Management of Metastatic Spinal Cord Compression Without Stereotactic Radiotherapy and Targeted Adjuvant Chemotherapy

  • Alessandro Gasbarrini
  • Gisberto Evangelisti
  • Riccardo Ghermandi
  • Marco Girolami
  • Guiseppe Tedesco
  • Valerio Pipola
  • Stefano BorianiEmail author


Metastatic epidural spinal cord compression (MESCC) is defined radiologically as an epidural metastatic lesion causing true displacement of the spinal cord from its normal position in the vertebral canal.

The choice of the most appropriate treatment is of crucial importance for the patient who may be severely disabled by the presence of untreated spinal metastases. These spinal metastases may not only be the cause of severe deterioration in the quality of life but also the direct or indirect cause of death. Bone metastases is an expression of a systemic disease, and therefore a multidisciplinary program, integrating radiotherapy (RT), chemotherapy (CHT), and surgery, is recommended. Our center advocates the designation of a “team leader” who works in strong collaboration with the entire multidisciplinary team. The most appropriate treatment for patients with metastatic disease of the vertebral column is controversial. As the number of patients with MESCC increases, the methods of treatment are also evolving.

Appropriate surgical treatment of bone metastases and tumors in general has now become an integral part of the correct approach to the tumor patient. The evolution of anesthetic techniques now allows more aggressive treatment of some patients with spinal metastases. These procedures can dramatically improve the patient’s quality of life and may prolong the patient’s life expectancy by preventing complications related to paralysis.


Metastases Cord compression Spine Decompression Stabilization Multidisciplinary team Quality of life Paralysis 



The authors thank Mr. Carlo Piovani for his helpful collaboration in patients’ image storage and editing.


  1. 1.
    Wise JJ, Fischgrund JS, Herkowitz HN, Montgomery D, Kurtz LT. Complication, survival rates and risk factors of surgery for metastatic disease of the spine. Spine. 1999;24(18):1943–51.CrossRefPubMedGoogle Scholar
  2. 2.
    Ryken TC, Eichholz KM, Gerszten PC, Welch WC, Gokaslan ZL, Resnick DK. Evidence-based review of the surgical management of vertebral column metastatic disease. Neurosurg Focus. 2003;15(5):11.CrossRefGoogle Scholar
  3. 3.
    Sundaresan N, Rothman A, Manhart K, Kelliher K. Surgery for solitary metastases of the spine: rationale and results of the treatment. Spine. 2002;27:1802–6.CrossRefPubMedGoogle Scholar
  4. 4.
    Hosono N, Yonenobu K, Fuji T, Ebara S, Yamashita K, Ono K. Orthopaedic management of spinal metastases. Clin Orthop. 1995;312:148–59.Google Scholar
  5. 5.
    Sioutos PJ, Arbit E, Meshulam CF, Galicich JH. Spinal metastases from solid tumors. Analysis of factors affecting survival. Cancer. 1995;76(8):1453–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Batson OV. Role of vertebral veins in metastatic processes. Ann Intern Med. 1942;16:38–45.CrossRefGoogle Scholar
  7. 7.
    Damron TA, Sim FH. Surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. Instr Course Lect. 2000;49:461–70.PubMedGoogle Scholar
  8. 8.
    Schuster JM, Grady MS. Medical management and adjuvant therapies in spinal metastatic disease. Neurosurg Focus. 2001;11(6):e3.CrossRefPubMedGoogle Scholar
  9. 9.
    Helweg-Larsen S, Sørenson PS. Symptoms and signs in metastatic spinal cord compression: a study from first symptom until diagnosis in 153 patients. Eur J Cancer. 1994;30:396–8.CrossRefGoogle Scholar
  10. 10.
    Livingstone KE, Perrin RG. The neurosurgical management of spinal metastases causing cord and cauda equina compression. J Neurosurg. 1978;49:839–43.CrossRefGoogle Scholar
  11. 11.
    Loblaw DA, Laperriere NJ, Mackillop WJ. A population-based study of malignant spinal cord compression in Ontario. Clin Oncol (R Coll Radiol). 2003;15:211–7.CrossRefGoogle Scholar
  12. 12.
    Quraishi NA, Gokaslan ZL, Boriani S. The surgical management of metastatic epidural compression of the spinal cord. J Bone Joint Surg. 2010;92(8):1054–60.CrossRefGoogle Scholar
  13. 13.
    Barron KD, Hirano A, Araki S, Terry RD. Experiences with metastatic neoplasmsinvolving the spinal cord. Neurology. 1959;9:91–106.CrossRefPubMedGoogle Scholar
  14. 14.
    Sciubba DM, Gokaslan ZL. Diagnosis and management of metastatic spine disease. Surg Oncol. 2006;15:141–51.CrossRefPubMedGoogle Scholar
  15. 15.
    Arguello F, Baggs RB, Duerst RE, et al. Pathogenesis of vertebral metastasis and epidural spinal cord compression. Cancer. 1990;65:98–106.CrossRefPubMedGoogle Scholar
  16. 16.
    Bradley Jacobs W, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001;11(6):e10.Google Scholar
  17. 17.
    Greenberg HS, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: results with a new treatment protocol. Ann Neurol. 1980;8:361–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Gasbarrini A, Cappuccio M, Mirabile L, Bandiera S, Terzi S, Barbanti Bròdano G, Boriani S. Spinal metastases: treatment evaluation algorithm. Eur Rev Med Pharmacol Sci. 2004;8:265–74.PubMedGoogle Scholar
  19. 19.
    Harrington KD. Orthopedic surgical management of skeletal complications of malignancy. Cancer. 1997;15(80):1614–27.CrossRefGoogle Scholar
  20. 20.
    Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg. 1980;53:741–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Klimo P, Schmidt MH. Surgical management of spinal metastases. Oncologist. 2004;9:188–96.CrossRefPubMedGoogle Scholar
  22. 22.
    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;366:643–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Li H, Gasbarrini A, Cappuccio M, Boriani S. Outcome of excisional surgeries for the patients with spinal metastases. Eur Spine J. 2009;18:1423–30.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Boriani S, Bandiera S, Colangeli S, Ghermandi R, Gasbarrini A. En bloc resection of primary tumors of the thoracic spine: indications, planning, morbidity. Neurol Res. 2014;36:566–76.CrossRefPubMedGoogle Scholar
  25. 25.
    Holly LT, Foley KT. Three-dimensional fluouroscopy-guided percutaneous thoracolumbar pedicle screw placement: technical note. J Neurosurg. 2003;99(Suppl):324–9.PubMedGoogle Scholar
  26. 26.
    Callstrom MR, Dupuy DE, Solomon SB, Beres RA, Littrup PJ, Davis KW, Paz-Fumagalli R, Hoffman C, Atwell TD, Charboneau JW, Schmit GD, Goetz MP, Rubin J, Brown KJ, Novotny PJ, Sloan JA. Percutaneous image-guided cryoablation of painful metastases involving bone: multicenter trial. Cancer. 2013;119(5):1033–41.CrossRefPubMedGoogle Scholar
  27. 27.
    Dabravolski D, Esser J, Lahm A, et al. Treatment of tumors and metastases of the spine by minimally invasive CAVITY-coblation method (plasma field therapy). J Neurosurg Sci. 2017;61(6):565–78.PubMedGoogle Scholar
  28. 28.
    Gasbarrini A, Campos WK, Campanacci L, et al. Electrochemotherapy to metastatic spinal melanoma: a novel treatment of spinal metastasis? Spine (Phila Pa 1976). 2015;40:E1340–6.CrossRefGoogle Scholar
  29. 29.
    Goetz MP, Callstrom MR, Charboneau JW, Farrel MA, Maus TP, Welch TJ, Wong GY, Sloan JA, Novotny PJ, Petersen IA, Beres RA, Regge D, Capanna R, Saker MB, Groenenmeyer D, Gevargez A, Ahrar K, Choti MA, de Baere TJ, Rubin J. Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study. J Clin Oncol. 2004;22:300–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Han PP, Kenny K, Dickman CA. Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures. Neurosurgery. 2002;51(Suppl):88–95.Google Scholar
  31. 31.
    Mühlbauer M, Pfisterer W, Eyb R, Knosp E. Minimally invasive retroperitoneal approach for lumbar corpectomy and anterior reconstruction: technical note. J Neurosurg. 2000;93(Suppl):161–7.PubMedGoogle Scholar
  32. 32.
    Groenemeyer D, Schirp S, Gevargez A. Image-guided radiofrequency ablation of spinal tumors: preliminary experience with expandable array electrode. Cancer J. 2002;8(1):33–9.CrossRefGoogle Scholar
  33. 33.
    Gellad FE, Sadato N, Numaguchi Y, et al. Vascular metastatic lesions of the spine: preoperative embolization. Radiology. 1990;176:683–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Georgy BA, Wong W. Plasma-mediated radiofrequency ablation assisted percutaneous cement injection for treating advanced malignant vertebral compression fractures. AJNR Am J Neuroradiol. 2007;28:700–5.PubMedGoogle Scholar
  35. 35.
    Sundaresan N, Choi IS, Hughes JE, et al. Treatment of spinal metastases from kidney cancer by presurgical embolization and resection. J Neurosurg. 1990;73:548–54.CrossRefPubMedGoogle Scholar
  36. 36.
    Prabhu VC, Bilsky MH, Jambhekar K, et al. Results of preoperative embolization for metastatic spinal neoplasms. J Neurosurg. 2003;98(Suppl 2):156–64.PubMedGoogle Scholar
  37. 37.
    Alvarez L, Pérez-Higueras A, Quinones D, Calvo E, Rossi RE. Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life. Eur Spine J. 2003;12:356–60.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Fourney DR, Schomer DF, Nader R, Chlan J, Suki D, Ahrar K, Rhines LD, Gokaslan ZL. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in cancer patients. J Neurosurg Spine. 2003;98:21–30.CrossRefGoogle Scholar
  39. 39.
    Pilitsis JG, Rengachary SS. The role of vertebroplasty in metastatic spinal disease. Neurosurg Focus. 2001;11:E9.CrossRefPubMedGoogle Scholar
  40. 40.
    Shimony JS, Gilula LA, Zeller AJ, Brown DB. Percutaneous vertebroplasty for malignant compression fractures with epidural involvement. Radiology. 2004;232(3):846–53.CrossRefPubMedGoogle Scholar
  41. 41.
    Reidy D, Ahn H, Mousavi P, Finkelstein J, Whine CM. A biomechanical analysis of intravertebral pressures during vertebroplasty of cadaveric spines with and without simulated metastases. Spine. 2003;28(14):1534–9.PubMedGoogle Scholar
  42. 42.
    Mendel E, Bourekas E, Gerszten P, Golan JD. Percutaneous techniques in the treatment of spine tumours: what are the diagnostic and therapeutic indications and outcomes? Spine. 2009;34(Suppl):93–100.CrossRefGoogle Scholar
  43. 43.
    Yu MK, Buys SS. Medical management of skeletal metastasis. Neurosurg Clin N Am. 2004;15:529–36.CrossRefPubMedGoogle Scholar
  44. 44.
    Witham TF, Khavkin YA, Gallia GL, et al. Surgery insight: current management of epidural spinal cord compression from metastatic spine disease. Nat Clin Pract Neurol. 2006;2:87–94.CrossRefPubMedGoogle Scholar
  45. 45.
    Delattre JY, Arbit E, Thaler HT, Rosenblum MK, Posner JB. A dose-response study of dexamethasone in a model of spinal cord compression caused by epidural tumor. J Neurosurg. 1989;70:920–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Turner S, Marosszeky B, Timms I, Boyages J. Malignant spinal cord compression: a prospective evaluation. Int J Radiat Oncol Biol Phys. 1993;26:141–6.CrossRefPubMedGoogle Scholar
  47. 47.
    Vecht CJ, Haaxma-Reiche H, van Putten WL, et al. Initial bolus of conventional versus high-dose dexamethasone in metastatic spinal cord compression. Neurology. 1989;39:1255–7.CrossRefPubMedGoogle Scholar
  48. 48.
    Fourney DR, Gokaslan ZL. Anterior approaches for thoracolumbar metastatic spine tumours. Neurosurg Clin N Am. 2004;15:443–51.CrossRefPubMedGoogle Scholar
  49. 49.
    Fourney DR, Abi-Said D, Rhines LD, et al. Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilisation. J Neurosurg. 2001;94(Suppl):232–43.PubMedGoogle Scholar
  50. 50.
    Manabe S, Tateishi A, Abe M, Ohno T. Surgical treatment of metastatic tumors of the spine. Spine. 1989;14:41–7.CrossRefPubMedGoogle Scholar
  51. 51.
    Sakaura H, Hosono N, Mukai Y, et al. Outcome of total en bloc spondylectomy for solitary metastasis of the thoracolumbar spine. J Spinal Disord Tech. 2004;17:297–300.CrossRefPubMedGoogle Scholar
  52. 52.
    Tomita K, Kawahara N, Baba H, et al. Total spondylectomy for solitary spinal metastases. Int Orthop. 1994;18:291–8.CrossRefPubMedGoogle Scholar
  53. 53.
    Tomita K, Toribatake Y, Kawahara N, Ohnari H, Kose H. Total en bloc spondylectomy and circumspinal decompression for solitary spinal metastasis. Paraplegia. 1994;32:36–46.PubMedGoogle Scholar
  54. 54.
    Boriani S, Biagini R, De Iure F, et al. En bloc resections of bone tumors of the thoracolumbar spine: a preliminary report on 29 patients. Spine. 1996;21:1927–31.CrossRefPubMedGoogle Scholar
  55. 55.
    Bilsky MH, Laufer I, Burch S. Shifting paradigms in the treatment of metastatic spine disease. Spine. 2009;34(Suppl):101–7.CrossRefGoogle Scholar
  56. 56.
    Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, Harrop JS, Fehlings MG, Boriani S, Chou D, Schmidt MH, Polly DW, Biagini R, Burch S, Dekutoski MB, Ganju A, Gerszten PC, Gokaslan ZL, Groff MW, Liebsch NJ, Mendel E, Okuno SH, Patel S, Rhines LD, Rose PS, Sciubba DM, Sundaresan N, Tomita K, Varga PP, Vialle LR, Vrionis FD, Yamada Y, Fourney DR. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine (Phila Pa 1976). 2010;35(22):E1221–9.CrossRefGoogle Scholar
  57. 57.
    Fourney DR, Gokaslan ZL. Spinal instability and deformity due to neoplastic conditions. Neurosurg Focus. 2003;14:e8.CrossRefPubMedGoogle Scholar
  58. 58.
    Wang JC, Boland P, Mitra N, et al. Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. J Neurosurg Spine. 2004;1:287–98.CrossRefPubMedGoogle Scholar
  59. 59.
    Akeyson EW, McCutcheon IE. Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis. J Neurosurg. 1996;85:211–20.CrossRefPubMedGoogle Scholar
  60. 60.
    Tokuhashi Y, Matsuzaki Y, Toriyama S, Kawano H, Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine. 1990;15:1110–3.CrossRefPubMedGoogle Scholar
  61. 61.
    Tomita K, Kawahara N, Kobayashi T, et al. Surgical strategy for spinal metastases. Spine. 2001;26:298–306.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Boriani S, Gasbarrini A. Point of view. Spine. 2005;30:2227–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Alessandro Gasbarrini
    • 1
  • Gisberto Evangelisti
    • 1
  • Riccardo Ghermandi
    • 1
  • Marco Girolami
    • 1
  • Guiseppe Tedesco
    • 1
  • Valerio Pipola
    • 1
  • Stefano Boriani
    • 2
    Email author
  1. 1.Department of Oncologic and Degenerative Spine SurgeryRizzoli Orthopaedic InstituteBolognaItaly
  2. 2.GSpine4 Spine Surgery UnitIRCCS Galeazzi Orthopaedic InstituteMilanItaly

Personalised recommendations