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Review
. 2025 Jan 17;30(1):oyae359.
doi: 10.1093/oncolo/oyae359.

Radiotherapy and surgery: can this combination be further optimized for patients with metastatic spine disease?

Jantijn J G J Amelink  1   2 , Bas J J Bindels  1 , Nicolien Kasperts  3 , Shannon M MacDonald  4 , Daniel G Tobert  2 , Jorrit-Jan Verlaan  1   3
Affiliations
Review

Radiotherapy and surgery: can this combination be further optimized for patients with metastatic spine disease?

Jantijn J G J Amelink et al. Oncologist. .

Abstract

This narrative review provides a comprehensive overview of the current status, recent advancements, and future directions in the management of metastatic spine disease using both radiotherapy and surgery. Emphasis has been put on the integrated use of radiotherapy and surgery, incorporating recent developments such as separation surgery, active dose sparing of the surgical field, and the implementation of carbon fiber-reinforced polymer implants. Future studies should explore the effects of minimizing the time between radiotherapy and surgery and investigate the potential of vertebral re-ossification after radiotherapy to obviate the need for stabilization surgery. Concerted efforts should be directed toward fostering multidisciplinary collaboration among radiation oncologists, spine surgeons, and medical oncologists.

Keywords: SBRT; interdisciplinary therapeutic approaches; radiotherapy; spinal metastases; surgery; systemic disease.

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Conflict of interest statement

Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted review. The authors declare the following financial affiliations: JJV is employed by and owns stock in SentryX B.V. a spin-off from the University Medical Center Utrecht developing implantable anesthetics. SMM received travel reimbursements from ICOTEC medical.

Figures

Figure 1.
Figure 1.
Schematic representation of the radiation situation without separation surgery and after separation surgery. Radiation of a spinal metastasis without separation surgery where the spinal cord is within the radiation field (left). Radiation of a spinal metastasis after separation surgery where a safe zone/margin between the tumor and spinal cord has been created using a spacer (right). Created with Biorender.com.
Figure 2.
Figure 2.
Visualization of preoperative and postoperative imaging using MRI with contrast before and after separation surgery with a Lyoplant spacer in situ; (1) transverse and sagittal images of a patient before separation surgery. (2) Transverse and sagittal images of a patient after separation surgery with implementation of Lyoplant spacer.
Figure 3.
Figure 3.
Different radiotherapy treatment plans for a single patient, demonstrating the impact of active dose-sparing of the surgical field in both preoperative and postoperative settings, using either conventional EBRT or SBRT. The (future) surgical field is outlined by the red line. The dark blue area receives 8 Gy, the turquoise area 12 Gy, the yellow area 16.2 Gy, the orange area 17.1 Gy, and the red area 20 Gy.
Figure 4.
Figure 4.
Visualization of postoperative imaging using radiograph, CT, and MRI after the implantation of a pedicle screw system with titanium or CFRP implants. Difference in postoperative radiologic visibility in two patients; (1) a patient treated with titanium implants (1A-1D), and (2) a patient treated with carbon fiber implants (2A-2D). (1A) Frontal and lateral radiograph after decompression of Th11 and open fixation of Th9-L1. (1B) Transverse and sagittal postoperative CT. (1C) Transverse and sagittal T1 postoperative MRI. (1D) Transverse and sagittal T2 postoperative MRI. (2A) Frontal and lateral radiograph after percutaneous fixation of T11-L1 with right-sided vertebral body stent augmentation of Th12. (2B) Transverse and sagittal postoperative CT. (2C) Transverse and sagittal T1 postoperative MRI. (2D) Transverse and sagittal T2 postoperative MRI.
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