CHAPTER
Ilya Laufer
140
The Surgical Treatment of
Metastatic Spine Disease
INTRODUCTION
Metastatic tumors to the spine represent a major source of mor-
bidity for cancer patients. Lytic bone tumors and epidural spi-
nal cord compression (ESCC) may result in severe instability
pain and loss of neurologic function that significantly impacts
a patients quality of life. The treatment of metastatic spine
tumors is based on the premise that interventions are palliative
and is offered to reduce pain, improve, or maintain neurologic
function, restore mechanical stability, and achieve local tumor
control. At the time of presentation, the fundamental decision
is whether radiation will offer effective palliation or whether
the patient requires an operation. A framework that incorpo-
rates neurologic, oncologic, mechanical stability, and systemic
disease considerations (NOMS) is used to help to delineate the
best treatment of the patient.
Surgery for metastatic spine tumors has evolved significantly
over the past 10 years. The evolution of techniques for surgical
decompression and instrumentation as well as the selective use
of percutaneous vertebroplasty and kyphoplasty has improved
the outcomes in metastatic cancer patients. The surgical tech-
niques and principles may differ from those applied to patients
with degenerative, traumatic, or deformity disorders and even
those with primary bone tumors. Patients with metastatic spinal
disease often have multiple comorbidities including other bone
lesions or visceral disease that may preclude an anterior or ret-
roperitoneal approach. For this reason, surgical approaches to
the spine may be modified from standard approaches used for
other pathologies. Additionally, the development of stereotac-
tic radiosurgery (SRS) has provided excellent tumor control
for radioresistant tumors. One may be less aggressive with
paraspinal tumor resection given the high probability of con-
trol of radiographic residual tumor using SRS. Surgery should
effectively achieve neural decompression and provide mechani-
cal stability but must be considered in the context of what the
patient can tolerate from the standpoint of systemic disease
and medical comorbidities.
DECISION MAKING
The NOMS framework is structured around the four funda-
mental considerations in decision-making: neurologic, onco-
logic, mechanical stability, and systemic disease and medical
LWBK836_Ch140_p1511-1519.indd 1511
Peter S. Rose
Mark H. Bilsky
comorbidities2,20(Fig. 140.1). The neurologic and oncologic
assessments are considered in concert; this has led to the cur-
rent treatment recommendation that patients with high-grade
spinal cord compression with radioresistant tumors are offered
surgery as the initial therapeutic intervention as opposed to
radiation. The neurologic assessment reflects not only the
severity of myelopathy and functional radiculopathy but also
the degree of ESCC, which is assessed on a scale from 0 to
3 where grades 2 and 3 are considered to be high grade
(Fig. 140.2).
The oncologic assessment reflects the radiosensitivity of the
tumor histology. Radiosensitive tumors, for example, lymphoma
and multiple myeloma, respond to conventional dose radiation
therapy (RT), such as 30 Gy in 10 fractions. These tumors often
do not require surgery even in the presence of high-grade
ESCC. Low-dose RT leads to apoptosis of the tumor and imme-
diate spinal cord decompression in these patients.4
The value of early surgical intervention in treating patients
with symptomatic spinal cord compression was recently demon-
strated in a prospective randomized trial by Patchell12 et al,
comparing surgery and conventional external beam radiation
to radiation alone. Patients undergoing surgery and external
beam RT had improved outcomes compared to those who
received RT alone in achieving maintenance or recovery of
ambulation as well as improved survival.4 Most solid tumors,
such as renal cell carcinoma (RCC) and thyroid carcinoma,
however, are resistant to conventional dose RT (Table 140.1).
Tumoricidal doses of radiation for these tumors present an
unacceptably high risk of spinal cord or adjacent organ (i.e.,
kidney) injury when delivered by conventional techniques.
Using new radiotherapy techniques, such as image-guided
intensity modulated radiation therapy (IGRT), cytotoxic doses
of high-dose photon RT (e.g., 24 Gy single fraction) can be
safely delivered to the tumor target while sparing the spinal
cord and other critical adjacent structures. Patients with high-
grade ESCC continue to require surgical decompression prior
to administration of IGRT due to constraints of radiation tar-
geting and spinal cord tolerance. IGRT is offered to patients
who have minimal or no ESCC or as a postoperative adjuvant
for tumors resistant to conventional dose RT.3,8
The second indication for surgery is mechanical instability
since radiation treatment has no ability to stabilize an unstable
spine. Definitions of instability are still being developed for
pathologic fractures. In general, patients with unstable fractures
1511
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 1512 Section XIII Tumor and Osteomyelitis

NEUROLOGIC

IGIMRT*
No/Minimal ESCC
+/- Myelopathy

High-grade ESCC
+/- Myelopathy

RADIATION THERAPY
ONCOLOGIC
Radiosensitive

SURGERY
(Lymphoma, MM)

Radioresistant
(RCC, NSCL Ca)

Prior radiation ROI

MECHANICAL
INSTABILITY
Level dependent

SYSTEMIC
DISEASE
Limited

Extensive

* IGIMRT: Image-guided intensity modulated radiation therapy

Figure 140.1. NOMS (neurologic, oncologic, mechanical, and systemic) algorithm. (Redrawn from
Bilsky M, Smith M. Surgical approach to epidural spinal cord compression. Hematol Oncol Clin North Am
2006;20:1307--1317, with permission from Elsevier.)

demonstrate severe movement-related pain that is characteris- Definitive therapy with radiation provides local tumor control
tic of specific spinal levels in correlation with radiographic find- without the need for surgery.
ings. Burst or compression fractures of the thoracic and lumbar Patients requiring instrumented fusion of the atlantoaxial
spine often present with axial load pain but do not require region have pain with flexion, extension, and rotation. However,
instrumented fixation. The pain from these fractures will fre- patients presenting with C1C2 pain and normal spinal align-
quently improve after a few days of bed rest and limited activity. ment or minimal subluxation respond well to external beam RT.
Alternatively, the fractures may respond to percutaneous These patients can be placed in a hard collar during treatment
cement augmentation, using vertebro- or kyphoplasty.1,6,9 and for 6 weeks following the completion of RT. Patients with
fracture subluxations greater than 5 mm or greater than 3.5 mm
subluxation and 11 angulation between C1 and C2 with move-
ment-related neck pain require instrumented spine fixation.5,17
Radiosensitivity of Common In the subaxial cervical and thoracic spine levels, simple
TABLE 140.1 Metastatic Tumors to burst and compression fractures may create kyphosis but often
Conventional Radiotherapy do not manifest instability pain. A burst or compression frac-
ture with extension into a unilateral joint, on the other hand, is
Radiation Sensitivity Metastatic Tumors often unstable. Instability pain in the subaxial cervical and tho-
Sensitive Myeloma racic spine is often produced with extension, which causes
Lymphoma unremitting pain as the patient straightens an unstable kypho-
Moderately sensitive Breast sis. Patients with thoracic or thoracolumbar instability often
Moderately resistant Colon give a history of sleeping upright in a chair because they cannot
NSCLC lie flat due to pain.
Highly resistant Thyroid As in the subaxial cervical and thoracic spine, lumbar patho-
Renal
logic burst fractures are frequently stable. Lumbar spine frac-
Melanoma
Sarcoma
tures may present with mechanical radiculopathy, in which the
patient develops severe radicular symptoms when the spine is

LWBK836_Ch140_p1511-1519.indd 1512 8/26/11 2:18:12 PM

 Chapter 140 The Surgical Treatment of Metastatic Spine Disease 1513

A B

C D

Figure 140.2. Epidural compression. (A) No subarachnoid space compression. (B) Subarachnoid space
partially obliterated; no cord compression. (C) Subarachnoid space partially obliterated with cord compres-
sion. (D) Subarachnoid space completely blocked, with cord compression.

axially loaded upon sitting or standing. This results from nar-
rowing of the neural foramen and, in our experience, does not
commonly respond to RT. Mechanical radiculopathy is often
seen in the presence of a burst fracture with extension of tumor
into the neural foramen.
The systemic disease assessment reflects what the patient
can tolerate physiologically from the standpoint of the systemic
disease and medical comorbidities. The systemic disease assess-
ment is typically aimed at survival prediction and whether the
patient will likely withstand surgery with an acceptable risk of
medical complications. Several authors have developed scoring
systems in an attempt to predict survival and potential benefit
in patients with metastatic disease to the spine.15,18,19 However,
these scores are based on historical data without the benefit of
current adjuvant therapies, and there remains a high variability
in the outcome of individual patients. As such, a poor score
on these instruments should be interpreted with caution and
should not preclude surgical intervention in otherwise satisfac-
tory candidates.
SURGICAL APPROACH
The surgical approaches to metastatic spinal disease can also be
assessed using a NOMS approach. The primary goals of surgery
are spinal cord decompression and providing spinal stability. A
secondary goal is maximizing tumor resection, such as remov-
ing chest wall or retroperitoneal disease adjacent to the spine,
in order to attempt to achieve better tumor control.
In order to achieve sufficient exposure to resect epidural
disease from the thecal sac and nerve roots, the laminectomy is
typically extended to include resection of a unilateral or bilat-
eral facet joint(s) and pedicle(s) depending on the extent of
lateral and anterior tumor compression. This extended lamine-
ctomy is referred to as a posterolateral approach. Using a high-
speed drill with a 3 mm match-head burr provides a fast and
safe method of resecting bone without transmitting pressure to
the spinal cord. Kerrison punches are used only when the bone
dissection is lateral to the spinal canal. As opposed to surgery
for degenerative disease, deformity, and traumatic fractures,

LWBK836_Ch140_p1511-1519.indd 1513 8/26/11 2:18:12 PM

 1514 Section XIII Tumor and Osteomyelitis
the facet joints, and interspinous ligaments are left intact at the
segments that are planned to be instrumented.
Resection of metastatic disease must achieve decompression
of the spinal cord. Epidural tumor should be grossly removed
circumferentially from the dura in order to effectively decom-
press the spinal cord and to provide an adequate margin for
adjuvant IGRT. The most common pattern of spinal cord com-
pression in the subaxial cervical, thoracic, and lumbar spine
involves tumor extending from the vertebral body pushing the
posterior longitudinal ligament (PLL) against the thecal sac
and then extending around the PLL to compress the spinal
cord laterally or circumferentially. This pattern of tumor exten-
sion causes the V sign seen on axial T2-weighted magnetic
resonance imaging (MRI) images (Fig. 140.3). Tumor rarely
insinuates between the PLL and anterior dura. Therefore,
regardless of whether an anterior or posterior approach is used,
the PLL is resected to provide a tumor-free margin on the ante-
rior dura. ESCC is fortunately most commonly caused by soft
tissue tumor growth and very rarely by solid bone. The tumor
may be resected using tenotomy scissors and a number 15 scal-
pel blade. From a posterior approach, it is helpful to establish a
normal dural plane at an adjacent spinal segment and to dis-
sect tumor from the dura under direct visualization. When
using an anterior approach, the surgeon must dissect through
tumor to identify dura, but resection of the PLL provides a
clean dural margin. Once the normal dura is identified, tumor
resection is relatively straightforward, recognizing that epidural
tumor rarely, if ever, extends intradurally.
In addition to the thecal sac, identification of nerve roots is
important in order to avoid unintentional rhizotomy of func-
tional nerve roots or creation of a CSF leak. Nerve roots are
frequently encased in tumor and pushed anteriorly adjacent
toward the PLL, although they may occasionally be pushed pos-
teriorly. Establishing normal anatomical landmarks is impor-
tant for the identification of nerve roots. Typically nerve roots
are identified on the lateral dura by dissecting between the
Figure 140.3. Typical V sign that results from the tumor push-
ing on the posterior longitudinal ligament.
LWBK836_Ch140_p1511-1519.indd 1514
pedicles, which are found at the level of the transverse pro-
cesses when using a posterior approach and are adjacent to the
ribs from an anterior approach. Spreading tenotomy scissors
along the lateral dura will often identify the nerve roots, which
can then be dissected free from tumor. Avoid cutting along the
lateral dura until the nerve roots have been identified. Once
identified, rhizotomy can be performed, if necessary, with vas-
cular clips or 2-0 silk ligatures.
The segmental blood supply of the spinal cord, including
the artery of Adamkiewicz, traverses the neural foramen with
the nerve root. If there is angiographic evidence of the artery
of Adamkiewicz, or if a preoperative angiogram has not been
performed, we avoid rhizotomy in the thoracic and lumbar
spine. Even in cases of bilateral rhizotomy, however, we have
not seen a vascular spinal cord injury, although there remains a
theoretical risk. When approaching the spine anteriorly, the
risk of spinal cord infarction may be reduced by dividing the
segmental artery at or ventrally to the midvertebral body and
avoiding the use of electrocautery near the neural foramen.
In metastatic tumor surgery, every attempt is made to pre-
serve functional nerve roots. Tumor can often be dissected
from the nerve root using tenotomy scissors from the lateral
dural margin to the brachial or lumbosacral plexus. Tumor will
rarely be densely adherent to the roots. Aggressive resection in
these cases may result in functional loss, possibly on the basis of
devascularizing the nerve root. If a normal plane cannot be
readily defined, tumor should be left on the nerve root.
Fortunately, this can be readily treated with IGRT.
RECONSTRUCTION OF MECHANICAL
STABILITY
Resection of metastatic spinal tumors virtually always necessitates
the instrumented reconstruction of the spine to restore mechan-
ical stability. Instrumentation strategies are tailored to each
patient, but there are some general guidelines that may be
applied. If possible, spinal implants should be MRI compatible,
such as titanium, polyetheretherketone (PEEK) carbon fiber, or
autologous or allogeneic bone. Polymethylmethacrylate (PMMA)
continues to be used selectively for anterior reconstruction as it
can interdigitate into adjacent vertebral bodies and is reliable for
reconstruction of osteoporotic bone. All of these implant materi-
als allow patients to be imaged for spinal recurrence using MRI
without the need for myelogram (Fig. 140.4).
Instrumentation strategies should account for the possibility
of osteoporotic bone or tumor progression at adjacent seg-
ments, both of which are commonly seen in metastatic tumor
patients. For this reason, long posterior constructs are typically
used with fixation placed at least two levels rostral and caudal to
the level(s) of the resection. Pedicle screw holes can be aug-
mented with PMMA or kypho- or vertebroplasty can be used at
fixation sites to improve the durability of fixation. Deformity
correction is controversial. We will typically accept the correc-
tion provided by patient positioning but do not attempt to
achieve perfect sagittal balance. Restoration of sagittal and cor-
onal alignment places significant stress on the boneimplant
interface with risk of failure of the boneimplant interface.
Finally, implants should be planned and positioned to give
immediate and durable fixation. Although bone graft is placed
in the majority of patients, the likelihood of arthrodesis in
these patients is limited due to the adjuvant radiation and
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 Chapter 140 The Surgical Treatment of Metastatic Spine Disease 1515

Figure 140.4. Implantation of polyetheretherketone carbon fiber minimizes magnetic resonance artifact
on follow-up, allowing early detection of recurrence.

chemotherapy. With rigid pedicle screw instrumentation, we stem stroke will help the surgeon to decide if aggressive resec-
do not use cement as an adjunct to posterior fixation as other tion of the tumor from the vertebral arteries will be feasible.
authors have suggested.11 Constructs should be placed with The location of the artery of Adamkiewicz may also be important
the expectation of making the patient brace independent. information obtained from preoperative angiography, particu-
Oncologic concerns in tumor surgery reflect an attempt to larly if one is considering sacrifice of bilateral segmental blood
achieve local tumor control. In the past, we have been very vessels or nerve roots in the thoracolumbar region.
aggressive with local tumor resection, including large paraspi-
nal masses. It has become increasingly clear that the extent of ATLANTOAXIAL REGION
surgical resection may not significantly improve local tumor
control, which in large part is dependent on the tumor biology. The major indication for surgical intervention on atlantoaxial
As the application of IGRT has improved local tumor control spine tumors is instability resulting from a significant fracture
even for radiation-resistant tumors, the key aspect of tumor subluxation. A number of authors have noted that patients with
resection seems to be clearing the epidural space of tumor and symptomatic spine tumors of C1C2 rarely develop epidural
providing room for reconstruction. disease that causes spinal cord compression.5,13,17 This lack of
soft tissue disease at presentation may reflect the severe pain
that patients develop with lytic bone destruction at this level,
VASCULAR STUDIES AND
EMBOLIZATION Vascularity of Common
TABLE 140.2
Metastatic Tumors
Consideration of tumor vascularity and pertinent arterial anat-
omy is important prior to surgery. Several tumor types, classically Hypervascular tumors
including renal cell and thyroid carcinoma, are hypervascular Renal cell carcinoma
and benefit from preoperative embolization.14,16 (Table 140.2). Follicular thyroid carcinoma
Consideration of preoperative embolization should be given to Neuroendocrine tumor
tumors where the organ of origin is vascular (e.g., hepatocellular Paraganglioma
Hepatocellular carcinoma
carcinoma), or if the tumor name indicates a vascular compo-
Leiomyosarcoma
nent, such as angiosarcoma or hemangiopericytoma. Multiple Angiosarcoma
myeloma and melanoma are relatively hemorrhagic at opera- Angio- or hemangioma/organ of origin is vascular
tion, but do not typically benefit from embolization because Hypervascular tumors
they do not have major segmental feeders. A number of com- (No benefit from embolization)
monly operated tumors are relatively avascular and do not typi- Multiple myeloma
cally need preoperative embolization. These include colon, Melanoma
non-small cell lung, and breast carcinoma. Nonvascular tumors
Consideration of the arterial anatomy is particularly impor- Colon carcinoma
tant in the cervical spine where the vertebral arteries may be Non-small cell lung carcinoma
Breast carcinoma
encased in tumor. A preoperative balloon occlusion test to
Sarcomas (e.g., osteogenic)
ensure that vertebral artery sacrifice will not result in a brain

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 1516 Section XIII Tumor and Osteomyelitis
Figure 140.5. A 33-year-old pregnant woman with metastatic leiomyosarcoma who presented with rapidly
progressing upper and lower extremity weakness. She underwent C1 laminectomy with occipitocervical
fusion followed by excellent restoration of strength and great response to radiation.
prompting early radiographic imaging. On this basis, spinal
cord compression at C1C2 is typically caused by an anterior
fracture with subluxation of the atlas relative to the axis. Reduc-
tion of the fracture in extension will decompress the spinal
cord, although often these fractures are difficult to reduce.
More commonly, spinal cord decompression is achieved with
laminectomies of C1 and C2. For metastatic tumors, an ante-
rior approach, such as high cervical exposure or mandibular
osteotomy, carries prohibitive morbidity in this patient popula-
tion. The anterior tumor commonly in the C2 body and odon-
toid can often be controlled with radiation or systemic therapy
without the need for direct decompression or resection.
The posterior instrumentation strategy depends on the
involved spinal elements and the ability to reduce the fracture
subluxation. In cases in which the fracture can be reduced, pos-
terior fixation without inclusion of the occiput is an option.
Given the degree of anterior lytic bone destruction, most patients
are not candidates for transarticular or C1C2 fixation using lat-
eral mass and pars interarticularis screws. Standard wiring tech-
niques or sublaminar clamps provide excellent fixation.
In cases of C1--2 fracture subluxations, posterior fixation is
achieved using occipitocervical fixation.5,7 (Fig. 140.5). The
surgeon must ensure that the head is aligned without rotation
prior to instrumentation because occipital fixation will only
allow approximately 20 of rotation. Additionally, translating
the neck too far posteriorly will cause significant postoperative
swallowing difficulties. The most common technique for poste-
rior fixation is a screw-rod system. Our current system provides
for a suboccipital plate to be attached to the midline keel of the
suboccipital bone with 2 to 3 bicortical screws of lengths vary-
ing from 10 to 16 mm. A preoperative CT scan will help deter-
mine the length and location of the thick suboccipital keel.
Occasionally, the midline keel will be deviated to the left or
right and may even be bifid. Lateral mass screws are extended
to C5 or C6 to ensure good fixation over 3 to 4 segments. No
attempt is made to reconstruct the anterior column. Allograft
bone is placed to enhance the potential for fusion.
SUBAXIAL CERVICAL SPINE
The most common indication for surgery for metastatic spinal
disease in the subaxial cervical spine is ESCC and, secondarily,
mechanical instability. As opposed to the atlantoaxial spine, the
LWBK836_Ch140_p1511-1519.indd 1516
subaxial cervical spine often requires both an anterior and a
posterior approach with circumferential fixation (Fig. 140.6).
Commonly, an anterior decompression for vertebral body
tumor is supplemented with posterior fixation. Standalone
anterior grafts and plates seem to have, in our experience, an
increased risk of subsidence. Loss of anterior fixation due to
disease progression at adjacent segments can be catastrophic.
The standard anterior cervical approach is used to expose
the cervical spine from C3 to C7. Cervical spine tumors often
have large paraspinal masses that may make exposure of the
spine difficult. The tumors can involve the hypoglossal, supe-
rior, and recurrent laryngeal nerves. One should elicit a history
of hoarseness or a surgical history of thyroplasty (vocal cord
medialization) to assess the possibility of vocal cord paralysis
that may have been caused by prior neck or chest surgery or the
presence of a large chest mass. Preoperative swallowing evalua-
tion and direct laryngoscopy are useful for identifying preexist-
ing recurrent and superior laryngeal nerve root deficits. If
identified, the approach should be from the side of the injured
nerve. Bilateral recurrent and laryngeal nerve injuries will ren-
der a patient tracheostomy and feeding tube dependent.
Prior RT to the neck may also tether the esophagus and
pharynx to the spine and obscure normal tissue planes. For
these reasons, it may be beneficial to employ the services of a
head and neck surgeon to facilitate the exposure and preserva-
tion of important anatomic structures. Occasionally, in our
experience, the head and neck surgeon has been unable to
achieve anterior exposure and we have had to abandon the
anterior procedure and use a posterolateral decompressive
approach.
Following successful mobilization of soft tissues, the paraspi-
nal tumor is resected to the level of the vertebral bodies and
the midline is identified. A cardinal rule of spine tumor surgery
is that tumor never involves the discs spaces, so these can reli-
ably be used to identify the proper levels. Disc spaces are often
resected first to identify the PLL. Intralesional resection of the
vertebral body tumor is then accomplished using suction,
curettes, and pituitary rongeurs. The PLL is then resected to
achieve an anterior margin on the dura. The vertebral arteries
are often encased in tumor and pushed laterally from their
normal location. Following decompression of the spinal
cord, the paraspinal masses lateral to the vertebral body are dis-
sected using tenotomy scissors to identify the vertebral artery.
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 Chapter 140 The Surgical Treatment of Metastatic Spine Disease
Figure 140.6. A 29-year-old woman with metastatic malignant peripheral nerve sheath tumor. She under-
went a C4--5 corpectomy with a vertical titanium cage and anterior plate reconstruction followed by C5--6
foraminotomy and posterior C2-T2 fixation and arthrodesis.
Alternatively if the chest has been opened for cervicothoracic
exposure, such as trap door or manubrial osteotomy, the verte-
bral arteries can be dissected from the takeoff of the subclavian
arteries. The goal of anterior tumor resection is ventral decom-
pression of the spinal cord and anterior structural support.
Anterior reconstruction following corpectomy is achieved with
a titanium, PEEK cage, or fibula allograft, and an anterior
plate.
Posterior decompression is often required to complete epi-
dural decompression, and posterior instrumentation is rou-
tinely placed both following decompression and as augmenta-
tion for anterior decompression and instrumentation. Most
commonly, patients require a laminectomy with unilateral or
bilateral facetectomies to completely resect the epidural tumor.
This is performed with a 3 mm burr in order to expose the lat-
eral spine and nerve roots. Lateral mass screw rod systems using
a 3.5 mm rod are used for posterior instrumentation. Lateral
mass screws are placed at C3 to C6, pars interarticularis screws
or translaminar screws at C2, and pedicle screws at C7 and the
thoracic spine. Palpation of the medial wall of the C2 pars and
the C7 pedicle via a laminoforaminotomy are routinely per-
formed to facilitate screw placement. In the thoracic spine, ana-
tomical landmarks are used for placement of thoracic screws,
using the freehand technique described by Lenke.10 Pars inter-
articularis screws have routinely been used at C2, but translami-
nar screws provide equally secure fixation, are easier to place,
and minimize the risk to the vertebral arteries.
THORACIC AND LUMBAR APPROACHES
The most common indication for resection of thoracic and
lumbar spine tumors is to relieve high-grade spinal cord com-
pression from radiation-resistant tumor and, less commonly,
mechanical instability. For this reason, most patients undergo
circumferential decompression and fixation. Epidural tumor
LWBK836_Ch140_p1511-1519.indd 1517
1517
resection is commonly performed via a posterolateral laminec-
tomy with resection of the lamina, pedicles, and facet joint. A
posterolateral laminectomy gives adequate exposure to resect a
lytic vertebral body tumor from a posterior approach. Resec-
tion of the vertebral body from a posterior approach is similar
to a decancellation procedure used in deformity surgery for
kyphosis reduction. Once the epidural tumor is resected from
the posterior and lateral dura, the PLL is opened lateral to the
dura. An intralesional vertebral body resection is then accom-
plished using curettes and pituitary rongeurs. The disc spaces
at the adjacent segments are resected to expose normal end-
plates. The PLL is then resected from the anterior dura by dis-
secting it with a Woodson dental tool. Tenotomy scissors are
used to cut the PLL in order to achieve a negative dural
margin.
Most commonly, anterior fixation is accomplished with
PMMA and Steinman pins, but bone graft or cages can be
placed from a posterior approach. In order to place Steinman
pins from a posterior approach, a right-angle awl is used to cre-
ate starting holes in the normal endplates and the appropriate
sized pin is placed into one endplate and then driven into the
adjacent vertebral body. Typically 2 pins are placed (Fig. 140.7).
PMMA is delivered through a 20-mL syringe and a 14 gauge
angiocatheter. It is essential that the PMMA surround the pins
in order to prevent rotation of the construct. As it hardens, the
PMMA is compressed against the anterior cortex with a Penfield
3, which allows the PMMA to distract against the endplates.
Posterior fixation is accomplished using pedicle screws in the
thoracic and lumbar spine extending at least two levels rostral
and caudal to the level of resection. For surgery at T1 and T2,
cervicothoracic junction (CTJ) reconstruction is required (Fig.
140.8). A dual-diameter rod construct using a tapered rod from
6.25 to 3.5 mm is used to connect thoracic pedicle screws to lat-
eral mass screws. The lateral mass screws are often extended to
C4 or C5. Even with polyaxial screws, it may be difficult to place
a C7 pedicle screw and C6 lateral mass screw because the
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 1518 Section XIII Tumor and Osteomyelitis

Figure 140.7. A 78-year-old woman with metastatic melanoma. She underwent posterior transpedicular
resection of T10 tumor with PMMA and Steinmann pins reconstruction and T8-L1 posterior fixation.

Figure 140.8. A 46-year-old man with history of metastatic melanoma who presented with acute onset
lower extremity weakness. He underwent posterolateral resection of T1--T4 epidural tumor with C5--T7 poste-
rior fixation using a dual-diameter rod.

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 Chapter 140 The Surgical Treatment of Metastatic Spine Disease
starting points are close together. The starting point for the C6
lateral mass screw may need to be moved cephalad in order to
engage the rod into both screw heads. Alternatively for a T2
decompression, a 6.25-mm rod construct can be used ending
the superior end of the construct with C7 and T1 pedicle screws,
obviating the need to extend the construct into the lateral
masses of the cervical spine. These constructs are reliable in
stabilizing the CTJ even in the presence of bilateral or multi-
level facetectomy. All spinal implants should be titanium or
cobalt chrome to maintain MRI compatibility.
CONCLUSION
The treatment of metastatic spine tumors is based on NOMS
assessment. Currently, surgery is indicated for patients with
high-grade ESCC (N) from RT-resistant tumors (O) or patients
who demonstrate gross spinal instability (M). The criteria for
instability vary with spinal level, but generally manifest with
movement-related pain. Patients must be able to tolerate sur-
gery from the perspective of systemic and medical comorbidi-
ties (S). At surgery, spinal cord decompression often requires
circumferential tumor resection that may be accomplished
using posterolateral approach. Aggressive resection of paraspi-
nal tumor may not be necessary since IGRT provides durable
tumor control, even for tumor resistant to conventional exter-
nal beam radiation. Anterior support may be achieved with
PMMA, PEEK or titanium cages, or allograft. Posterior instru-
mentation must reliably provide support in osteoporotic spine
of cancer patients. Screw-rod constructs are used at all levels for
reconstruction. Long posterior constructs at least two-levels
superior and inferior to the decompression level are used to
prevent loss of fixation with adjacent segment tumor progres-
sion. Screw sites can be augmented with PMMA in osteoporotic
bone.
LWBK836_Ch140_p1511-1519.indd 1519
1519
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