Concepts, rationale, and techniques of the open approach in the surgical management of metastatic spine disease

Advancements in medical therapy have led to the increased incidence of metastatic spine tumor surgery (MSTS) owing to the increased survivability of cancer patients. Over the years, surgical techniques have evolved from simple laminectomy to advanced radical surgery with reconstruction. Surgery with radiotherapy (RT) and chemotherapy have been established as key paradigms for the management of metastatic spine disease (MSD). In general, surgical treatment is split into two categories, open and minimally invasive. Decompression and stabilization form the basis of the common surgical techniques for managing MSD. Pedicle screw-rod instrumentation forms the basis of fixation, whereas decompression can be achieved through techniques such as laminectomy, separation surgery, partial corpectomy, near piecemeal corpectomy, or en bloc corpectomy. However, complications such as infection, wound dehiscence, and instrument failure remain the challenges of MSTS. This gives the need for auxiliary techniques and advancements to improve the efficacy of MSTS and reduce complications. Recent advancements such as intraoperative cell salvage in MSTS have reduced the need for allogenic blood transfusion, thus reducing the risk of infection and other complications. Additionally, implant materials such as carbon-fiber-reinforced polyether–ether-ketone (PEEK) and titanium-coated PEEK with better biocompatibility, imaging, and RT compatibility have been explored for use in MSTS. Current trends in MSTS are shifting toward minimally invasive surgery (MIS); however, open surgery remains the “gold standard.” Open surgery is preferred in cases with compromised visibility, i.e., hypervascular tumor secondaries and in regions of spinal column with limited access where the MIS approach is likely to be dangerous. We recommend that all spine surgeons be familiar with the concepts and techniques of open surgery for MSD.