Posterolateral Approach to Thoraco-Lumbar Metastases - Separation Surgery
Treatment of metastatic spinal disease is a multidisciplinary team effort. With scientific and technological advancements, decision-making has become increasingly complex. Neurologic, oncologic, mechanical and systemic (NOMS) is an adaptive treatment algorithm that integrates advances in cancer care and can aid in strategic treatment planning as it covers the four major considerations in spine tumor care: neurology, oncology, mechanical stability, and systemic status and co-morbidities. Spine stereotactic radiosurgery (SSRS) has revolutionized the treatment of spinal metastatic disease and has been demonstrated to deliver an ablative tumoral dose resulting in high rates of local control. SSRS is defined as high-dose conformal photon therapy and overcomes radioresistance seen with conventional external beam radiation therapy by fundamentally changing the radiobiologic effect. The response to SSRS is dose-dependent, and in order to deliver a tumoricidal dose, a safe distance between the spinal cord and tumor must be present or created. Hence, patients with high-grade cord compression from “radioresistant” tumors undergo hybrid separation surgery-SSRS treatment. This entails a single-stage posterolateral surgical approach enabling circumferential spinal cord decompression and stabilization. This hybrid separation surgery-radiosurgery therapy has been proven to be safe and efficient but also improves patients’ health-related quality of life (HRQoL) (Barzilai et al., Neuro Oncol Pract, 2017).
KeywordsSpine Tumor Metastases Surgery Separation surgery Radiosurgery
- 1.Barzilai O, Amato MK, McLaughlin L, Reiner AS, Ogilvie SQ, Lis E, Yamada Y, Bilsky MH, Laufer I. Hybrid surgery-radiosurgery therapy for metastatic epidural spinal cord compression: a prospective evaluation using patientreported outcomes. Neurooncol Pract. 2018;5(2):104–13. https://doi.org/10.1093/nop/npx017. Epub 2017 Jul 22.CrossRefGoogle Scholar
- 10.Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. 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
- 18.Laufer I, Iorgulescu JB, Chapman T, Lis E, Shi W, Zhang Z, et al. Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine. 2013;18(3):207–14.CrossRefGoogle Scholar
- 27.Rades D, Fehlauer F, Stalpers LJ, Wildfang I, Zschenker O, Schild SE, et al. A prospective evaluation of two radiotherapy schedules with 10 versus 20 fractions for the treatment of metastatic spinal cord compression: final results of a multicenter study. Cancer. 2004;101(11):2687–92.CrossRefGoogle Scholar
- 33.Zelefsky MJ, Greco C, Motzer R, Magsanoc JM, Pei X, Lovelock M, et al. Tumor control outcomes after hypofractionated and single-dose stereotactic image-guided intensity-modulated radiotherapy for extracranial metastases from renal cell carcinoma. Int J Radiat Oncol Biol Phys. 2012;82(5):1744–8.CrossRefGoogle Scholar