State of the art treatment of spinal metastatic disease

Abstract

Treatment paradigms for patients with spine metastases have evolved signifcantly overthe past decade. Incorporating stereotactic radiosurgery into these paradigms has beenparticularly transformative, offering precise delivery of tumoricidal radiation doses withsparing of adjacent tissues. Evidence supports the safety and efcacy of radiosurgeryas it currently offers durable local tumor control with low complication rates even fortumors previously considered radioresistant to conventional radiation. The role for surgicalintervention remains consistent, but a trend has been observed toward less aggressive,often minimally invasive, techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity. Additionally,targeted agents such as biologics and checkpoint inhibitors have revolutionized cancercare, improving both local control and patient survivals. These advances have broughtforth a need for new prognostication tools and a more critical review of long-termoutcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists, and pain specialists. This review recapitulates the current state-of-the-art,evidence-based data on the treatment of spinal metastases, integrating these data into adecision framework, NOMS, which integrates the 4 sentinel decision points in metastaticspine tumors: Neurologic, Oncologic, Mechanical stability, and Systemic disease andmedical co-morbidities.