Making Decisions on Surgery for Spinal Tumors

Benzel, M.D., director of the Spinal Disorders Program in the department of neurological surgery at the Cleveland Clinic (OH, USA; www.clevelandclinic.com). Following are some guidelines for decision making, based on his experience.

Tumors in the spine, like other tumors in the body, vary in histology, morphology, clinical presentation, and outcome, ranging from benign vertebral tumors needing no treatment to untreatable malignant tumors. Between these two extremes are cases where surgery may be beneficial to patients. Deciding which cases these are depends on both the surgeon and the patient, both of whom must confront the facts honestly, with no false expectations. Among the objective criteria that should be considered are tumor location, spinal instability, systemic involvement, life expectancy, chance for cure, likelihood of achieving surgical objectives, patient fears, and risks of treatment.

Some spine tumors, such as metastatic spine tumors, are not appropriate for surgery because decompression would further threaten spinal stability or because bone quality is so poor that spinal stabilization could not be achieved. This means that surgery is not an option, even though neurologic function and spinal stability are threatened. On the other hand, certain metastatic spine tumors threaten stability and neurologic function in otherwise healthy patients. In such cases, an extremely aggressive surgical approach may be most appropriate, particularly if the patient has a life expectancy greater than two years and is fully functional.

In some patients, malignant tumors may be cured by using aggressive surgical procedures such as three-level, complete, ventral, and dorsal spondylectomy and reconstruction. These are warranted for a certain chordoma of the thoracic spine, where the chance for a cure by surgery outweighs the risks of progressive paralysis and mortality without surgery.