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Irradiation mostly palliativeipain control in ca. 75%

Fig.3 Surgery ideally should be carried out before irradiation [1]. Irradiation which preceding surgery [2] has a significantly higher complication rate [21]

perience with the introduction of instrumentation shows that the realignment of a multiply involved collapsing spine has significantly improved the neurological deficit of patients with spinal metastases (Fig. 2) [5, 6, 10, 13, 32, 41, 48, 57].

Today the debated question is whether irradiation alone is sufficient for most of the patients or whether it must be combined with decompression and stabilization, and, if so, whether the surgery comes first followed by the irradiation or in the opposite sequence. From the surgical stand point of view surgery should definitely be before irradiation if there is any probability that irradiation alone may not be sufficient to treat the patient (Fig. 3). Surgery into irradiated tissue has a significantly higher infection rate (30%) and is more difficult to perform than done before the irradiation [12, 15, 21, 34].

Surgical options

Indications for surgery are:

- Pain due to mechanical compression of the different pain-producing structures or clear instability

- Symptomatic mechanical compression of neurostructures (neurological deficit)

- Rapidly progressing neurological deficit due to mechanical compression

- Unknown primary tumor with clearly defined metasta-tic involvement of the spine

- Radioresistant tumor

- Neurological deterioration or increasing pain during or after radiotherapy (should be avoided by a careful evaluation of the tumor potential before irradiation is decided) [21]

Surgery generally is said to be indicated when the patient is still in a general condition which safely allows surgery, and if life expectancy is at least 6 months. The latter increasingly depends on the kind of surgical procedures and approaches which need to be chosen. This 6-month rule may be overruled by the possibilities of less invasive surgical procedures which allow a faster recuperation and cause less surgical trauma.

Many of the criteria are used to make a surgical indication cannot be handled rigidly and must be weighted in an interdisciplinary decision-making process. For example, there is substantial debate over what is exactly an unstable spine, and consequently there may be patients who are definitely overtreated with all the technical options available today on the base of an obscure understanding of instability. For example, applying the Denis classification for traumatic thoracolumbar fractures may not be appropriate as indication basis for surgical indications. There are more appropriate concepts developed in oncological surgery which should be applied to the metastatic spine [13, 16, 32, 50, 51].

Fig. 4 Anterior surgery for metastatic spine disease. a Woman with a kidney cancer, metastasing in the middle-thoracic spine. b Anterior resection and stabilization by a metal-cement compound and subsequent irradiation. c A 62-year-old woman with a breast cancer metastases into the C7 vertebra. d Resection, reconstruction with a tri-calcium bone substitute block, and plating with consecutive irradiation

Fig. 4 Anterior surgery for metastatic spine disease. a Woman with a kidney cancer, metastasing in the middle-thoracic spine. b Anterior resection and stabilization by a metal-cement compound and subsequent irradiation. c A 62-year-old woman with a breast cancer metastases into the C7 vertebra. d Resection, reconstruction with a tri-calcium bone substitute block, and plating with consecutive irradiation

In most instances the need to operate as radically as possible is usually also an overkill since radicality in most instances is not really possible, and most studies show that the local surgery of the spine does not fundamentally change the survival rate of these tumor patients, and very rarely the operated local spinal tumor is the cause of the mortality [16, 24, 25, 33, 36, 54, 55, 56]. This, again, needs to be kept in mind when deciding for surgery. The severity and extent of surgery can be influenced by adjuvant measures that may moderate the surgical intervention to an acceptable degree. One such measure is the preoperative em-bolization in vascularized spinal metastases or primary tumors. This can reduce blood loss and consequently morbidity and mortality drastically and facilitate the surgeon's work significantly. Kidney tumors, multiple myeloma, and thyroid tumors should definitely be considered for preop-erative embolization to reduce the blood loss.

Technically a spinal tumor located predominantly in the vertebral body can be approached by anterior surgery alone (Fig. 4) or in combination with a posterior procedure (Fig. 2c-e), or it can be performed entirely through a posterior approach leaving the patient with less morbidity (Fig. 5). However, is must be recognized that endoscopic anterior surgery for vertebral tumors, specifically in the thoracic spine, where the surgeon can profit from the natural thoracic cavity in contrast to the lumbar spine, may considerably diminish the morbidity of extensive anterior surgery in the elderly. The goal is in any case to operate on the patient in such a way that stay in the intensive care unit can be avoided. Again, with modern retractor systems and less invasive technology it is possible to perfect the posterolateral approach to the anterior spine elements of the thoracolumbar spine through a midline incision which allows a laminectomy, a vertebral body resection, the anterior column reconstruction and posterior stabilization in a single approach (Fig. 5) [41, 42]. In the middle and lower cervical spine the anterior approach is most straightforward and yields little morbidity (Fig. 4c-d). In rare cases

Fig. 5 Posterior surgery for metastatic spine disease. a A 73-year-old man with a metastases in L2 from a stomach cancer. b, c Through a single median posterior incision laminectomy, posterolateral resection of the vertebral body through both pedicles, and posterior reconstruction and stabilization with a short pedicular, angle stable system combined with an anterior column reconstruction with metal-cement compound through the posterior approach. d, e Partial resection and posterior stabilization of the upper cervical spine involved by lung metastases followed by irradiation in a 73-year-old man. Note the combination of a metal-cement compound posteriorly instead of bony fusion a combined procedure may be indicated to control the pain mostly due to the instability (Fig. 5). At the occipitocervical junction a posterior resection and stabilization combined with irradiation is generally sufficient as palliative measure. Some authors have recently enthusiastically advocated minimally invasive technology to approach certain lesions in particular in the vertebral body involvement: Vertebroplasty or kyphoplasty as palliative technique may increasingly gain significance in patients with high morbidity index or elevated risk for open surgery [37, 38].

Reconstruction of the anterior column for stability reasons as well as realignment of the spine is rarely carried out with autologous bone because the average life expectancy does not justify it, and a possible postoperative irradiation would damage the healing potential of an auto-graft. Today this reconstruction is performed either with a metal-cement compound as in building construction or with the use of metal or ceramic spacers in combination with cement, which may or may not be filled with bone substitutes. Major allograft may be an alternative; however, the biological conditions for its integration are not satisfactory, specifically in the case of adjuvant irradiation and possible chemotherapy.

The stability of a diseased segment after tumor resection can certainly be enhanced by a strong posterior instrumentation in combination with the anterior reconstruction of the anterior column and is biomechanically superior to a purely anterior reconstruction, even with anterior instrumentation [32]. The surgeon needs to keep in mind that the major goal of the surgery is to put the patient in a condition to be as soon as possible independently mobile without any brace, which is an additional burden in those severely ill and often rather cachectic patients with the potential of pressure sores and unease with external fixation devices.

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