**2.1. Management and surgical indication**

The evaluation of clinical general and neurological conditions of patients with advanced cancer and spinal metastases is performed with the Karnowsky performance scale (KPS) and the American Spinal Injury Association (ASIA) scores. Total spine MRI and total body CT scan is mandatory in order to update the stadium of the disease and to planning the most correct treatment.

Approximately 90% of cancer patients with spinal metastases have bone and/or back pain, followed by radicular pain. Half of these patients have sensory and motor dysfunction, and more than half have bowel and bladder dysfunction. Five to 10% of cancer patients present with cord compression as their initial symptom; among these, 50% are non-ambulatory at diagnosis, and 15% are paraplegic [8].

The initial functional neurological score, evaluated with ASIA score, is the most important prognostic factor for the neurological recovery of patients undergoing surgery. Surgery, in the

majority of spinal metastasis cases, does not have a curative aim, but only palliative, to assure stability, pain control, and maintenance of neurologic integrity [3]. Surgery is also important to confirm the primary diagnosis, to debulk or remove the tumor mass for a more effective adjuvant therapy, and permit a patient's mobilization.

The main indications for surgery in case of spinal metastases are the progressive neurologic deficit before, during, or after chemo- and radiotherapy, the intractable pain unresponsive to conservative treatment, the need for histological diagnosis, the treatment of radio-resistant tumor histology (e.g., RCC, melanoma), and to restore the spinal stability.

Numerous grading systems has been proposed, like the modified Bauer Scoring System (mBS), in order to give an indication to a conservative, palliative or more aggressive surgical treatment to a metastatic spine disease. The modified Bauer classification results equal or inferior then 3 points in case of patients with short- or mid-term life expectancy (**Figure 1**).


**Figure 1.** Modified Bauer Scoring System and the prognostic score.

**1. Introduction**

422 Neurooncology - Newer Developments

Spinal cord involvement due to vertebral metastases is a frequent complication in cancer patients and metastatic lesions of spine can significantly condition their quality of life, potentially producing untreatable pain, vertebral fractures, or even neurological deficit due to spinal cord or radicular involvement [1, 2]. Spinal metastases are likely to increase their incidence because patients with cancer today can live longer, due to early detection, as well as to improvements in cancer treatment and care [3]. These lesions should be considered and treated both medically or surgically to prevent undesired sequelae, and to preserve or,

The spine is the third most common site for cancer cells to metastasize, following the lungs and the liver. Almost 70% of cancer patients are expected to have spinal metastasis. In case of symptomatic lesions, the majority (60–70%) are found in the thoracic region, while of the remainder, 20% are found in the lumbar region, and 10% are found in the cervical spine. More

Surgery of spinal metastases cannot be curative, but only palliative, aimed to preserve or, whenever possible, improve quality of life for patients with short- or mid-term life expectan‐ cy. In such cases, surgery is indicated for the stabilization of involved segments, for spinal cord

In the optic of reducing post-operative morbidity and accelerate the post-operative recovery, minimally invasive spine surgery (MISS) may represent the best option to achieve equiva‐ lent or superior outcomes to those of traditional open spine surgery, and to reduce the impact of surgery on critical patients with poor general and neurological conditions with short- or

**2. Patients with advanced cancer and thoraco-lumbar spine metastases**

The evaluation of clinical general and neurological conditions of patients with advanced cancer and spinal metastases is performed with the Karnowsky performance scale (KPS) and the American Spinal Injury Association (ASIA) scores. Total spine MRI and total body CT scan is mandatory in order to update the stadium of the disease and to planning the most correct

Approximately 90% of cancer patients with spinal metastases have bone and/or back pain, followed by radicular pain. Half of these patients have sensory and motor dysfunction, and more than half have bowel and bladder dysfunction. Five to 10% of cancer patients present with cord compression as their initial symptom; among these, 50% are non-ambulatory at

The initial functional neurological score, evaluated with ASIA score, is the most important prognostic factor for the neurological recovery of patients undergoing surgery. Surgery, in the

than 50% of patients with spinal metastasis have more than one level involved [6, 7].

whenever possible, improve the quality of their residual life [4, 5].

or root decompression, and for tissue diagnosis.

**2.1. Management and surgical indication**

diagnosis, and 15% are paraplegic [8].

mid-term life expectancy.

treatment.

To improve outcomes for patients with metastatic spine disease, many aggressive surgical strategies have been proposed. Nevertheless, an aggressive strategy is frequently associated with high morbidity and complication rates, and is not generally indicated in patients with poor general conditions and a limited life expectancy [9, 10].

These patients, in fact, often suffer from co-morbidities, malnourishment, diminished immunity, considerable pain, and they cannot face major surgery. Thus extensive surgical procedures or prolonged hospital stays are neither acceptable nor feasible in many of such patients.

Therefore, surgical risks must be weighed against life expectancy and quality of life, in order to justify standard surgical interventions.
