Timing of Surgery and Chemo/Radiation for Spinal Metastases: Results from a Systematic Review

Introduction: Treatment for metastatic spine disease has evolved rapidly over the last two decades. Adjuvant radiotherapies or chemotherapy and stereotactic radiosurgery are now commonly used in combination to mitigate risk of recurrence and wound complications, improve post-operative spinal column stabilization, and optimize recovery time. We review the most recent primary clinical findings to establish current standards of care.

Methods: PubMed databases were searched for primary studies evaluating pre- and post-operative chemotherapy, radiotherapy, and brachytherapy for metastatic spinal cancers. A complete abstract screen, full text review, and resolution of reviewer conflicts were completed by two reviewers.

Results: From the initial article search (n = 1178) results, 163 articles were included for full text screening, of which 19 articles specifically addressed timing of adjuvant therapy relative to initial surgical management. These articles comprised the clinical course of 2971 patients with spinal metastases; outcome variables included rate of wound complication, local control of disease, progression-free survival, pain control, surgical complication rate, and neurological/functional status. Multiple articles described significantly increased occurrence of wound complications in patients that received radiotherapy either 1 week before or 1 week after surgery compared to patients that received radiotherapy >1 week before or after surgery. Several articles also recommended radiotherapy to follow spinal decompression, oftentimes due to the clinical urgency of reducing mass effect on the spinal cord.

Conclusion : For management of spinal metastases, recent evidence suggests that surgery (resection and decompression/stabilization) of the spine should precede radiotherapy by at least 1 week, to immediately treat and prevent sequelae of spinal compression and reduce the risk of wound infection. Subsequent work is required to determine the optimal time course for specific primary lesions.