Posterolateral Approach to Thoraco-Lumbar Metastases - Separation Surgery

  • Ori Barzilai
  • Ilya Laufer
  • Mark H. BilskyEmail author


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).


Spine Tumor Metastases Surgery Separation surgery Radiosurgery 


  1. 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. Epub 2017 Jul 22.CrossRefGoogle Scholar
  2. 2.
    Cobb CA 3rd, Leavens ME, Eckles N. Indications for nonoperative treatment of spinal cord compression due to breast cancer. J Neurosurg. 1977;47(5):653–8.CrossRefGoogle Scholar
  3. 3.
    Wong DA, Fornasier VL, MacNab I. Spinal metastases: the obvious, the occult, and the impostors. Spine (Phila Pa 1976). 1990;15(1):1–4.CrossRefGoogle Scholar
  4. 4.
    Sciubba DM, Petteys RJ, Dekutoski MB, Fisher CG, Fehlings MG, Ondra SL, et al. Diagnosis and management of metastatic spine disease. A review. J Neurosurg Spine. 2010;13(1):94–108.CrossRefGoogle Scholar
  5. 5.
    Klimo P Jr, Schmidt MH. Surgical management of spinal metastases. Oncologist. 2004;9(2):188–96.CrossRefGoogle Scholar
  6. 6.
    North RB, LaRocca VR, Schwartz J, North CA, Zahurak M, Davis RF, et al. Surgical management of spinal metastases: analysis of prognostic factors during a 10-year experience. J Neurosurg Spine. 2005;2(5):564–73.CrossRefGoogle Scholar
  7. 7.
    Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics, 2000. CA Cancer J Clin. 2000;50(1):7–33.CrossRefGoogle Scholar
  8. 8.
    Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 2013;18(6):744–51.CrossRefGoogle Scholar
  9. 9.
    Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324–8.CrossRefGoogle Scholar
  10. 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
  11. 11.
    Nair S, Gobin YP, Leng LZ, Marcus JD, Bilsky M, Laufer I, et al. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors: technique and outcomes from a single center. Interv Neuroradiol. 2013 Sep;19(3):377–85.CrossRefGoogle Scholar
  12. 12.
    Costa F, Dorelli G, Ortolina A, Cardia A, Attuati L, Tomei M, et al. Computed tomography-based image-guided system in spinal surgery: state of the art through 10 years of experience. Neurosurgery. 2015;11(Suppl 2):59–67; discussion −8.PubMedGoogle Scholar
  13. 13.
    Rades D, Fehlauer F, Schulte R, Veninga T, Stalpers LJ, Basic H, et al. Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression. J Clin Oncol. 2006;24(21):3388–93.CrossRefGoogle Scholar
  14. 14.
    Amankulor NM, Xu R, Iorgulescu JB, Chapman T, Reiner AS, Riedel E, et al. The incidence and patterns of hardware failure after separation surgery in patients with spinal metastatic tumors. Spine J. 2014;14(9):1850–9.CrossRefGoogle Scholar
  15. 15.
    Elder BD, Ishida W, Goodwin CR, Bydon A, Gokaslan ZL, Sciubba DM, et al. Bone graft options for spinal fusion following resection of spinal column tumors: systematic review and meta-analysis. Neurosurg Focus. 2017;42(1):E16.CrossRefGoogle Scholar
  16. 16.
    Bilsky MH, Boland P, Lis E, Raizer JJ, Healey JH. Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases. Spine (Phila Pa 1976). 2000;25(17):2240–9; discussion 250.CrossRefGoogle Scholar
  17. 17.
    Bilsky M, Smith M. Surgical approach to epidural spinal cord compression. Hematol Oncol Clin North Am. 2006;20(6):1307–17.CrossRefGoogle Scholar
  18. 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
  19. 19.
    Alongi F, Arcangeli S, Filippi AR, Ricardi U, Scorsetti M. Review and uses of stereotactic body radiation therapy for oligometastases. Oncologist. 2012;17(8):1100–7.CrossRefGoogle Scholar
  20. 20.
    Chang BK, Timmerman RD. Stereotactic body radiation therapy: a comprehensive review. Am J Clin Oncol. 2007;30(6):637–44.CrossRefGoogle Scholar
  21. 21.
    Lovelock DM, Zhang Z, Jackson A, Keam J, Bekelman J, Bilsky M, et al. Correlation of local failure with measures of dose insufficiency in the high-dose single-fraction treatment of bony metastases. Int J Radiat Oncol Biol Phys. 2010;77(4):1282–7.CrossRefGoogle Scholar
  22. 22.
    Yamada Y, Bilsky MH, Lovelock DM, Venkatraman ES, Toner S, Johnson J, et al. High-dose, single-fraction image-guided intensity-modulated radiotherapy for metastatic spinal lesions. Int J Radiat Oncol Biol Phys. 2008;71(2):484–90.CrossRefGoogle Scholar
  23. 23.
    Joaquim AF, Powers A, Laufer I, Bilsky MH. An update in the management of spinal metastases. Arq Neuropsiquiatr. 2015;73(9):795–802.CrossRefGoogle Scholar
  24. 24.
    Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes? Spine (Phila Pa 1976). 2009;34(22 Suppl):S78–92.CrossRefGoogle Scholar
  25. 25.
    Mizumoto M, Harada H, Asakura H, Hashimoto T, Furutani K, Hashii H, et al. Radiotherapy for patients with metastases to the spinal column: a review of 603 patients at Shizuoka Cancer Center Hospital. Int J Radiat Oncol Biol Phys. 2011;79(1):208–13.CrossRefGoogle Scholar
  26. 26.
    Maranzano E, Latini P. Effectiveness of radiation-therapy without surgery in metastatic spinal-cord compression – final results from a prospective trial. Int J Radiat Oncol. 1995;32(4):959–67.CrossRefGoogle Scholar
  27. 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
  28. 28.
    Yamada Y, Katsoulakis E, Laufer I, Lovelock M, Barzilai O, McLaughlin LA, et al. The impact of histology and delivered dose on local control of spinal metastases treated with stereotactic radiosurgery. Neurosurg Focus. 2017;42(1):E6.CrossRefGoogle Scholar
  29. 29.
    Yamada Y, Lovelock DM, Yenice KM, Bilsky MH, Hunt MA, Zatcky J, et al. Multifractionated image-guided and stereotactic intensity-modulated radiotherapy of paraspinal tumors: a preliminary report. Int J Radiat Oncol Biol Phys. 2005;62(1):53–61.CrossRefGoogle Scholar
  30. 30.
    Gerszten PC, Burton SA, Ozhasoglu C, Welch WC. Radiosurgery for spinal metastases: clinical experience in 500 cases from a single institution. Spine (Phila Pa 1976). 2007;32(2):193–9.CrossRefGoogle Scholar
  31. 31.
    Ghia AJ, Chang EL, Bishop AJ, Pan HY, Boehling NS, Amini B, et al. Single-fraction versus multifraction spinal stereotactic radiosurgery for spinal metastases from renal cell carcinoma: secondary analysis of phase I/II trials. J Neurosurg Spine. 2016;24(5):829–36.CrossRefGoogle Scholar
  32. 32.
    Gerszten PC, Burton SA, Ozhasoglu C, Vogel WJ, Welch WC, Baar J, et al. Stereotactic radiosurgery for spinal metastases from renal cell carcinoma. J Neurosurg Spine. 2005;3(4):288–95.CrossRefGoogle Scholar
  33. 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
  34. 34.
    Chang UK, Cho WI, Lee DH, Kim MS, Cho CK, Lee SY, et al. Stereotactic radiosurgery for primary and metastatic sarcomas involving the spine. J Neuro-Oncol. 2012;107(3):551–7.CrossRefGoogle Scholar
  35. 35.
    Gerszten PC, Burton SA, Quinn AE, Agarwala SS, Kirkwood JM. Radiosurgery for the treatment of spinal melanoma metastases. Stereotact Funct Neurosurg. 2005;83(5–6):213–21.CrossRefGoogle Scholar
  36. 36.
    Moulding HD, Elder JB, Lis E, Lovelock DM, Zhang Z, Yamada Y, et al. Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases. J Neurosurg Spine. 2010;13(1):87–93.CrossRefGoogle Scholar
  37. 37.
    Nasser R, Nakhla J, Echt M, et al. Minimally invasive separation surgery with intraoperative stereotactic guidance: a feasibility study. World Neurosurg. 2018;109:68–76.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Memorial Sloan Kettering Cancer Center, Department of NeurosurgeryNew YorkUSA
  2. 2.Department of Neurological SurgeryWeill Cornell Medical CollegeNew YorkUSA

Personalised recommendations