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Surgery in Combination with Radiotherapy

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As mentioned previously, the optimal management of individuals with metastatic spine lesions remains an area of active research. Historically, the standard of care for symptomatic lesions consisted of early radiation therapy along with corticosteroids. In many individuals, this strategy reliably improves pain and prevents neurologic decline in the short term. However, some individuals have better overall prognosis while some lesions are resistant to radiotherapy. In these circumstances, surgical interventions are usually performed. Various groups have studied the efficacy of various treatment approaches. Table 9 summarizes some of the existing literature in this area which aims to determine the utility and cost-effectiveness of decompressive surgery along with varying radiotherapy regimens.
Table 10 Surgery in Combination with Radiotherapy for Compression from Metastatic Lesions
Table 11 Systematic Reviews Examining Surgery with Radiotherapy for Metastatic Lesions

Discussion

The overall aim of treatments for symptomatic spinal metastases is to relieve symptoms and, where possible, prevent further neurologic deficits. Three separate systematic reviews (Kim et al., 2012; Klimo et al., 2005; Lee et al., 2014) have summarized the evidence and provided support for surgery and radiotherapy over radiotherapy alone. Numerous studies have confirmed that younger individuals, those with better pre-morbid functional status, or individuals with radio-resistant tumors should be offered surgery to decompress and stabilize the spine. For example, Patchell et al. (2005) conducted an randomized controlled trial to study the benefit of early surgery in addition to radiotherapy. The trial was discontinued because of the significant benefits within the surgical group which included longer ambulation and improved survival at 3 and 6 months. A study by Furlan et al. (2012) found comparable cost-effectiveness between either approach.

Conclusion

There is level 1b evidence (from several studies) that radiotherapy and steroids, with or without surgery, improves pain from symptomatic metastatic spine compression. Additionally, for individuals younger than 65 years, the addition of surgical decompression to radiotherapy and steroids improves ambulation and survival. 

  • Radiotherapy and surgery for the management of symptomatic metastatic spine compression is effective; early surgical intervention to decompress the spine should be performed after considering tumor features and patient status.