Separation surgery for metastatic epidural spinal cord compression: A qualitative review

Abstract

Introduction: The new concept of separation surgery has changed the surgical paradigms for the treatment of metastatic epidural spinal cord compression (MESCC), shifting from aggressive cytoreductive surgery towards less invasive surgery with the aim to achieve circumferential separation of the spinal cord and create a safe target for high dose Stereotactic Body Radiation Therapy (SBRT), which turned out to be the real game-changer for disease's local control.

Discussion: In this review a qualitative analysis of the English literature has been performed according to the rating of evidence, with the aim to underline the increasingly role of the concept of separation surgery in MESCC treatment. A review of the main steps in the evolution of both radiotherapy and surgery fields have been described, highlighting the important results deriving from their integration.

Conclusion: Compared with more aggressive surgical approaches, the concept of separation surgery together with the advancements of radiotherapy and the use of SBRT for the treatment of MESCC showed promising results in order to achieve a valuable local control while reducing surgical related morbidities and complications.

Keywords: CTV, Clinical tumor volume; Carbon fiber/PEEK cement; ECOG PS, Eastern Cooperative Oncology Group Performance Status Scale; ESCC, Epidural Spinal Cord Compression; Epidural spinal cord compression; GTV, Gross tumor volume; KPS, Karnofsky Performance Status; LC, Local Control; LITT, Laser Interstitial Thermal Therapy; MAS, Minimal Access Spine; MESCC, Metastatic Epidural Spinal Cord Compression; MIS techniques; MIS, Minimally Invasive Surgical; NSCLC, Non-Small Cell Lung Cancer; NSE, Neurologic Stability Epidural compression; PEEK, Polyetheretherketone; PLL, Posterior Longitudinal Ligament; PMMA, Poly-Methyl-Methacrylate; PRV, Spinal cord planning risk volume; PTV, Planning target volume; SBRT, Stereotactic Body Radiation Therapy; SINS, Spinal Instability Neoplastic Score; SRS, Stereotactic Radiosurgery; SS, Separation Surgery; Separation surgery; Spinal metastases; Stereotactic body radiation therapy; cEBRT, conventional External Beam Radiation Therapy.

Fig. 1

PRISMA Flow Chart.

Fig. 2

Short posterior carbon fiber instrumentation ad separation surgery (D, E) in a case of high grade ESCC (A), due to lytic lung metastatic lesion of T8 (B, C).

Fig. 3

Clinical case (A-G): A, B) Pre-operative CT scan showing T9 MESCC (Bilsky grade: 2, SINS score: 12) from lung cancer, C) Circumferential separation surgery was performed and D) intra-operative US assessing ventral separation of the spinal cord from the tumor is shown. E) Posterior carbon fiber instrumentation two level above and below the pathological vertebra. F) Post-operative CT myelography showing restored CSF space around the cord. G) Post-operative CT scan revealing screw instrumentation.