The posterior approach to the lumbar spine and sacrum is familiar to most spine surgeons and avoids the need for an access surgeon. Given the familiarity of this technique, the posterior approach is a workhorse for most spine surgeons when treating tumors in this region. For most situations involving metastatic tumors to the spine, an intralesional tumor debulking strategy is used to decompress the nerve roots, separate tumor from the dura, and simultaneously stabilize the spine. The advantage of the posterior approach is that this can all be done in the same setting.
Unlike the treatment for primary spinal column tumors such as chordoma and chondrosarcoma where en bloc, excisional-type resection strategies are ideal for local tumor control and potential cure, in the metastatic setting, the intent is not usually curative. Thus, the scope and extent of surgery required in this region is usually limited. The posterior approach is effective in this regard as it minimizes the surgical morbidity associated with either anterior or lateral approaches to the lumbar spine and sacrum. Given the goals of addressing cancer-related biologic and mechanical pain in the least destructive manner in the palliative setting, the posterior approach helps minimize the potential complications associated with the other approaches.
In this chapter, the regional challenges of posterior fixation, decompression, and reconstruction are discussed through a case-based approach in a practical manner.
Intralesional tumor resection Spinal metastases Posterior stabilization Spinal reconstruction Separation surgery Palliative surgery
This is a preview of subscription content, log in to check access.
Dea N, Charest-Morin R, Sciubba DM, Bird JE, Disch AC, Mesfin A, et al. Optimizing the adverse event and HRQOL profiles in the management of primary spine tumors. Spine (Phila Pa 1976). 2016;41(Suppl 20):S212–S7.CrossRefGoogle Scholar
Laufer I, Zuckerman SL, Bird JE, Bilsky MH, Lazary A, Quraishi NA, et al. Predicting neurologic recovery after surgery in patients with deficits secondary to MESCC: systematic review. Spine (Phila Pa 1976). 2016;41(Suppl 20):S224–S30.CrossRefGoogle Scholar
Glennie RA, Rampersaud YR, Boriani S, Reynolds JJ, Williams R, Gokaslan ZL, et al. A systematic review with consensus expert opinion of best reconstructive techniques after osseous en bloc spinal column tumor resection. Spine (Phila Pa 1976). 2016;41(Suppl 20):S205–S11.CrossRefGoogle Scholar
Altaf F, Weber M, Dea N, Boriani S, Ames C, Williams R, et al. Evidence-based review and survey of expert opinion of reconstruction of metastatic spine tumors. Spine (Phila Pa 1976). 2016;41(Suppl 20):S254–S61.CrossRefGoogle Scholar
Pennicooke B, Laufer I, Sahgal A, Varga PP, Gokaslan ZL, Bilsky MH, et al. Safety and local control of radiation therapy for chordoma of the spine and sacrum: a systematic review. Spine (Phila Pa 1976). 2016;41(Suppl 20):S186–S92.CrossRefGoogle Scholar
Fehlings MG, Nater A, Tetreault L, Kopjar B, Arnold P, Dekutoski M, et al. Survival and clinical outcomes in surgically treated patients with metastatic epidural spinal cord compression: results of the prospective multicenter AOSpine study. J Clin Oncol. 2016;34(3):268–76.CrossRefGoogle Scholar
Choi D, Fox Z, Albert T, Arts M, Balabaud L, Bunger C, et al. Rapid improvements in pain and quality of life are sustained after surgery for spinal metastases in a large prospective cohort. Br J Neurosurg. 2016;30(3):337–44.CrossRefGoogle Scholar
Klimo P Jr, Schmidt MH. Surgical management of spinal metastases. Oncologist. 2004;9(2):188–96.CrossRefGoogle Scholar
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
Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2001;26(3):298–306.CrossRefGoogle Scholar
Hu Y, Xia Q, Ji J, Miao J. One-stage combined posterior and anterior approaches for excising thoracolumbar and lumbar tumors: surgical and oncological outcomes. Spine (Phila Pa 1976). 2010;35(5):590–5.CrossRefGoogle Scholar
Villavicencio AT, Oskouian RJ, Roberson C, Stokes J, Park J, Shaffrey CI, et al. Thoracolumbar vertebral reconstruction after surgery for metastatic spinal tumors: long-term outcomes. Neurosurg Focus. 2005;19(3):E8.PubMedGoogle Scholar
Walsh GL, Gokaslan ZL, McCutcheon IE, Mineo MT, Yasko AW, Swisher SG, et al. Anterior approaches to the thoracic spine in patients with cancer: indications and results. Ann Thorac Surg. 1997;64(6):1611–8.CrossRefGoogle Scholar
Shankar GM, Clarke MJ, Ailon T, Rhines LD, Patel SR, Sahgal A, et al. The role of revision surgery and adjuvant therapy following subtotal resection of osteosarcoma of the spine: a systematic review with meta-analysis. J Neurosurg Spine. 2017;27(1):97–104.CrossRefGoogle Scholar
Ailon T, Torabi R, Fisher CG, Rhines LD, Clarke MJ, Bettegowda C, et al. Management of locally recurrent chordoma of the mobile spine and sacrum: a systematic review. Spine (Phila Pa 1976). 2016;41(Suppl 20):S193–S8.CrossRefGoogle Scholar
Zuckerman SL, Laufer I, Sahgal A, Yamada YJ, Schmidt MH, Chou D, et al. When less is more: the indications for MIS techniques and separation surgery in metastatic spine disease. Spine (Phila Pa 1976). 2016;41(Suppl 20):S246–S53.CrossRefGoogle Scholar
Massicotte E, Foote M, Reddy R, Sahgal A. Minimal access spine surgery (MASS) for decompression and stabilization performed as an out-patient procedure for metastatic spinal tumours followed by spine stereotactic body radiotherapy (SBRT): first report of technique and preliminary outcomes. Technol Cancer Res Treat. 2012;11(1):15–25.CrossRefGoogle Scholar
Muhlbauer M, Pfisterer W, Eyb R, Knosp E. Minimally invasive retroperitoneal approach for lumbar corpectomy and anterior reconstruction. Technical note. J Neurosurg. 2000;93(1 Suppl):161–7.PubMedGoogle Scholar
Ho JC, Tang C, Deegan BJ, Allen PK, Jonasch E, Amini B, et al. The use of spine stereotactic radiosurgery for oligometastatic disease. J Neurosurg Spine. 2016;25(2):239–47.CrossRefGoogle Scholar
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
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
Hussain I, Barzilai O, Reiner AS, DiStefano N, McLaughlin L, Ogilvie S, et al. Patient-reported outcomes after surgical stabilization of spinal tumors: symptom-based validation of the spinal instability neoplastic score (SINS) and surgery. Spine J. 2017;18(2):261–7.CrossRefGoogle Scholar
Street J, Fisher C, Sparkes J, Boyd M, Kwon B, Paquette S, et al. Single-stage posterolateral vertebrectomy for the management of metastatic disease of the thoracic and lumbar spine: a prospective study of an evolving surgical technique. J Spinal Disord Tech. 2007;20(7):509–20.CrossRefGoogle Scholar
Sundaresan N, Galicich JH, Lane JM, Bains MS, McCormack P. Treatment of neoplastic epidural cord compression by vertebral body resection and stabilization. J Neurosurg. 1985;63(5):676–84.CrossRefGoogle Scholar
Eleraky M, Setzer M, Vrionis FD. Posterior transpedicular corpectomy for malignant cervical spine tumors. Eur Spine J. 2010;19(2):257–62.CrossRefGoogle Scholar
Mesfin A, Sciubba DM, Dea N, Nater A, Bird JE, Quraishi NA, et al. Changing the adverse event profile in metastatic spine surgery: an evidence-based approach to target wound complications and instrumentation failure. Spine (Phila Pa 1976). 2016;41(Suppl 20):S262–S70.CrossRefGoogle Scholar