Javascript not enabled
OncologyFocus On...

The surgical management of metastatic spinal cord compression

I. Siddique, A. J. Stirling
PDF icon FocusOn_oct10_03.pdf801.4 KB


Metastatic spinal cord compression (MSCC) is defined as the compression of the dural sac and its contents by an extradural tumour mass.1  Improved oncological outcomes2 have resulted in more frequent presentation of MSCC.3 Autopsy data demonstrate spinal metastases in 70% of the commonest cancers and an the incidence of symptomatic MSCC in up to 10%.4  Successful treatment achieves maintenance or recovery of spinal cord function, pain control, spinal stability, improved quality of life and is cost-effective.


Until the 1980s posterior decompressive laminectomy was the usual surgical option.  Cohort studies subsequently demonstrated that laminectomy has no advantage over radiotherapy in terms of neurological function or pain control, with the additional risks of wound breakdown, infection and instability.5,6  Therefore radiotherapy became the mainstay of treatment until the mid 1980s when improved outcomes with anterior decompression were reported.7  Recent technological advances and improved evidence in the form of a meta-analysis8 and randomised controlled trial9 have strengthened surgery’s role.  Spinal decompression and stabilisation have been shown to restore or maintain ambulation, provide pain relief, improve quality of life10,11 and survival.12-15

Role of surgery

Current guidelines suggest that surgery is considered for in patients with a prognosis exceeding a life expectancy of more than three months16.  This estimate is typically made by oncologists and is dependant primarily on the tumour type and staging.  Given that the reported surgical complication rate is between 20% and 30%,17,18 risks must be carefully balanced against the potential benefits when deciding the preferred treatment in order to maximise the quality of remaining life.

Indications for surgery

Spinal surgery is undertaken, where possible, before the development of spinal cord compression in those with a life expectancy, tumour type and physiological status favouring surgical intervention over conservative treatment.  In these patients the indications for surgery are;

  1. Mechanical. Instability is typically manifest as mechanical axial pain exacerbated by movement, standing, and walking.  Computed tomography is the best imaging modality to assess bone quality, the risk of fracture and potential or actual collapse requiring stabilisation.
  2. Neurological.  Impending or actual cord compromise.  Magnetic resonance imaging will normally demonstrate neural compression whether or not there is an associated neurological deficit.
  3. Palliative.  Pain not responding to conservative measures.
  4. Oncological.  Patients with an apparently truly solitary metastasis in whom curative strategies may occasionally be indicated. Usually this is only considered for renal cell and thyroid carcinomas.

Indications for radiotherapy

Radiotherapy is indicated in patients who are not surgical candidates.  In surgical candidates pre-operative radiotherapy carries the risk of wound infection and breakdown19,20 but has an important role after operation.  Given the exquisite radio-sensitivity of haematological malignancies such as lymphoma and multiple myeloma, treatment with conventional external beam radiation can be employed as first-line treatment, providing the spine is stable. 

Classification and scoring

Prognostic scoring systems such as that suggested by Tokuhashi, Ajiro and Umezawa21 can help in deciding the appropriateness of scale and type of surgery.  Factors include performance status, histological type, neurological deficit and the number of bone, vertebral and visceral metastases.  Evaluation and summation of these factors can help to predict survival and plan a surgical strategy. Strategies range from palliative posterior decompression and stabilisation for those with a prognosis of less than one year to resection and reconstruction of the vertebral column through anterior, posterior or combined approaches for those with a prognosis longer than this.

Role of spinal angiography and embolisation

Spinal angiography may be indicated to facilitate surgery through embolisation of hypervascular tumours (particularly those of renal or thyroid origin) through either transarterial or transcutaneous routes using particles, coils, polyvinyl alcohol (PVA) or Gelfoam (Pfizer Inc., New York).  Retrospective comparative studies have shown a reduction in subsequent intra-operative blood loss by over 50%,17,22-24 with surgery ideally being performed within a few days (embolised vessels eventually recanalise).   Embolisation, particularly of cervical tumours, carries a small risk (1.4%) of permanent neurological complications.

Surgical strategies for thoracolumbar metastases

Of symptomatic metastases, 80% to 90% involve the thoracolumbar spine.  Axial pain is the most common symptom.25  The surgical approach depends on the level and anatomical distribution of the disease.  In the upper thoracic spine (T2 to T5) posterior transpedicular or posterolateral approaches (costotransversectomy) are often used because of the anatomical difficulties of anterior access at this level.  For lesions between T6 and L5 anterior, posterior or combined procedures can be employed depending on the surgeon’s preference, prognosis, relevant comorbidities and tumour topography (distribution of disease within the spine overall as well as the individual vertebra).  There is some evidence that an anterior approach is preferable in terms of minimising blood loss and wound-related complications while allowing a durable reconstruction of the anterior column (Fig. 1).26 Wound infection and healing problems have an incidence of between 2.4% and 19% for posterior approaches, 1% and 5% for anterior approaches and 11% and 25% for combined approaches.26


Figure 1. Plain radiographs of a metastasis in the L4 vertebral body treated with a combined anterior and posterior reconstruction, nine years earlier.


Surgical strategies for cervical metastases

The cervical spine is involved in 8% to 20%.27  Lesions at the occipitocervical junction (C0 to C2) are less likely to cause neurological compromise because of the greater canal capacity at this level, although they may require stabilisation with posterior instrumentation.28 In the absence of instability radiotherapy is recommended.

The subaxial cervical spine (C3 to C6) is the predominant region affected; the recommended surgical approach is anterior corpectomy and reconstruction (Fig. 2).  Combined anterior-posterior surgery is employed for circumferential disease or multi-level involvement.29  At the cervicothoracic junction (C7 to T2) there is greater risk of neurological deficit because of any kyphosis, a smaller spinal canal and a poorer local blood supply.  Modern cervicothoracic posterior instrumentation techniques have improved biomechanically and may suffice, without the complexity of  anterior-posterior and posterolateral approaches.28


Figure 2. MR and plain radiographs of a C5 metastasis treated with an anterior cervical cage and plate reconstruction.

Courtesy of Mr M.F. Grainger, Royal Orthopaedic Hospital, Birmingham


Role of vertebroplasty and kyphoplasty

Vertebroplasty and kyphoplasty are among the most commonly used treatments for axial mechanical pain secondary to vertebral osteolysis or compression fractures.  Prospective studies have demonstrated effective pain relief and satisfactory functional outcomes.30-36  Vertebroplasty involves the injection of radiopaque polymethylmethacrylate cement under fluoroscopic control and kyphoplasty involves balloon insufflation inside the vertebra followed by balloon removal and cement injection.  The cement stabilises the vertebral body37 and also has an anti-tumour effect through cytotoxic activity38 and thermal necrosis.39  The advantage of improved sagittal alignment in patients undergoing kyphoplasty appears short-lived.36,40  However, kyphoplasty does appear to have a lower incidence of symptomatic cement extravasation (up to 13.5% with vertebroplasty).41  Contraindications to vertebroplasty or kyphoplasty include a retropulsed bone fragment or epidural tumour causing myelopathy, coagulopathy and allergy to either the bone cement or opacification agent.42

The combination of vertebroplasty/kyphoplasty and posterior spinal instrumentation in the form of a “hybrid construct” (Fig. 3) has the advantage of providing anterior structural support and restoring the posterior tension-band with a posterior surgical approach and a shorter posterior construct.


Figure 3. Plain radiographs of two-level metastases treated with a ‘hybrid’ construct; posterior instrumentation with anterior column augmentation using vertebroplasty.


Surgical management of a solitary spinal renal metastasis

The potentially curative outcome of en bloc tumour resection for a solitary renal cell carcinoma metastasis is well known.  En bloc resection involves surgical removal of the tumour in a single piece, fully encased in a layer of healthy tissue. In the spine this is often not feasible given the distribution of disease, the need to preserve neurological function and the scale of procedure necessary for restoration of spinal stability.  The recurrence rate after en bloc resection of a solitary renal metastasis in the published literature is 13% across six publications (2/15 patients).43-48  Boriani presented unpublished data in 25 patients undergoing en bloc resection, demonstrating 4% recurrence at 30 months, compared with 24% in 42 patients undergoing intralesional gross resection.  Whether en bloc resection actually alters survival rates is unknown.

Organisation and provision of service

In order to efficiently and effectively diagnose, treat and provide appropriate overall care for patients with MSCC there are a number of requirements. Patients and their carers (including medical staff) need improved education about the possibility of MSCC and who to contact if concerned . In each cancer network and every hospital there need to be clear pathways for referral and investigation. A lead coordinator (MSCC co-ordinator) provides a reliable point of contact, triage, advice on immediate spinal care and access to defined availability of urgent magnetic resonance imaging. Co-ordinators should liaise with defined senior professional advisers (oncologists, spinal surgeons and, when necessary, radiologists) to achieve timely decision-making about definitive management16 and its timing.


The primary aims of surgery in the treatment of metastatic spinal cord compression are to preserve or recover neurological function, treat spinal instability and provide pain relief with the aim of maintaining functional independence and quality of life.  This can be effectively achieved through a variety of surgical approaches that are dependent on physiological status, clinical symptomatology, life expectancy, primary diagnosis and tumour topography. Improved oncological control of  the primary disease means many patients are now living for years with their disease, thereby making  more durable spinal reconstruction a more frequent  and justifiable consideration.



1. Loblaw DA, Laperriere NJ, Mackillop WJ. A population-based study of malignant spinal cord compression in Ontario. Clin Oncol  2003;15:211-17.

2. Brenner H, Gondos A, Arndt V. Recent major progress in long-term cancer patient survival disclosed by modeled period analysis. J Clin Oncol 2007;25:3274-80.

3. Hatrick NC, Lucas JD, Timothy AR, Smith MA. The surgical treatment of metastatic disease of the spine. Radiother Oncol 2000;56:335-9.

4. Ibrahim A, Crockard A, Antonietti P, Boriani S, Bunger C, Gasbarrini A, Grejs A, Harms J, Kawahara N, Mazel C, Melcher R, Tomita K. Does spinal surgery improve the quality of life for those with extradural (spinal) osseous metastases? An international multicenter prospective observational study of 223 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2007. J Neurosurg Spine 2008;8:271-8.

5. Sorensen S, Borgesen SE, Rohde K, Rasmusson B, Bach F, Boge-Rasmussen T, Stjernholm P, Larsen BH, Agerlin N, Gjerris F, et al. Metastatic epidural spinal cord compression. Results of treatment and survival. Cancer 1990;65:1502-8.

6. Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg 1980;53:741-8.

7. Harrington KD. The use of methylmethacrylate for vertebral-body replacement and anterior stabilization of pathological fracture-dislocations of the spine due to metastatic malignant disease. J Bone Joint Surg [Am] 1981;63-A:36-46.

8. Klimo P, Jr., Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neuro Oncol 2005;7:64-76.

9. Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, Mohiuddin M, Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005;366:643-8.

10. Falicov A, Fisher CG, Sparkes J, Boyd MC, Wing PC, Dvorak MF. Impact of surgical intervention on quality of life in patients with spinal metastases. Spine  2006;31:2849-56.

11. Wai EK, Finkelstein JA, Tangente RP, Holden L, Chow E, Ford M, Yee A. Quality of life in surgical treatment of metastatic spine disease. Spine 2003;28:508-12.

12. Bauer HC. Posterior decompression and stabilization for spinal metastases. Analysis of sixty-seven consecutive patients. J Bone Joint Surg [Am] 1997;79-A:514-22.

13. Helweg-Larsen S. Clinical outcome in metastatic spinal cord compression. A prospective study of 153 patients. Acta Neurol Scand 1996;94:269-75.

14. Klekamp J, Samii H. Surgical results for spinal metastases. Acta Neurochir (Wien) 1998;140:957-67.

15. Rompe JD, Hopf CG, Eysel P. Outcome after palliative posterior surgery for metastatic disease of the spine--evaluation of 106 consecutive patients after decompression and stabilisation with the Cotrel-Dubousset instrumentation. Arch Orthop Trauma Surg 1999;119:394-400.

16. Metastatic spinal cord compression.  Diagnosis and management of adults at risk of and with metstatic spinal cord compression. NICE Guidelines CG75: TJ International Ltd, Cardiff, UK, 2008.

17. Sundaresan N, Choi IS, Hughes JE, Sachdev VP, Berenstein A. Treatment of spinal metastases from kidney cancer by presurgical embolization and resection. J Neurosurg 1990;73:548-54.

18. Cooper PR, Errico TJ, Martin R, Crawford B, DiBartolo T. A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine. Neurosurgery 1993;32:1-8.

19. Pascal-Moussellard H, Broc G, Pointillart V, Simeon F, Vital JM, Senegas J. Complications of vertebral metastasis surgery. Eur Spine J 1998;7:438-44.

20. Rompe JD, Eysel P, Hopf C, Heine J. Decompression/stabilization of the metastatic spine. Cotrel-Dubousset-Instrumentation in 50 patients. Acta Orthop Scand 1993;64:3-8.

21. Tokuhashi Y, Ajiro Y, Umezawa N. Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis. Spine 2009;34:69-73.

22. Berkefeld J, Scale D, Kirchner J, Heinrich T, Kollath J. Hypervascular spinal tumors: influence of the embolization technique on perioperative hemorrhage. AJNR Am J Neuroradiol 1999;20:757-63.

23. Manke C, Bretschneider T, Lenhart M, Strotzer M, Neumann C, Gmeinwieser J, Feuerbach S. Spinal metastases from renal cell carcinoma: effect of preoperative particle embolization on intraoperative blood loss. AJNR Am J Neuroradiol 2001;22:997-1003.

24. Wirbel RJ, Roth R, Schulte M, Kramann B, Mutschler W. Preoperative embolization in spinal and pelvic metastases. J Orthop Sci 2005;10:253-7.

25. Holman PJ, Suki D, McCutcheon I, Wolinsky JP, Rhines LD, Gokaslan ZL. Surgical management of metastatic disease of the lumbar spine: experience with 139 patients. J Neurosurg Spine 2005;2:550-63.

26. Polly DW, Jr., Chou D, Sembrano JN, Ledonio CG, Tomita K. An analysis of decision making and treatment in thoracolumbar metastases. Spine 2009;34(Suppl):S118-27.

27. Jenis LG, Dunn EJ, An HS. Metastatic disease of the cervical spine. A review. Clin Orthop 1999-359:89-103.

28. Fehlings MG, David KS, Vialle L, Vialle E, Setzer M, Vrionis FD. Decision making in the surgical treatment of cervical spine metastases. Spine 2009;34(Suppl):S108-17.

29. Jonsson B, Jonsson H, Jr., Karlstrom G, Sjostrom L. Surgery of cervical spine metastases: a retrospective study. Eur Spine J 1994;3:76-83.

30. Cahana A, Seium Y, Diby M, Martin JB, Ruefenacht D, Dietrich PY. Percutaneous vertebroplasty in octogenarians: results and follow-up. Pain Pract 2005;5:316-23.

31. Anselmetti GC, Zoarski G, Manca A, Masala S, Eminefendic H, Russo F, Regge D. Percutaneous vertebroplasty and bone cement leakage: clinical experience with a new high-viscosity bone cement and delivery system for vertebral augmentation in benign and malignant compression fractures. Cardiovasc Intervent Radiol 2008;31:937-47.

32. Cotten A, Dewatre F, Cortet B, Assaker R, Leblond D, Duquesnoy B, Chastanet P, Clarisse J. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up. Radiology 1996;200:525-30.

33. Cortet B, Cotten A, Boutry N, Dewatre F, Flipo RM, Duquesnoy B, Chastanet P, Delcambre B. Percutaneous vertebroplasty in patients with osteolytic metastases or multiple myeloma. Rev Rhum Engl Ed 1997;64:177-83.

34. Khanna AJ, Reinhardt MK, Togawa D, Lieberman IH. Functional outcomes of kyphoplasty for the treatment of osteoporotic and osteolytic vertebral compression fractures. Osteoporos Int 2006;17:817-26.

35. Gerszten PC, Germanwala A, Burton SA, Welch WC, Ozhasoglu C, Vogel WJ. Combination kyphoplasty and spinal radiosurgery: a new treatment paradigm for pathological fractures. J Neurosurg Spine 2005;3:296-301.

36. Pflugmacher R, Kandziora F, Schroeder RJ, Melcher I, Haas NP, Klostermann CK. Percutaneous balloon kyphoplasty in the treatment of pathological vertebral body fracture and deformity in multiple myeloma: a one-year follow-up. Acta Radiol 2006;47:369-76.

37. Jensen ME, Kallmes DE. Percutaneous vertebroplasty in the treatment of malignant spine disease. Cancer J 2002;8:194-206.

38. Dahl OE, Garvik LJ, Lyberg T. Toxic effects of methylmethacrylate monomer on leukocytes and endothelial cells in vitro. Acta Orthop Scand 1994;65:147-53.

39. Deramond H, Wright NT, Belkoff SM. Temperature elevation caused by bone cement polymerization during vertebroplasty. Bone 1999;25(Suppl):17S-21S.

40. Pflugmacher R, Taylor R, Agarwal A, Melcher I, Disch A, Haas NP, Klostermann C. Balloon kyphoplasty in the treatment of metastatic disease of the spine: a 2-year prospective evaluation. Eur Spine J 2008;17:1042-8.

41. Mendel E, Bourekas E, Gerszten P, Golan JD. Percutaneous techniques in the treatment of spine tumors: what are the diagnostic and therapeutic indications and outcomes? Spine 2009;34 Suppl:S93-100.

42. McGraw JK, Cardella J, Barr JD, Mathis JM, Sanchez O, Schwartzberg MS, Swan TL, Sacks D. Society of Interventional Radiology quality improvement guidelines for percutaneous vertebroplasty. J Vasc Interv Radiol 2003;14 Pt 2:S311-15.

43. Abe E, Kobayashi T, Murai H, Suzuki T, Chiba M, Okuyama K. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord 2001;14:237-46.

44. Liljenqvist U, Lerner T, Halm H, Buerger H, Gosheger G, Winkelmann W. En bloc spondylectomy in malignant tumors of the spine. Eur Spine J 2008;17:600-9.

45. Melcher I, Disch AC, Khodadadyan-Klostermann C, Tohtz S, Smolny M, Stockle U, Haas NP, Schaser KD. Primary malignant bone tumors and solitary metastases of the thoracolumbar spine: results by management with total en bloc spondylectomy. Eur Spine J 2007;16:1193-202.

46. Sakaura H, Hosono N, Mukai Y, Ishii T, Yonenobu K, Yoshikawa H. Outcome of total en bloc spondylectomy for solitary metastasis of the thoracolumbar spine. J Spinal Disord Tech 2004;17:297-300.

47. Stener B. Complete removal of vertebrae for extirpation of tumors. A 20-year experience. Clin Orthop 1989;245:72-82.

48. Tomita T, Galicich JH, Sundaresan N. Radiation therapy for spinal epidural metastases with complete block. Acta Radiol Oncol 1983;22:135-43.