The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 10

Instructional Course Lecture | May 16, 2012

Modern Techniques in the Treatment of Patients with Metastatic Spine Disease

Han Jo Kim, MD¹; Jacob M. Buchowski, MD, MS¹; Charbel D. Moussallem, MD¹; Peter S. Rose, MD¹

¹ Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63144. E-mail address for J.M. Buchowski: buchowskij@wustl.edu

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Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in March 2013 in Instructional Course Lectures, Volume 62. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

J Bone Joint Surg Am, 2012 May 16;94(10):943-951. doi: 10.2106/JBJS.L00192

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The surgical management of metastatic disease of the spine continues to evolve. For most of the recent three decades, radiation therapy provided the mainstay of treatment for patients with symptomatic metastatic disease of the spine. Surgical treatment during this era often involved dorsal spinal cord decompression with no or limited spinal instrumentation^1,2. These procedures generally provided only an indirect decompression of the spinal cord and often increased spinal instability. However, with advances in the understanding of metastatic processes in the spine and evolution of surgical techniques and instrumentation, surgical treatment plays a prominent role in the care of patients with metastatic epidural spinal cord compression. Studies have now yielded Level-I evidence on the efficacy of surgery for metastatic disease of the spine for improving quality of life and outcomes in patients with spinal metastasis. Concurrently, advances in radiation oncology now allow high-precision targeting of tumors and increased efficacy when treating radioresistant lesions³. These advances together have led to important advances in the treatment of metastatic disease of the spine.

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Introduction

Research findings continue to identify appropriate candidates for surgical intervention for metastatic spinal disease as well as to define optimal surgical and radiation therapy techniques. In considering treatment methods, it is essential to account for factors such as tumor type and/or biology, extent of disease, neurologic status, an individual patient's expectations, quality of life, and life expectancy. For example, hematopoietic tumors reliably respond to radiation therapy and rarely require surgery for a compressive neurologic deficit alone. Aggressive surgical intervention may be futile in the face of established neurologic deficit and/or rapidly advancing tumor refractory to treatments. However, many patients continue to present with symptomatic solid organ metastases and reasonable life expectancies and will benefit from a comprehensive evaluation by surgeons in concert with medical and radiation oncologists.

Surgical Staging and Assessing Prognosis

Although some patients clearly face a more dire prognosis than others, the prediction of life expectancy for any individual patient remains difficult and subject to error⁴. As new chemotherapeutic agents become available, older data may not apply to individual patients. For example, the treatment of metastatic renal cell carcinoma has changed dramatically since the approval of tyrosine kinase inhibitors in 2007; prognostic criteria from older cohorts of patients may not fully apply to contemporary clinical scenarios. Patients are generally considered candidates for aggressive surgical treatment of metastatic disease if their life expectancy exceeds three to four months, acknowledging the difficulties in accurately predicting this. Recent data have helped us to understand the role that patient age plays in predicting the benefit from surgical intervention⁵.

To aid in better estimating prognosis, several scoring systems that take into consideration individual prognostic markers (i.e., primary tumor type, presence of metastasis, etc.) and designate a score that provides an indication for overall prognosis and/or life expectancy have been developed^6-10. The Tomita scoring system was derived from a retrospective review of sixty-seven patients and uses three main factors: grade of malignancy, visceral metastasis, and bone metastasis⁸. Another scoring system is the revised Tokuhashi scoring system⁹, which is different from the Tomita system in that it also considers performance status, types and locations of metastatic lesions, and paralysis with use of the Frankel classification to assign a score. The initial Tokuhashi system was inconsistent in predicting prognosis and actual survival; however, the revised scoring system, developed after 1998 and reported subsequently in 2005, has an accuracy of up to 86% in prospective studies^6,7,9,10. Both of the aforementioned scoring systems attempt to develop a score that will guide treatment algorithms and surgical options for managing metastatic spine disease. Generally speaking, the scores indicate an assessment on prognosis (in the Tokuhashi system, high scores indicate good prognosis and, in the Tomita system, lower scores indicate good prognosis) (Fig. 1). In our practice, systems are used as a framework to guide the aggressiveness of treatment rather than as absolute cutoff points to define patient care.

Fig. 1

The revised Tokuhashi scoring system. A higher score indicates a better prognosis. PS = performance status. (Reproduced, with permission, from: Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine [Phila Pa 1976] 2005 Oct 1;30[19]:2186-91.]

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Preoperative Optimization and Considerations

If aggressive surgical treatment is under consideration, the fitness of the patient for surgery is carefully assessed. This begins with a thorough history and physical examination to assess comorbidities and the overall general condition of the patient. Preoperative medical optimization is an essential element in the management of patients with metastatic disease of the spine. Often enteral or parenteral supplemental nutrition is necessary in the perioperative period to optimize metabolic balance in the body toward an anabolic state to promote recovery and healing. Patient comorbidities must be managed in the postoperative period to anticipate complications and limit their manifestations. Complication rates after spine surgery for metastatic spine disease can be as high as 40%^11,12. Recently, the Charlson Comorbidity Index has been used to predict the risk of thirty-day postoperative complications in patients with metastatic spine disease¹². In this study, a Charlson Comorbidity Index of ≥2 was associated with a five times higher likelihood of developing a complication within thirty days after surgery. Efforts to anticipate and prevent complications in these patients will allow better selection of surgical candidates and likely improve patient outcomes.

Preoperative tumor embolization is used to minimize intraoperative blood loss for tumors that are prone to bleeding¹³. Although renal cell carcinoma is the most common hypervascular metastatic tumor, thyroid and hepatocellular carcinomas also benefit from embolization. Surgery is ideally performed within twenty-four to forty-eight hours after embolization to minimize revascularization of the tumor.

Patients are often undergoing treatment with chemotherapy, so careful attention to the myelosuppressive effects of chemotherapy or potential wound-healing impairments is necessary in evaluating and managing patients perioperatively.

Surgical Planning Techniques

Surgical staging strategies are designed for planning operative approaches for tumors of the spine; these should not be confused with overall oncologic staging to define the systemic extent of disease. Examples are the classification systems described by Tomita et al. (Figs. 2-A and 2-B)⁸ and by Weinstein, Boriani, and Biagini (Figs. 3-A and 3-B)^14,15. The Weinstein, Boriani, and Biagini system provides an excellent template for planning en bloc resections of spinal tumors at a specific level, but it fails to take into consideration the possibility of multiple levels of involvement. In this respect, the Tomita classification system is more valuable; however, areas of resection are not noted in that classification system with the precision of the Weinstein, Boriani, and Biagini system⁸. Therefore, the Weinstein, Boriani, and Biagini classification system is an excellent tool for communicating the extent and location of a resection for tumors at a given level independent of the patient's prognosis.

Fig. 2-A Fig. 2-B

The Tomita staging system showing the location and site of the lesion, which are used to produce a prognostic score (Fig. 2-A) that ultimately dictates the surgical strategy for the management of the metastatic lesion (mets.) (Fig. 2-B). A lower score indicates a good prognosis. (Reproduced, with permission, from Tomita K, Kawahara N, Kobayashi T, Yoshida A, Murakami H, Akamaru T. Surgical strategy for spinal metastases. Spine [Phila Pa 1976] 2001 Feb 1;26[3]:298-306.)

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The modified staging system of Weinstein, Boriani, and Biagini (WBB) from the Spine Oncology Study Group.

Fig. 3-A

The location of the lesion on the diagram, which is separated into radiating zones, dictates the type of surgical approach used for resection.

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Fig. 3-B

Table showing the correlation of the WBB stages with the surgical procedures. (Reproduced, with permission, from: Boriani S, Weinstein JN, Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine [Phila Pa 1976] 1997 May 1;22[9]:1036-44.)

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Options and Considerations for Surgical Approach

Surgical management of spinal metastases is considered for four primary indications: compression of the neural elements; spinal instability, including pathologic fracture; unrelenting pain; and, rarely, when a histologic diagnosis must be established. Patients with metastatic spinal disease requiring surgical intervention may be treated with either an en bloc spondylectomy (considered in the rare patient with a solitary metastasis and favorable prognosis) or more commonly with an intralesional decompression and stabilization.

Traditionally, anterior approaches were used because they aided in achieving disease-free margins in en bloc spondylectomies. However, we routinely approach our spondylectomies from an all-posterior approach to avoid the morbidity associated with an anterior approach. This applies to metastatic lesions in the thoracic as well as the lumbar spine, where a thoracotomy or laparotomy adds substantial morbidity and increases complications. Although disease-free margins are difficult to achieve without direct visualization of the anterior aspect of the spine, careful operative planning with computed tomography (CT) and magnetic resonance imaging (MRI) aids in guiding en bloc spondylectomies from an all-posterior approach. Stereotactic navigation may be useful in the surgical plan and execution of en bloc resections¹⁶. Although the Weinstein, Boriani, and Biagini system is still used to classify the location and exact position for resections, tomogram-based navigation systems may allow for more accurate resections with tumor-free margins from an all-posterior approach¹⁶. This is especially important for the patients with the best prognosis and solitary spinal metastatic lesions for whom the goal is a curative resection and minimization of the tumor burden.

Frequently, clear margins and true en bloc spondylectomies cannot be performed because of the local extent of the tumor. This is especially true in patients in whom the metastatic lesion has spread to the posterior elements through the lamina or vice versa from the lamina through the pedicle into the anterior vertebral body. In such situations, the most feasible approach is to achieve a marginal resection since a laminectomy and violation of the posterior elements is necessary to remove the anterior elements en bloc without injury to the spinal cord. In this respect, the majority of vertebral en bloc resections are, at best, contaminated marginal resections. In such cases, postoperative radiation may aid in minimizing local recurrence of disease^3,17,18. Improved survival in patients undergoing en bloc resection compared with those who have marginal resection for metastatic disease of the spine has not been documented; in addition, these procedures are technically demanding and are associated with a high rate of morbidity. For these reasons, we reserve these aggressive procedures for patients with a solitary metastasis following a long disease-free interval.

Most patients with metastatic spinal disease requiring surgical intervention are treated with an intralesional resection. The goals of surgery are to adequately decompress the neural elements, stabilize the spine, and achieve a gross total resection of the tumor. The offending tumor is most commonly located in the vertebral body; however, the surgical approach need not be anterior in all patients. In patients with multilevel disease or (nearly) circumferential dural compression, anterior approaches may not be suitable for decompression. Posterolateral transpedicular or costotransversectomy approaches have been increasingly utilized to provide safe and effective neural decompression and spinal stabilization while avoiding the morbidity (particularly pulmonary) associated with anterior approaches and providing the flexibility to extend the surgery over multiple symptomatic levels. Regardless of the approach utilized, adequate spinal fixation or instrumentation is necessary to provide immediate stability and to avoid the use of spinal orthoses postoperatively. Usually, subsequent radiation therapy is employed to minimize the risk of local tumor recurrence.

Reconstruction and Stabilization Considerations

Reconstruction of the anterior part of the spine after en bloc resections usually necessitates structural support. These options include metallic cages, cortical structural allografts, or methylmethacrylate bone cement (Figs. 4-A and 4-B). The selection of instrumentation used is based on patient-related factors and surgeon preference. Generally speaking, expandable cages can hold bone graft and allow for the possibility of a fusion¹⁹. However, they are costly, require a greater exposure for insertion, and may compromise postoperative imaging studies. Their use may be more beneficial for patients with a good long-term prognosis and those in whom a successful tumor-free margin was achieved intraoperatively so that postoperative radiation is not necessary. Cortical structural allografts may also provide benefits similar to those of an expandable cage, and at a fraction of the cost, but may lead to fatigue fracture and nonunion. Methylmethacrylate bone cement is an inexpensive and readily available option for immediate anterior column reconstruction (Figs. 4-A and 4-B). No comparative data exist to define the benefit of one method over the other in these circumstances.

A fifty-seven-year-old woman was diagnosed with a T11 metastatic lesion from an adrenal cortical adenocarcinoma with epidural cord compression and clinical signs of myelopathy. A right thoracotomy approach was used to visualize the anterolateral aspect of the vertebral column. A T11 corpectomy, including discectomies at T10-T11 and T11-T12, was done. The reconstruction was performed with use of methylmethacrylate in a chest tube to minimize the risk of expansion and thermal injury to the spinal cord and surrounding structures. A locking plate was added to stabilize the construct. After the surgery, the patient was fully able to walk.

Fig. 4-A

Preoperative imaging included a sagittal computed tomography (CT) scan showing a lytic lesion in the T11 vertebral body (a), an axial CT scan showing destruction of the posterior wall of the T11 vertebral body (b), a sagittal T2-weighted fast-spin-echo MRI showing cord compression (c), an axial T1-weighted fat-saturated MRI showing epidural extension of the disease (d), and a spinal angiogram demonstrating that the anterior spinal artery arises from the left T9 vertebral artery (e).

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Fig. 4-B

Postoperative imaging included an intraoperative image showing the methylmethacrylate in a chest tube (a), an intraoperative image showing stabilization of the construct by a locked plate (b), a sagittal CT scan showing good sagittal balance of the spine (c), a coronal CT scan showing good alignment of the spine (d), and an axial CT scan showing adequate decompression of the spinal canal (e).

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Spinal instrumentation is used to restore stability after surgery for metastatic disease. For anterior procedures, plate-and-screw constructs are used; for posterior procedures, pedicle screw systems are used. As the healing potential of patients is uncertain in these circumstances, robust fixation minimizes the likelihood of instrumentation failure during the patient's remaining life.

Less Invasive Options

When prognostic indicators are extremely poor, less invasive measures can be explored to relieve pain more than to decrease the tumor burden or achieve a decompression of the spinal cord²⁰. Kyphoplasty and vertebroplasty are efficacious in addressing pain associated with vertebral compression fractures resulting from metastatic lesions from a solid organ tumor as well as multiple myeloma with minimal complications^21-25. These procedures can be combined with radiation and chemotherapy without much concern for wound dehiscence and without much delay. Substantial pain control can be achieved with this technique^17,23,24,26. However, vertebroplasty and kyphoplasty do not allow for decompression of the spinal cord. In addition, the patients with a substantial loss of vertebral body height, posterior vertebral body cortex violation, or canal compromise are at increased risk during these percutaneous techniques. Preliminary data on percutaneous instrumentation coupled with limited open procedures for patients with metastatic disease have been favorably reported²⁷.

Advances in Radiation Oncology

Radiation therapy is used in the treatment of patients with metastatic spinal disease to achieve local control of tumors. Traditionally, standard fractionated radiation therapy was used to achieve local control and minimize symptomatic local recurrence¹⁷. Standard radiation therapy provides excellent treatment for most patients with metastatic disease of the spine. Although the spinal cord and adjacent organs are exposed to radiation, the modest doses used and limited life expectancy of the patients makes the likelihood of radiation-associated complications less than 5%.

However, radioresistant tumors may not reliably respond to conventional radiation therapy techniques (Fig. 5). As well, repeat irradiation of recurrent tumor is problematic with conventional radiation therapy. Stereotactic delivery techniques that allow high-precision treatment of tumors have been developed^3,17,18,28. The high-precision targeting of these techniques allows for hypofractionated treatment schemes to increase their effectiveness against radioresistant tumors. Further research continues to define the exact role of stereotactic radiation techniques in the treatment of patients with metastatic disease¹⁶.

Fig. 5

Radiosensitivity of a tumor that is based on the histological findings.

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If standard fractionated radiation therapy is used as an adjunct to surgery, we recommend its use postoperatively since preoperative radiation can increase the prevalence of surgical site infections and wound-healing complications. Although treatment is individualized, patients undergoing anterior procedures can usually begin treatment in two to three weeks and those undergoing posterior procedures, in three to four weeks.

Overview

The treatment of metastatic disease remains a common clinical problem for spine surgeons. Patients with reasonable health and life expectancies are considered for surgical treatment when they present with compressive neurologic deficits from radioresistant tumors. Patient wishes, histological findings, and the extent of spinal and extraspinal disease influence treatment decisions.

Many patients are managed without surgery. In those requiring operative intervention, intralesional decompression and stabilization with postoperative radiation therapy is the mainstay of treatment. Patients are considered for aggressive en bloc resections if they present with a solitary metastasis after a long disease-free interval or have other unique clinical indications. Similarly, a subset of patients will benefit from high-precision and/or stereotactic radiation techniques. Surgery plays a powerful and increasing role in the treatment of these patients.

Young RF; Post EM; King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg. 1980 Dec;53( 6):741-8.

Patchell RA; Tibbs PA; Regine WF; Payne R; Saris S; Kryscio RJ; Mohiuddin M; Young B. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005 Aug 20-26;366( 9486):643-8.

Shin JH; Chao ST; Angelov L. Stereotactic radiosurgery for spinal metastases: update on treatment strategies. J Neurosurg Sci. 2011 Sep;55( 3):197-209.

Nathan SS; Healey JH; Mellano D; Hoang B; Lewis I; Morris CD; Athanasian EA; Boland PJ. Survival in patients operated on for pathologic fracture: implications for end-of-life orthopedic care. J Clin Oncol. 2005 Sep 1;23( 25):6072-82.

Chi JH; Gokaslan Z; McCormick P; Tibbs PA; Kryscio RJ; Patchell RA. Selecting treatment for patients with malignant epidural spinal cord compression-does age matter?: results from a randomized clinical trial. Spine (Phila Pa 1976). 2009 Mar 1;34( 5):431-5.

Yamashita T; Siemionow KB; Mroz TE; Podichetty V; Lieberman IH. A prospective analysis of prognostic factors in patients with spinal metastases: use of the revised Tokuhashi score. Spine (Phila Pa 1976). 2011 May 15;36( 11):910-7.

Tokuhashi Y; Matsuzaki H; Toriyama S; Kawano H; Ohsaka S. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 1990 Nov;15( 11):1110-3.

Tomita K; Kawahara N; Kobayashi T; Yoshida A; Murakami H; Akamaru T. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2001 Feb 1;26( 3):298-306.

Tokuhashi Y; Matsuzaki H; Oda H; Oshima M; Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine (Phila Pa 1976). 2005 Oct 1;30( 19):2186-91.

Tokuhashi Y; Ajiro Y; Umezawa N. Outcome of treatment for spinal metastases using scoring system for preoperative evaluation of prognosis. Spine (Phila Pa 1976). 2009 Jan 1;34( 1):69-73.

Bauer H; Tomita K; Kawahara N; Abdel-Wanis ME; Murakami H. Surgical strategy for spinal metastases. Spine (Phila Pa 1976). 2002 May 15;27( 10):1124-6.

Arrigo RT; Kalanithi P; Cheng I; Alamin T; Carragee EJ; Mindea SA; Boakye M; Park J. Charlson score is a robust predictor of 30-day complications following spinal metastasis surgery. Spine (Phila Pa 1976). 2011 Sep 1;36( 19):E1274-80.

Truumees E; Dodwad SN; Kazmierczak CD. Preoperative embolization in the treatment of spinal metastasis. J Am Acad Orthop Surg. 2010 Aug;18( 8):449-53.

Boriani S; Weinstein JN; Biagini R. Primary bone tumors of the spine. Terminology and surgical staging. Spine (Phila Pa 1976). 1997 May 1;22( 9):1036-44.

Chan P; Boriani S; Fourney DR; Biagini R; Dekutoski MB; Fehlings MG; Ryken TC; Gokaslan ZL; Vrionis FD; Harrop JS; Schmidt MH; Vialle LR; Gerszten PC; Rhines LD; Ondra SL; Pratt SR; Fisher CG. An assessment of the reliability of the Enneking and Weinstein-Boriani-Biagini classifications for staging of primary spinal tumors by the Spine Oncology Study Group. Spine (Phila Pa 1976). 2009 Feb 15;34( 4):384-91.

Smitherman SM; Tatsui CE; Rao G; Walsh G; Rhines LD. Image-guided multilevel vertebral osteotomies for en bloc resection of giant cell tumor of the thoracic spine: case report and description of operative technique. Eur Spine J. 2010 Jun;19( 6):1021-8. Epub 2010 Jan 13.

Lanni TB Jr; Grills IS; Kestin LL; Robertson JM. Stereotactic radiotherapy reduces treatment cost while improving overall survival and local control over standard fractionated radiation therapy for medically inoperable non-small-cell lung cancer. Am J Clin Oncol. 2011 Oct;34( 5):494-8.

Haley ML; Gerszten PC; Heron DE; Chang YF; Atteberry DS; Burton SA. Efficacy and cost-effectiveness analysis of external beam and stereotactic body radiation therapy in the treatment of spine metastases: a matched-pair analysis. J Neurosurg Spine. 2011 Apr;14( 4):537-42. Epub 2011 Feb 11.

Alfieri A; Gazzeri R; Neroni M; Fiore C; Galarza M; Esposito S. Anterior expandable cylindrical cage reconstruction after cervical spinal metastasis resection. Clin Neurol Neurosurg. 2011 Dec;113( 10):914-7.

Huang TJ; Hsu RW; Li YY; Cheng CC. Minimal access spinal surgery (MASS) in treating thoracic spine metastasis. Spine (Phila Pa 1976). 2006 Jul 15;31( 16):1860-3.

Bouza C; López-Cuadrado T; Cediel P; Saz-Parkinson Z; Amate JM. Balloon kyphoplasty in malignant spinal fractures: a systematic review and meta-analysis. BMC Palliat Care. 2009 Sep 9;8:12.

Chew C; Craig L; Edwards R; Moss J; O'Dwyer PJ. Safety and efficacy of percutaneous vertebroplasty in malignancy: a systematic review. Clin Radiol. 2011 Jan;66( 1):63-72. Epub 2010 Nov 16.

Lane MD; Le HB; Lee S; Young C; Heran MK; Badii M; Clarkson PW; Munk PL. Combination radiofrequency ablation and cementoplasty for palliative treatment of painful neoplastic bone metastasis: experience with 53 treated lesions in 36 patients. Skeletal Radiol. 2011 Jan;40( 1):25-32. Epub 2010 Aug 5.

Sandri A; Carbognin G; Regis D; Gaspari D; Calciolari C; Girardi V; Mansueto G; Bartolozzi P. Combined radiofrequency and kyphoplasty in painful osteolytic metastases to vertebral bodies. Radiol Med. 2010 Mar;115( 2):261-71. Epub 2009 Aug 7.

Tancioni F; Lorenzetti M; Navarria P; Nozza A; Castagna L; Gaetani P; Aimar E; Levi D; Di Ieva A; Pisano P; Santoro A; Scorsetti M; Rodriguez y Baena R. Vertebroplasty for pain relief and spinal stabilization in multiple myeloma. Neurol Sci. 2010 Apr;31( 2):151-7.

Lee B; Franklin I; Lewis JS; Coombes RC; Leonard R; Gishen P; Stebbing J. The efficacy of percutaneous vertebroplasty for vertebral metastases associated with solid malignancies. Eur J Cancer. 2009 Jun;45( 9):1597-602. Epub 2009 Feb 14.

Rose PS; Clarke MJ; Dekutoski MB. Minimally invasive treatment of spinal metastases: techniques. Int J Surg Oncol. 2011;2011:494381. Epub 2011 Jun 28.

Al-Mamgani A; Tans L; Teguh DN; van Rooij P; Zwijnenburg EM; Levendag PC. Stereotactic body radiotherapy: a promising treatment option for the boost of oropharyngeal cancers not suitable for brachytherapy: a single-institutional experience. Int J Radiat Oncol Biol Phys. 2012 Mar 15;82( 4):1494-500. Epub 2011 Jul 26.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

neoplasm metastasis ; spinal diseases ; secondary malignant neoplasm of spinal cord

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Han Jo Kim, Jacob M. Buchowski, Charbel D. Moussallem, Peter S. Rose; Modern Techniques in the Treatment of Patients with Metastatic Spine Disease. The Journal of Bone & Joint Surgery. 2012 May;94(10):943-951.

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