloc Spondylectomy]] ---- Techniques of decompression without stabilization have resulted in a worse outcome, and this has misled many in the past to believe that radiotherapy is the preferred option to surgery ((Findlay GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry. 1984;47:761–768. doi: 10.1136/jnnp.47.8.761.)) ((Steinmetz MP, Mekhail A, Benzel EC. Management of metastatic tumors of the spine: strategies and operative indications. Neurosurg Focus. 2001;11(6):e2. doi: 10.3171/foc.2001.11.6.3.)) ((Weigel B, Maghsudi M, Neumann C, et al. Surgical management of symptomatic spinal metastases. Post-operative outcome and quality of life. Spine. 1999;24:2240–2246. doi: 10.1097/00007632-199911010-00012)) ((Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg. 1980;53:741–748. doi: 10.3171/jns.1980.53.6.0741.)) If the patient and the presenting pathology are feasible for surgery, 1 of the major criteria is the expected life expectancy of the patient. Generally, if the expected survival is > 3 months, patients are eligible for surgery ((Heary RF,Bono CM. Metastatic spinal tumors. Neurosurg Focus. 2001; 11: e1.)). Of course, the predicted survival is not the only criterion with which to decide whether the patient is a surgical candidate. The wishes of the patient, comorbidity, and local characteristics are of course of equal importance. In general, a search for other metastases is performed. The patient is assessed by an oncologist and a survival rate is estimated. This estimation is not very accurate ((Chow E,Davis L,Panzarella T, et al. Accuracy of survival prediction by palliative radiation oncologists. Int J Radiat Oncol Biol Phys. 2005; 61: 870–873.)) ((Chow E,Harth T,Hruby G,Finkelstein J,Wu J,Danjoux C. How accurate are physicians' clinical prediction of survival and the available prognostic tools in estimating survival times in terminally ill cancer patients? A systematic review. Clin Oncol. 2001; 13: 209–218.)). A randomized, controlled trial proved the effectiveness of surgery in spinal metastatic disease with regard to the improvement of neurologic function. It did not contribute to a longer survival, but to an improvement in the quality of remaining life. One of the most important selection criteria for surgery is life expectancy. Estimation of the life expectancy includes numerous factors such as nature and extension of the primary tumor, clinical performance of the patient, presence of metastases, etc. ((Patchell RA,Tibbs PA,Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005; 366: 643–648.)). At first, surgery was proven to fail in the management of spinal metastases and, compared with radiation therapy, surgery had more complications, whereas neurologic recovery and survival rates did not improve. At that time, surgery was abandoned for the treatment of spinal metastases. It should be stated that surgery was in fact laminectomy ((Jacobs WB,Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001; 11: 1–11.)). [[Percutaneous]] [[fixation]] with [[cement-augmented pedicle screw]]s in patients with pathological [[spine fracture]]s provides an improvement in mechanical [[back pain]], with a low [[incidence]] of [[failure]], and in some patients, spontaneous facet fusion was observed. Further research is necessary with regard to both short-term benefits and long-term outcomes ((Meleis A, Larkin MB, Bastos DCA, Muir MT, Rao G, Rhines LD, Cowles CE, Tatsui CE. Single-center outcomes for percutaneous pedicle screw fixation in metastatic spinal lesions: can spontaneous facet fusion occur? Neurosurg Focus. 2021 May;50(5):E9. doi: 10.3171/2021.1.FOCUS20671. PMID: 33932939.)).