Here we may consider chemotherapy, bisphosphonates, and in some specific tumors hormonal therapy (breast, prostate, thyroid cancer) and as a general medication steroids such as dexamethasone. This is the most frequently used cortico-steroid despite the fact that in the literature there is no valid comparison of dexamethasone and methylprednisolone [35, 40]. Two dosing regimen are used: the high-dose dexameth-asone regimen comprises an initial bolus of 100 mg with subsequent dose of 96 mg/day. This regimen seems to have only a historical value since significant side effects have been associated with its use. It should be administered only to patients with rapidly progressing neurological deficit. The moderate-dose dexamethasone regimen starts with 10 mg intravenous bolus and continues with 16 mg/day four times daily [40, 52]. This dosage is well tolerated, and it is the regimen of choice in symptomatic patients. No steroids are proposed in nonparetic ambulatory patients.
Recently a new dimension in the treatment of bony metastases has been advocated. Since it is well established that bony metastases in general and of the spine in particular increase treatment costs and may significantly prolong hospital stay, new means of simple treatment of bony metastases are being evaluated . Bisphosphonates have stood the test of time in the treatment of bony complications because they stop the vicious circle of tumor progression and pathological bone turnover. Under the effect of the tumor cells the balance between bone resorption and new bone formation is disturbed; tumor cells seed in the bone under the attraction of growth factors . There they deliberate mediators which stimulate both the osteoclasts and osteoblasts, which start to turnover the bone in an unphysiological way. Again, growth factors are released which stimulate tumor cells for proliferation. The vicious circle of pathological bone remodeling and tumor progression starts. Subsequently bone quality and bone density diminish. The stability of the bone strongly decreases. Bisphosphonates show a high affinity to bone and are augmented mainly in locations with high bone turnover. They are therefore ideal medications to stop the vicious circle of bone metastasing and damaging . The most successful medication is pamidronate (second-generation bisphosphonate) which is successful mostly in bony metastases of breast cancer and in osteolysis in multiple myeloma . Zoledronic acid is one of the most recently developed agents and is characterized by an imidazol ring. In animal experiments the effect was 100-850 times better than that with the older pamidronate [30, 39, 44].
The objective clinical success of the bisphosphonate depends significantly on the reduction and delay of skeletal complications (SREs=pathological fracture, spinal cord compression, need for irradiation or surgery for stabilization) [19, 22]. It can be anticipated today that the bisphosphonates have an immediate antitumoral effect. Bisphos-phonate treatment has the goal of diminishing the incidence of bony complications, vertebral body fractures, pain, and osteoporosis. The outcome should be determined by the survival time - once a spinal metastasis is detected -in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. The mean survival time is 14- 18 months depending obviously on the patient's condition before entering treatment for the spinal problem. Wise et al.  report a mean survival time of 15.9 months after surgery for spinal metastasis, whereas Weigel  reports a 13.1 months mean survival time with 11.1 months mean time at home after surgery. In our own material of 67 fully documented cases between 1996 and 2001 the mean survival after surgery was 14.2 months (unpublished data). Tomita et al.  published recently survival times that were longer in cases in which wide or marginal excision was made (38.2 months), with only 7% local tumor recurrence, and the survival time in patients treated with intralesional excision was 21.5 months and 31% local tumor recurrence whereas only in patients with palliative surgery and stabilization the survival was 10.1 months and the local tumor recurrence 28%. They based their surgical decision making on a new prognostic scoring system. Sundaresan et al.  reported a mean survival time of 30 months in patients with surgery for solitary metastases of the spine and with a survival of 5 years and more in 18% of their cases. Mazel et al.  achieved a mean survival rate of 16.7 months in 21 of 35 patients who died and 38.2 months in 14 of 35 patients who were alive at follow-up with a so-called radical excision of tumors of thoracic and cervicothoracic metastases.
These results also suggest a concept of differentiated surgery with more radical options than just palliative surgery. The neurological outcome is crucial and depends on the initial neurological deficit before surgery. About one-half of the paraparetic patients at the time of diagnosis regain the ability to walk, but only fewer than 5% of patients, who are paraplegic regain ambulation . Postoperative complications are frequent and are found in 15 -30% of cases [55, 56].
Wai et al.  assessed prospectively the overall quality of life after surgical management of metastatic spine disease, using a validated global health status quality-of-life instrument (Edmonton Symptoms Assessment Scale). They found the greatest improvement in the domain of pain reduction, but there was also improvement in other domains of quality of life. The clinical results of nonsur-gical treatment for spinal metastases has been presented in a prospective analysis of 101 patients who were treated with radiation therapy and/or chemotherapy. Of these, 66% remained neurologically stable or improved after treatment; 67% had pain relief, and 64% improved functionally, which was more related to the general debility than local tumor recurrence . Unfortunately no prospective study has compared nonsurgical and surgical treatment of spinal metastases with clearly defined conditions and parameters to allow a differentiated decision about the best solution for the patient. It has also been considered that such a study may be extremely difficult to execute also for ethical reasons.
This leaves us with the necessity to assess every patient individually and to weigh the different elements in shared decision making of an interdisciplinary team together with the patient. It is a complex algorithm tailored to the patient's individual problem and therapeutic options available (Fig. 6). It cannot be emphasized enough that a decision for a conservative treatment, specifically with irradiation, should not be taken unless there is a clear understanding that a later surgical option is very improbable. There is no doubt that preoperative irradiation has a significantly negative effect on surgical outcome .
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