REVIEW

VERTEBRAL COLUMN METASTASES

Diagnosis and Treatment of Vertebral Column Metastases

ROBERT D. ECKER, MD; TOSHIKI ENDO, MD; NICHOLAS M. WETJEN, MD; AND WILLIAM E. KRAUSS, MD

The vertebral column is recognized as the most common site for the vertebral column malignancies.7 Among patients with
bony metastases in patients with systemic malignancy. Patients
with metastatic spinal tumors may present with pain, neurologic cancer, 12% to 20% present initially with spinal column
deficit, or both. Some tumors are asymptomatic and are detected metastases.8,9
during screening examinations. Treatment options include medi-
cal therapy, surgery, and radiation. However, diversity of patient
condition, tumor pathology, and anatomical extent of disease ANATOMICAL LOCALIZATION
complicate broad generalizations for treatment. Historically, sur-
gery was considered the most appropriate initial therapy in pa- AND PATHOPHYSIOLOGY
tients with spinal metastasis with the goal of eradication of gross
disease. However, such an aggressive approach has not been Spinal metastases can occur in 3 locations: extradural,
practical for many patients. Now, operative intervention is often intradural extramedullary (IDEM), and intramedullary
palliative, with pain control and maintenance of function and (IM). More than 98% of spinal metastases are extradural
stability the major goals. Surgery is reserved for neurologic com-
promise, radiation failure, spinal instability, or uncertain diagno- because the dura mater provides a relative barrier for
sis. Recent literature has revealed that surgical outcomes have metastatic disease; IDEM and IM disease account for less
improved with advances in surgical technique, including refine- than 1% of spinal metastatic disease.6,10 Both IDEM and
ment of anterior, lateral, posterolateral, and various approaches
to the anterior spine, where most metastatic disease is located. IM disease most commonly originate from drop me-
We review these surgical approaches for which a team of sur- tastases in the setting of patients with either primary or
geons often is needed, including neurosurgeons and orthopedic, metastatic brain disease. This review focuses on extradu-
general, vascular, and thoracic surgeons. Overall, a multimodality
approach is useful in caring for these patients. It is important that ral metastases.
clinicians are aware of the various therapeutic options and their Paralleling vertebral body size, metastases occur most
indications. The optimal treatment of individual patients with frequently in the lumbar spine followed by the thoracic and
spinal metastases should include consideration of their neurologic
status, anatomical extent of disease, general health, age, and then the cervical spine.11 However, thoracic lesions (70%)
quality of life. are most often symptomatic due to the smaller space avail-
Mayo Clin Proc. 2005;80(9):1177-1186 able for the spinal cord in this region, followed by lumbar
(20%) and cervical (10%) lesions.4,12 Eighty percent of
BS = bone scan; CSF = cerebrospinal fluid; CT = computed tomography; spinal metastases involve vertebral bodies rather than pos-
IDEM = intradural extramedullary; IM = intramedullary; MRI = magnetic
resonance imaging; PET = positron emission tomography; SPECT = terior vertebral elements.13 Extradural metastases are be-
single-photon emission CT lieved to occur through 3 mechanisms: (1) direct local
extension into the extradural space, (2) retrograde spread
through the valveless extradural venous channels of the

T he vertebral column is the most common site for bony

metastases, with an incidence of 30% to 70% in pa-
tients with metastatic neoplasms.1-3 Furthermore, metas-
spine (Batson plexus), and (3) arterial emboli with subse-
quent spread through cortical veins.14,15

tases are the most frequent spinal column tumor in the

PRESENTATION
United States, with approximately 18,000 new cases diag-
nosed annually.4 Breast, lung, prostate, and kidney cancers The presentation of bony metastases includes bony pain,
have been the most common malignancies with secondary pathologic fracture, radiculopathy, myelopathy, and pro-
spine involvement.5,6 However, in a postmortem series of gressive deformity. Spinal cord compression can occur
842 consecutive autopsies of patients with known meta- from fracture, tumor invasion, or progressive osteoblastic
static malignancy, lung cancer, breast cancer, lympho- remodeling.16 Among patients with spinal cord compres-
reticular malignancies, and myeloma accounted for 65% of sion, 90% present with pain and 47% present with neuro-
logic symptoms.17-19 Symptomatic spinal cord compression
From the Department of Neurologic Surgery, Mayo Clinic College of Medicine, occurs in 8.5% to 20% of patients with vertebral column
Rochester, Minn. Dr Ecker is now with the University at Buffalo Neurosurgery Inc, metastases.20,21 Radiculopathy secondary to posterior ele-
Buffalo, NY. Dr Endo is now with the Karolinska Hospital, Stockholm, Sweden.
ment involvement and subsequent nerve root impingement
Address reprint requests and correspondence to William E. Krauss, MD,
Department of Neurologic Surgery, Mayo Clinic College of Medicine, 200 First
also can occur. Only 11% to 34% of patients presenting
St SW, Rochester, MN 55905. with spinal cord compression are ambulatory at diagno-
© 2005 Mayo Foundation for Medical Education and Research sis.22 Sensory loss occurs in 70% to 80%, paraparesis or

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VERTEBRAL COLUMN METASTASES

TABLE 1. Brice and McKissock Classification of metastases. However, vertebral body collapse can be
Grade associated with nonneoplastic lesions in up to 22% of
I Mild weakness, but able to walk cases.3 To be visible on plain radiography, 30% to 40% of
II Moderate weakness, able to move legs but not against gravity the bone must be eroded; therefore, lesions can be missed
III Severe weakness, slight residual motor and sensory function on plain radiography alone.16 However, about 90% of pa-
IV No motor, sensory, or sphincter function below the lesion
tients with symptomatic disease have abnormal findings on
plain radiography.18,28
Contrast-enhanced MRI of the entire spinal axis is the
paraplegia in more than 60%, and bowel and/or bladder current standard for the diagnosis and evaluation of spinal
difficulty in 14% to 77%.23 Simple neurologic grading column metastases.29-31 Misleading sensory levels in up to
scales similar to that of Brice and McKissock24 or the 26% of patients, multiple levels of asymptomatic disease,
Karnofsky scale25 allow clinicians to communicate clearly and the large amount of bone destruction necessary to
and to assess clinical outcome (Table 1). visualize metastases on plain radiography necessitate lib-
eral use of MRI, often of the complete spinal axis.29 With
its superior delineation of soft tissue, MRI provides unpar-
DIAGNOSIS
alleled imaging of paraspinal and epidural masses, multi-
Initial evaluation should begin with a detailed medical level distortion of cerebrospinal fluid (CSF) spaces, and
history, clinical examination, and directed laboratory tests. occult metastases. However, MRI is second to CT in imag-
Preoperative assessment and documentation of bowel/ ing of the bony anatomy of the spine.
bladder function, motor weakness, and sensory deficits are Tailored CT with sagittal, coronal, and 3-dimensional
critical to postoperative outcome assessment. Determina- reconstruction provides excellent detail of the bony
tion of general health and nutritional status is essential in anatomy of the spine, essential to both preoperative and
the preoperative assessment of the patient with cancer be- intraoperative surgical planning and postoperative evalua-
cause both affect healing and infection risk. Laboratory tions.32-35 Also, CT angiography can visualize the vertebral
studies should include the following: complete blood cell arteries in the foramen transversarium and as they enter the
count, creatinine, electrolytes, liver function, albumin, cranium, which assists surgical decision making and pa-
prealbumin, amylase, lipase, and coagulation. Electrolyte tient safety.36,37 The patient avoids the risk of conventional
imbalance, coagulopathy, and neutropenia should be cor- angiography. The angulation, rotation, and overall instabil-
rected. Nutritional optimization should be pursued in pa- ity of a fracture; the extent of erosion of the vertebral body,
tients with malnutrition. Ultrasonography and computed pedicles, and posterior elements; and the degree of osteo-
tomography (CT) of both the abdomen and chest may be blastic canal compromise are well visualized on CT.
helpful for localizing primary neoplasms. Other imaging modalities include radionuclide BS,
The imaging armamentarium available to the clinician SPECT, and PET, which are available at multiple institu-
includes plain radiography, CT, magnetic resonance imag- tions. Although BS is the oldest technique, almost 50% of
ing (MRI), myelography, radionuclide bone scan (BS), its results are false-negative for bone metastases.38 Also,
single-photon emission CT (SPECT), and positron emis- BS does not accurately distinguish between pathologic and
sion tomography (PET). In the setting of complete sub- nonpathologic fractures. A recent comparison of BS,
arachnoid block, myelography may increase the risk of SPECT, and PET with fluorodeoxyglucose F 18 found that
neurologic deterioration. Therefore, it is used most often in PET with fluorodeoxyglucose F 18 was as accurate as
patients who cannot undergo MRI because of implanted MRI.38 However, because of limited availability and re-
devices or foreign bodies. More than 85% of patients have sources, SPECT and PET are not part of the standard
multiple-level involvement if results from MRI, CT, plain evaluation.
radiography, and surgery are pooled.12 Plain radiography, Either needle or open biopsy can be used to obtain tissue
CT, and MRI comprise the core imaging modalities for for diagnosis. With serial lumbar taps, CSF cytology re-
patients with vertebral metastases. sults are positive in up to 90% of patients with lepto-
Plain radiography is useful and should be obtained for meningeal carcinomatosis.39 In patients with an unknown
most patients. Common findings on plain radiography in- primary neoplasm, CT-guided needle biopsy is a safe and
clude vertebral body collapse, pedicle erosion, osteoblastic easily performed procedure with a 70% to 95% chance of
and osteolytic lesions, and pathologic fracture-disloca- yielding a pathologic diagnosis.40-43 In patients with com-
tion.26,27 The disk margins usually are spared in contrast to pressive and/or unstable lesions, progressive neurologic
marked disk destruction seen in infectious processes. Bone deficit, and nondiagnostic needle biopsies, open biopsy or
destruction and substantial sclerosis are reliable indicators surgical excision usually is needed. Preoperative angiogra-

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 VERTEBRAL COLUMN METASTASES

phy with embolization especially for vascular tumors, such either to start with 10 mg of dexamethasone and then taper
as renal cell carcinoma, can reduce blood loss by 50% or to 4 mg 4 times daily, or to use the spinal cord injury
more in selected patients.44 protocol of a 30 mg/kg bolus followed by 5.4 mg/kg of
methylprednisolone for 23 hours before surgery.
Bisphosphonates are assuming a greater role in the treat-
TREATMENT OF SPINAL METASTASES
ment of bony metastatic disease in the spine and axial
Treatment options available for metastatic disease of the limbs. By preventing osteoclastic resorption of bone, these
spine include medical therapy, surgery, and radiation. Op- pharmaceuticals help with both cancer pain and prevention
erative intervention is most often palliative with pain con- of fracture. Their potential to delay bony metastatic disease
trol, maintenance of neurologic function, and spinal stabil- is intriguing.53 Patients with breast cancer, prostate cancer,
ity as primary goals. For years, many considered surgery and multiple myeloma all have shown benefit.54-56
the best initial therapy, with the goal of gross total resec-
tion. Realistically, such an aggressive approach requires en VERTEBRAL AUGMENTATION
bloc resection, which is not feasible in most patients. This In patients with painful metastases without epidural com-
is because spinal cord or vital neural elements commonly pression, minimally invasive surgical techniques are now
locate within the margin of the tumor. Laminectomy, the available to help alleviate their pain. Vertebroplasty, the
most common procedure, has a poor track record in recent injection of methylmethacrylate into the compression frac-
studies,45,46 in large part due to the usual location of spinal ture, and kyphoplasty, the injection of methylmethacrylate
metastatic disease in the anterior components of the spine, into a balloon inflated in the vertebral body, are performed
which is inaccessible via laminectomy. Subsequently, ra- increasingly in patients with epidural metastatic lesions
diation therapy has become the most common treatment, with good pain relief. Most of these procedures are per-
with surgery reserved for salvage or adjuvant therapy. With formed under biplane fluoroscopy; however, they can be
advances in surgical technique and surgical thinking in- used as intraoperative adjuvants to bolster fusions or to
cluding refinement of anterior and lateral approaches to the treat painful levels without epidural compression.
anterior spine, the location of most spine metastases, surgi- Kyphoplasty in selected patients can lead to restoration of
cal outcomes have improved. Patchell et al47 showed that vertebral body height. More than 80% of patients experience
patients with spinal cord compressions treated with radical significant pain relief, leading to greater mobilization.57,58
direct decompressive surgery plus postoperative radio- Major complications include extravasation of contrast into
therapy survived longer and regained the ability to walk the canal with nerve root or spinal cord compression and
more often than patients treated with radiation alone. With leakage of cement into large venous fistulas, leading to
these refinements, a team of surgeons including neuro- pulmonary embolus. The latter can be minimized with
surgeons and orthopedic, general, vascular, and thoracic preinjection venography and potentially plugging of the fis-
surgeons is often needed to access, decompress, and recon- tula with absorbable gelatin sponge. The overall complica-
struct the spine. In summary, treatment of individual pa- tion rate for both vertebroplasty and kyphoplasty is less than
tients with spinal metastases should include consideration 10%.57,58 Vertebra plana fractures and extensive epidural
of neurologic status, general health, age, anatomical extent compression are the main contraindications.
of disease, and the relative sensitivity of the tumor to
radiotherapy and chemotherapy. RADIATION
The mean postoperative survival of patients with symp- External beam radiation is an effective treatment for many
tomatic spinal metastases ranges from 10 to 16.5 months, patients with radiation-sensitive tumors including hemato-
according to previous studies.48-50 The patient’s life expec- poietic, prostate, and germ cell malignancies. In radiosensi-
tancy needs to be considered before such extensive surgery tive lesions, radiation therapy alone can be successful in
is performed. more than 80% of patients.17 Overall, with radiation, more
than 30% of patients experience neurologic improvement
CORTICOSTEROIDS AND BISPHOSPHONATES from epidural compression, and more than 60% gain sig-
Although the mechanism for improvement is not under- nificant pain relief.6,22 A typical dose is 30 Gy in 10 frac-
stood fully, intravenous or oral corticosteroid use often tions. Nausea, vomiting, and radiation-induced esophagitis
leads to improvement or resolution of neurologic symp- are common. Delayed radiation myelopathy can occur but
toms and pain in patients with epidural spinal metastases. is rare with modern treatment paradigms. Radiation
Decrease in reactive vasogenic edema in the spinal cord therapy usually is recommended postoperatively in patients
and nerve roots has been shown experimentally.51,52 There with radiosensitive tumors in whom gross or microscopic
is no standard dosage regimen. It has been our practice disease remains after surgery.

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VERTEBRAL COLUMN METASTASES

FIGURE 1. Positioning of the patient, skin incision line, and expo- FIGURE 3. Exposure of cervical spine via the anterior approach.
sure of the vertebral bodies with transection of the rib for the
posterolateral approach.

Stereotactic radiosurgery has substantially enhanced to treat spinal metastatic disease. The approach depends on
treatment of patients with intracranial metastases. New the location of the tumor and the surgical goal. Currently,
stereotactic systems have been designed that can target technical advances allow resection of tumors at all levels of
lesions in the body and spine. Pain relief and actual shrink- the spinal column (Figures 1-9). Options differ regarding
age of epidural tumors with improved neurologic function timing, surgical approach, and reconstruction.
have been documented in some series.59,60 Dosing plans and A major goal of surgery is to restore stability to the
appropriate patient selection are still not defined. spine. A widely used and easily applied clinical scale of
spinal stability is a 3-column concept proposed by Denis61
SURGICAL TREATMENT for assessing traumatic fractures. The anterior column in-
The need to access the spine to obtain a diagnosis, to cludes the anterior longitudinal ligament, anterior half of
decompress neural elements, or to stabilize and/or recon- the annulus, and anterior half of the vertebral body. The
struct the spine are indications for surgery. The goals of middle column includes the posterior half of the vertebral
surgery are to decrease pain, to preserve or to improve body, the posterior annulus, and the posterior longitudinal
neurologic function, and to mobilize the patient without ligament. The posterior column includes the posterior ele-
lifelong external orthosis. Many surgical strategies are used ments and ligaments. In general, disruption of 2 or more
columns will render the spine unstable. Even with this clear
categorization, determination of stability is not always
straightforward. Furthermore, there is no consensus regard-
ing what constitutes instability except in obvious cases of
fracture-dislocations, translational instability, or notable
kyphosis. Kostuik and Smith,62 Siegal and Siegal,63 and
Harms64 have all devised criteria to assess spinal stability
in patients with tumors of the spine. Five of the common
threads in these studies include (1) anterior and middle
column involvement or more than 50% collapse of verte-
bral body height, (2) middle and posterior column in-
volvement or shearing deformity, (3) 3-column involve-
ment, (4) involvement of the same column in 2 or more
adjacent vertebrae, and (5) iatrogenic, including laminec-
tomy to treat anterior or middle column disease and resec-
tion of more than 50% of the cut surface of the vertebral
body.
FIGURE 2. Surgical approach and skin incision line for the transoral- The spine is a load-sharing system with 80% to 90% of
transpalatopharyngeal approach. the axial load bearing absorbed by the vertebral bodies and

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 VERTEBRAL COLUMN METASTASES

FIGURE 4. A 63-year-old man, with a history of renal cell carcinoma 9 years previously, experienced
neck pain radiating into the bilateral upper limbs on the left side more than the right for 2 weeks. The
patient had weakness in the left C7 myotome. Preoperative computed tomogram (CT) (A) shows
destruction of the C7 vertebral body and left greater than right pedicles. Axial (B) and sagittal (C) T1-
weighted magnetic resonance images with contrast show abnormally enhanced tissue circumferentially
around the C7 vertebral body in epidural space and paravertebral soft tissues, centered at the left C7
foramen. Postoperative cervical CT with reconstruction (D) and plain radiograph (E) show anterior plating
and fibular strut graft placed after C6 and C7 corpectomy via the anterior approach. Surgical specimen
was consistent with metastatic renal cell carcinoma.

approximately 10% to 20% through the posterior joints. Emergency surgery is mandated in the setting of rapidly
Although most tumors involve the middle and anterior progressive or advanced paraplegia or tetraplegia. Severe
columns, anterior reconstruction alone may be insufficient and irreversible spinal cord injury will result without
for restoring torsional stability or tensile strength because prompt decompression of the thecal sac and nerve roots.
the pedicles and joint may be involved. After radical resec- Surgical decompression is not likely to reverse complete
tion of a metastatic spinal tumor, anterior constructs may paralysis with a duration greater than 24 hours.
be supplemented by posterior fixation. Several attempts have been made to identify clinical
Because most metastatic disease involves the vertebral prognosticators in cases of spinal metastatic disease.
bodies and pedicles, it seems that all patients would require Yamashita et al65 reported longer survival in patients with
anteroposterior fixation. However, clinical experience has spinal or pelvic lesions compared with those with appen-
found that such extensive surgery is often unnecessary. The dicular lesions or both. Tokuhashi et al66 proposed a scoring
rationale for surgery should be based not only on biome- system using 6 parameters to determine survival after sur-
chanical considerations but also on the expected goals of gery for metastatic spinal tumors: general condition, num-
therapy and the longevity of the patient. Extensive surgery is ber of vertebral metastases, number of metastases to in-
rarely justified in patients with limited survival. Elderly, ternal organs, number of metastases to extraspinal bone,
debilitated patients with impaired immune function, poor primary site, and severity of spinal cord injury. Each pa-
nutritional status, and low bone marrow reserve are at a rameter was given a score of 0 to 2. Although no individual
much higher risk of mortality and morbidity, regardless of parameter was predictive, summed scores correlated with
surgical approach. survival periods. Scores of 9 or higher were predictive of

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VERTEBRAL COLUMN METASTASES

compression, pain, and general systemic condition; thus, the

initial consideration of a patient for operative management
of spinal epidural disease should be multifactorial.
Posterior Approaches. Traditionally, decompressive
laminectomy has been used to relieve compression of the
spinal cord, cauda equina and nerve roots and is performed
easily in the cervical, thoracic, and lumbar spine. The
approach has undergone review and was revealed to be
beneficial in only 40% of patients.69,70 In studies comparing
combined radiotherapy and laminectomy with laminec-
tomy alone, authors found no significant difference in out-
come.71,72 In a large series, Bach et al73 reported improve-
ment rates of 46% in patients who underwent laminectomy,
35% in patients who underwent radiation, and 59% in
patients who underwent combined laminectomy and ra-
FIGURE 5. Positioning of the patient, skin incision line, and expo-
sure of the thoracic vertebral bodies for the anterior transthoracic
diation. Other large series have corroborated these data
approach. with improved outcomes from laminectomy alone ranging
from 38% to 50%.69,74 Schoeggl et al75 especially analyzed
bladder/bowel dysfunction in patients who underwent de-
survival of at least 12 months; scores of 5 or less were compressive laminectomy with partial or total tumor re-
predictive of survival of less than 3 months. The authors moval. Among their patients, 56% experienced bladder or
suggested that patients with scores of 9 or higher undergo bowel dysfunction preoperatively. In total, 18% of patients
surgery with the primary goal of excision, whereas for reported improvement postoperatively, although none who
those with scores of 5 or less, palliation is the goal. Other required preoperative catheterization showed improvement.
studies have corroborated the work of Yamashita et al but The mediocre outcomes of laminectomy are not surpris-
also have found that ambulatory status, age less than 60 ing because pure posterior lesions are uncommon and the
years, and single vertebral segment involvement were inde- procedure does not adequately decompress the ventral spi-
pendent predictors of good outcome.48,49,67,68 Weigel et al49 nal cord. The failure to individualize surgical approach
showed statistically significant correlation between the post- based on tumor location has contributed to the failure of
operative Karnofsky scale and duration of survival. Ambula- this traditional procedure.76 Major limitations of laminec-
tory status is influenced by multiple factors including neural tomy are inadequate access to the anterior aspect of the

FIGURE 6. A 67-year-old man with a history of hyperthyroidism and coronary artery disease presented with
sudden onset of interscapular back pain and gait disturbance. The patient had upper motor neuron type
weakness in bilateral lower limbs. A preoperative sagittal T2-weighted magnetic resonance image (A)
shows a T7 burst fracture associated with marked narrowing of the spinal canal (arrow); T7 corpectomy
through left thoracotomy was performed. Postoperative computed tomogram with sagittal reconstruction
(B) shows a titanium implant (Synex cage, Synthes, Inc, West Chester, Pa) in place. Postoperative plain
radiographs (C and D) show the posterior fusion from T2 through T12 performed in a second staged
operation. The pathology was metastatic renal cell carcinoma.

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 VERTEBRAL COLUMN METASTASES

spinal cord and loss of stability, which may play a role in

patients who are rapidly deteriorating neurologically and
have medical comorbidity or when there is strong suspicion
of a radiation-sensitive tumor. Through the same posterior
incision, a more lateral pediculectomy can be performed to
further decompress the spine and nerve roots with minimal
retraction on the spinal cord and nerve roots. This allows
better decompression of the anterior spinal elements than
laminectomy alone. Notable postlaminectomy kyphosis is
a potential complication in long-term survivors.
After decompression of the spinal cord and/or nerve
roots, resultant spinal instability requires instrumentation
and fusion for reconstruction of the spine. Hooks that at-
tach to the lamina, facet joints, or transverse processes and
pedicle screw systems are used for posterior instrumenta-
tion. As a general principle, posterior spinal instrumenta-
tion is attached to normal spinal elements above and below
the decompressed area to restore stability. The number of
levels and construct depend on the strength of the bone, the
FIGURE 7. Positioning of the patient, skin incision line, and expo-
quality of fixation, and the presence of additional me- sure of the vertebral bodies in the thoracolumbar junction.
tastases within the fusion segment. Although the addition
of posterior stabilization may improve pain relief and
maintain neurologic function compared with laminectomy The transoral-transpalatopharyngeal approach to the
alone, overall results are not ideal. craniocervical junction provides exposure to the ventrome-
Posterolateral Approaches. Posterolateral approaches dial spine from the midclivus to the C2-3 interspace.77-79
combine the simplicity of laminectomy with the ability to The tongue or palate may be split in combination with this
decompress the ventral aspect of the dural tube. These approach to gain more exposure (Figure 2).80,81
approaches are useful in patients with ventral disease and Another route to the upper cervical spine and clivus is
comorbidity that prevent transthoracic, transabdominal, or the lateral extrapharyngeal approach. This provides expo-
retroperitoneal approaches. Costotransversectomy with re- sure limited by the ramus of the mandible, parotid gland,
moval of 1 or more ribs is the only commonly performed hyoid bone, hypoglossal nerve, and carotid sheath.82-84
posterolateral approach. This approach involves removal A posterior approach provides access to the posterior
of the proximal rib and the transverse process to expose the foramen magnum and extends laterally to the jugular
posterolateral aspects of the spine (Figure 1). It provides bulb.85-88 It combines the standard dorsal midline incision
adequate access to the posterolateral spine while allowing with the lateral cerebellar approach and may include re-
concurrent posterior access. The anatomy of the upper and moval of the mastoid process and occipital condyle.
lower thoracic spine presents unique problems. These 3 approaches, described in detail by Menezes,79
In the upper thoracic spine, the scapula needs to be provide circumferential exposure of the upper cervical
mobilized, and the reversal of thoracic kyphosis can make spine and can be combined with the subtemporal, infratem-
resection of tumor and vertebral bodies difficult. At T11- poral fossa, preauricular, and postauricular exposures to
12, the diaphragm progressively limits the working space. access the cranial base.
Also, with posterolateral approaches, the working distance Cervical Spine. The subaxial cervical spine may be
can be extensive, making surgery difficult. approached anteriorly via a lateral retropharyngeal ap-
Anterior Approaches. Craniocervical Junction. The proach. This corridor is commonly used in degenerative
craniocervical junction encompasses the foramen magnum, and traumatic spinal disease. Usually, during an anterior
the C1 and C2 vertebrae, and the structures contained approach, corpectomy of the involved bone is performed.
within these bony landmarks including the vertebral arter- Autologous or allogeneic bone graft and other materials
ies, spinal cord, lower cranial nerves, and CSF spaces. such as titanium mesh cages, carbon fiber cages, poly-
Surgical decompression should be achieved from the same etheretherketone implants, and polymethylmethacrylate
vector as the compressive mass. If the tumor is compress- are used to replace the excised bone. An anterior plate is
ing the spinal cord anteriorly, an anterior or anterolateral used to complete the reconstruction. Exposure usually can
approach should be used. be gained from C2 to approximately the T3 level (Figures 3

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VERTEBRAL COLUMN METASTASES

jury in this exposure. Chest tube drainage is routine after

such surgery.
Thoracolumbar Junction. The thoracolumbar junction
provides a challenge to anterior spinal exposure. Opening
of the thorax and abdomen adds considerably to patient
morbidity. Similar to the anterior thoracic approach, the
patient is placed in the lateral decubitus position, and a
thoracotomy incision is made over the lower thoracic ribs.
The intrathoracic exposure is identical to that of the ante-
rior thoracic approach, but now the diaphragm is divided
to expose the upper 2 lumbar levels. This additional ex-
posure places the kidneys, ureters, spleen, sympathetic
trunk, and intra-abdominal contents at potential risk. All
patients should be expected to have an ileus postopera-
tively (Figure 7).
Lumbar Spine. Anterolateral retroperitoneal approaches
through variations of oblique incisions from the 12th rib to
the lower abdomen can be used to approach the upper
lumbar spine. However, these approaches, although less
FIGURE 8. Skin incision lines for various approaches including the
morbid for higher-risk patients, provide limited exposure
retroperitoneal and transperitoneal approaches to expose the upper for tumor resection and reconstruction compared with
lumbar spine. paramedian incisions around the rectus muscle. By using a
paramedian incision, both transperitoneal and retroperito-
neal exposures can be undertaken. Generally, we prefer the
and 4). The great vessels can be retracted for improved retroperitoneal approach because it provides greater pro-
inferior exposure and the brachiocephalic vein ligated as tection for the intra-abdominal contents. With a retroperito-
necessary. Posterior instrumentation should be considered neal approach, the intra-abdominal contents and the hypo-
at the cervicothoracic junction because there is a high risk gastric plexus can be mobilized as a unit. After exposure of
of junctional kyphosis. This is due to the transition from the the appropriate vertebral level, tumor resection and recon-
mobile cervical spine to the stiff thoracic spine. struction can begin (Figures 8 and 9).
Thoracic Spine. The use of anterior transthoracic expo- Complications of surgery include damage to the great
sures has paralleled improvements in anesthesia/critical vessels, ureters and intra-abdominal contents. Also, urogeni-
care and surgical techniques. These advances have substan- tal complications, such as retrograde ejaculation, due to
tially reduced the morbidity and mortality from thoracic sympathetic injury are well described.89 As with thoraco-
surgery. The midthoracic vertebral bodies are best exposed abdominal exposure, damage to the anterior spinal artery can
(Figures 5 and 6). High lesions including T3-4 are usually occur with anterior approaches. There are areas of limited
approached from the right as the aortic arch can limit left- blood supply to the anterior spinal cord at the upper and
sided visualization. However, T5-10 is generally ap- lower cervical and throughout the thoracic spine. The artery
proached from the left because the liver is difficult to of Adamkiewicz, the largest radiculomedullary artery sup-
mobilize. In an excellent case series of transthoracic verte- plying the inferior thoracic cord, generally branches from the
brectomy for metastatic spinal tumors, Gokaslan et al4 left side between T8 and L2. However, this complication has
reported that postoperatively, 17 of 33 ambulating but been described only in scoliosis surgery.90
weak patients (52%) regained normal strength, 10 of 13
nonambulatory patients (77%) could walk, and 60 of 65
CONCLUSIONS
patients (92%) experienced significant improvement in
pain. The 30-day mortality rate was 3% with a 1-year No prospective studies guide the modern treatment of spi-
survival of 62%. nal epidural metastases. It is difficult to generalize regard-
After tumor exposure and resection, usually a structural ing outcome with the diversity of surgical approaches,
allograft or a vertebral bony replacement device and a decompressive and reconstructive techniques, patient vari-
plate are used to replace the vertebrectomy-removed de- ables, and tumor pathology. However, it is clear from large
fect. The aorta, subclavian artery, esophagus, inferior vena modern series that more than 90% of well-selected patients
cava, thoracic duct, and azygous vein are all at risk of in- receive pain relief and that more than 50% experience

1184 Mayo Clin Proc. • September 2005;80(9):1177-1186 • www.mayoclinicproceedings.com

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
 VERTEBRAL COLUMN METASTASES

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