The current role of surgery in metastatic spine disease: a new era.

The study by Lee et al. is a large retrospective study of 577 patients with spinal metastases treated in South Korea from 2005 to 2010. The authors attempted to identify certain key epidemiological and survival variables between the conservatively and surgically treated groups. The spinal metastases predominantly included lung, liver, and breast/colorectal cancers. The inclusion criteria for surgery included patients with neurological compromise due to tumor and/or intractable pain. Patients with poor general health (as determined subjectively by the physicians), patients with incidental spinal metastases without neurological compromise, and patients who refused surgery were allocated to the conservative treatment group. They identify female gender, use of adjuvant therapy postoperatively (chemotherapy and/or radiotherapy), and postoperative survival as important positive prognostic factors in the surgery group, while presence of preoperative neurological symptoms, significant systemic disease, and particular tumor histology were classified as prognostic of poor outcome in the conservatively treated group. As Lee et al. discuss, spinal metastatic disease is often considered the terminal stage of that primary cancer, and for many years, palliative therapy has often been the treatment of choice. However, this article sheds a positive light on the role of surgery in truly treating metastatic disease aggressively, as opposed to merely providing palliation. Lee et al. show a clear increase in mean survival in the surgically treated group after the time of diagnosis by approximately 13 months (p \ 0.009). Also, as demonstrated in other studies, the authors point out the role of specific neurological compromise and/or acute spinal instability due to tumor burden as an important variable in offering that patient a possible surgical treatment that would likely increase quality of life and survival. Patchell et al. performed the only randomized control trial in 2005 looking at 101 patients with metastatic spine disease. They demonstrated that patients younger than 65 had significantly improved ambulation, continence, and survival after surgical treatment followed by adjuvant radiotherapy compared to radiotherapy alone. They also point out that a particular subtype of tumor—breast cancer—had better survival compared to other tumor types. Another significant advancement for spinal metastatic disease is the use of radiotherapy with or without surgery. Over the last few years, there have been a few landmark studies describing the benefit and cost effectiveness of surgery plus radiotherapy versus radiotherapy alone. Gerszten et al. authored a landmark study describing the use of radiosurgery, even in the setting of prior fractionated radiotherapy, as providing a stronger symptomatic response and local control independent of histology. Additionally, they state that conventional radiotherapy is an option for adequate local control and symptomatic improvement, particularly for radiosensitive histologic tumor types. Choosing the appropriate first-line treatment remains controversial. Studies have demonstrated an increase in postoperative infections after spinal surgery preceded by conventional radiotherapy, with infections mostly due to the associated wound breakdown. This problem remains unanswered with the use of stereotactic radiosurgery before surgical treatment. As physicians and surgeons taking care of patients with metastatic spine disease, we must ask ourselves a number of questions before treatment. First, what is the current performance score and general health of the patient? Second, what role do we as surgeons have that may improve this patient’s quality of life and life expectancy, while diminishing neurological compromise or pain during that Society of Surgical Oncology 2012