Posterior minimally invasive percutaneous short-segment fixation combined with mini-open anterior L5 corpectomy for metastatic tumor: a case report and literature review.

Introduction

Hepatocellular carcinoma is a malignant epithelial tumor showing hepatocytic differentiation ( 1 ). These tumors are often highly aggressive and present significant diagnostic and therapeutic challenges.

The skeletal system is one of the most common sites of metastasis for many types of solid tumors ( 2 , 3 ). Bone metastases are associated with a high risk of serious complications such as pathological fractures, pain, hypercalcemia, and spinal cord compression, which can seriously impair patients’ quality of life ( 4 , 5 ) and increase both morbidity and mortality ( 6 , 7 ).

Spinal metastases occur in approximately 40%–70% of patients with malignant tumors ( 8 ). The L5 vertebra is the largest vertebra in the lumbar spine. A recent study conducted in China revealed that solitary L5 metastases constituted 10.89% of lower lumbar spine metastases ( 8 ). Additionally, it identified that pain was the chief presenting symptom among patients with lower lumbar spine metastases ( 8 ).

Corpectomy is indicated for the L5 vertebral body metastasis. Despite the potential for cure, corpectomy for L5 vertebral body tumors is a technically challenging procedure requiring multidisciplinary expertise and careful preoperative planning to limit potential morbidity and postoperative disability for the patient.

Selecting an appropriate surgical approach for L5 corpectomy is challenging due to the complex anatomy of the lumbosacral junction. The biomechanics of this region, marked by a sloped transition from the mobile lower lumbar spine to the relatively immobile sacrum and pelvis, subject surgical constructs to high stress from combined sliding and compressive forces ( 9 ). Therefore, careful selection of the surgical approach is essential.

A combined posterior-anterior approach is usually selected for the corpectomy for L5 tumors ( 10 ). Various complications of the posterior-anterior approach, such as longer operation time, more blood loss, and larger trauma, were reported by other studies ( 11 , 12 ). To minimize the risk of these complications, several techniques were utilized in our case. Firstly, percutaneous transpedicular fixation was performed at the levels L4-S1 through a posterior minimally invasive approach: a small incision was made, avoiding extensive tissue trauma. Secondly, only the body of the L5 vertebra was resected through a mini-open anterior approach, and the lamina was left intact, which allowed us to preserve the integrity of the posterior column of the spine.

It is important to highlight that the number of case reports on the surgical removal of lower lumbar spine tumors is very limited. Among the studies included in our literature review, the specific combination of posterior minimally invasive percutaneous short-segment fixation and mini-open anterior L5 corpectomy with preservation of the L5 posterior column was not identified. Therefore, we decided to present a technically challenging case of a 62-year-old man who was diagnosed with hepatocellular carcinoma metastasis of the L5 vertebral body with primary origin in the liver, complicated by the malignant L5 nerve root compression. In addition, we describe in detail a two-stage technique - mini-open anterior approach to the resection of the body of L5 and its reconstruction, as well as a posterior minimally invasive approach to the posterior percutaneous short-segment fixation with preservation of the physiological and anatomical structures of the posterior column of the spine.

Case description

A 62-year-old patient was hospitalized at the JSC “National Center for Neurosurgery” with complaints of persistent pain in the lumbar spine, which increased with minor physical activity, bending, vertical positioning, and changing body posture ( Table 1 ). The pain radiated to the left lower extremity along the distribution of the L5 nerve root. Additional symptoms included numbness in the left foot (hypesthesia), weakness in the lower extremities (Medical Research Council (MRC) Scale for Muscle Strength - grade 3/5), and a forced antalgic horizontal position of the body. These symptoms had persisted for two weeks. However, the patient reported lumbar pain for the preceding two years. The patient had a known diagnosis of hepatocellular carcinoma: cT3NxM1.

The Karnofsky Performance Status was assessed at 40%. The straight-leg raise test was positive on the left at 10 degrees. Pain intensity was rated 8/10 on the Visual Analogue Scale (VAS). Frankel’s grade was C. The MRI ( Figures 1A, B ) and CT ( Figures 1C, D ) of the lumbosacral region revealed L5 vertebral body metastasis and tumor metastasis in the right iliac bone ( Figures 1E, F ). No evidence of visceral metastases beyond the skeletal system was reported at the time of surgical decision-making. Weinstein, Boriani, and Biagini surgical staging (WBB) was 4–9, B-D. Tumor-related instability was unstable with 13 points based on the Spinal Instability Neoplastic Score system (SINS), suggesting the need for urgent surgical stabilization. Revised Tokuhashi Score was 7 points, indicating the mean survival of less than 6 months.

Pre-operation period

The patient underwent surgery 24 h after admission. Preoperative management included anti-edema therapy with dexamethasone (16 mg) and analgesic support. The basic therapy included antihypertensive medications: indapamide + perindopril tert-butylamine (2 mg + 0.625 mg) and bisoprolol 2.5 mg. Additionally, the patient received ademetionine 400 mg three times daily and ursodeoxycholic acid 250 mg.

Operation

The surgery was performed in two stages on the same day.

Stage 1. Posterior paraspinal approach - percutaneous transpedicular fixation of L4-S1

The patient was placed in the prone position under general anesthesia. Antibiotic prophylaxis was administered with 2000mg of Ceftriaxone. The surgical field was disinfected with Betadine solution. Under fluoroscopic guidance, four cannulated screws were inserted percutaneously in a lateromedial trajectory through the pedicles into the vertebral bodies of L4 to S1. A transpedicular structure consisting of four screws, two rods, and four locking nuts was created.

Stage 2. Anterior transabdominal, extraperitoneal approach – resection of the L5 vertebral body and interbody fusion using a VLIFT titanium cage

With the patient in the supine position, a cushion was placed beneath the sacrococcygeal spine to facilitate access. The surgical level was determined using an image intensifier. After preparing the surgical field with Betadine solution, a transverse skin incision of up to 7.0 cm was made at the junction of the upper and middle thirds of the distance between the biiliac line and the superior border of the pubic symphysis.

The anterior linea alba was mobilized and dissected longitudinally. Using a combination of blunt and sharp dissection, the aponeurosis was separated bilaterally from the underlying rectus abdominis muscles. From under the muscle and orienting toward the lateral iliac fossa, the fibers of the transversalis fascia were bluntly separated to access the retroperitoneal space.

A Triplex system was inserted. The surgical level was then reconfirmed using an image intensifier. A surgical microscope was used for enhanced visualization. The right and left common iliac arteries and veins were carefully mobilized at the level of the L4–S1 discs. The intra-abdominal fascia and surrounding fatty tissue were bluntly dissected until the anterior longitudinal ligament of the spine was exposed. The anterior longitudinal ligament was then dissected. Curettage of the L4–L5 and L5–S1 intervertebral discs was performed to prepare the site for interbody fusion.

Using a diamond-tipped electric burr, a conochotome, and Kerisson rongeurs, the L5 vertebral body was resected. During the procedure, a sharp decrease in bone density was observed, with partial replacement by soft tissue. Profuse bleeding from the vertebral body was observed. A complete blood count and a biochemical blood test were taken intraoperatively - anemia was identified, and reinfusion therapy and albumin transfusion were started. Fragments of the resected vertebra were sent for histopathological examination. Following the resection of the L5 vertebral body, pulsation of the dura mater improved. A VLIFT titanium cage was installed in the L4-S1 interbody space. Image intensifier monitoring confirmed satisfactory positioning and condition of the VLIFT titanium cage and associated posterior metal structure. The amount of blood loss during the operation was 800 mL. The duration of operation was 4 h.

Histology

In the examined histological specimens stained with hematoxylin and eosin, the tumor fragments were composed of proliferations of multiple acinar structures. These structures varied in shape and size and were lined by polymorphic, hyperchromatic cells. Tubular and cribriform patterns were also observed. Within the fibrous stroma, tumor cells formed scirrhous structures. Despite these atypical histological features, a diagnosis of poorly differentiated hepatocellular carcinoma metastasis was established based on immunohistochemical findings confirming hepatocellular differentiation.

Postoperative period and follow-up

The patient was mobilized on the first postoperative day. Neurological status remained at the preoperative level throughout the postoperative period, and pelvic functions were preserved. At discharge, the patient was able to ambulate independently. The Karnofsky Performance Status was 80%. VAS score decreased significantly to 2–3 points.

A control CT scan of the lumbar spine was performed in the postoperative period ( Figures 2A–E ). The patient was discharged from the department on the 7th day after the operation and referred to stereotactic radiosurgery for further treatment due to resistance to regular radiotherapy ( 13 ).

Two weeks after surgery, the patient underwent a single course of postoperative adjuvant spine SBRT, delivered in two fractions. A 4-week postoperative follow-up at the outpatient level revealed the following findings: spinal pain, neurological deficits, and clinical evidence of implant-related complications were not observed. The patient was able to walk independently. No postoperative complications were observed from discharge through the 11-week follow-up period. A contrast-enhanced MRI of the lumbosacral spine was scheduled for the three-month follow-up. However, the patient died 11 weeks after the operation due to progression of hepatocellular carcinoma before the planned examination.

Discussion

Metastatic carcinoma of the spine is the most common form of malignant bone disease ( 14 ). Tumors that frequently metastasize to the spine include breast, lung, kidney, liver, prostate, and thyroid carcinomas, as well as melanoma, multiple myeloma, lymphoma, and colorectal cancer ( 15 ). The L5 vertebra poses surgical challenges due to its anatomical position at the lumbosacral junction and its exposure to biomechanical load. For this reason, surgical treatment of tumors at this level requires careful planning to achieve pain relief, adequate decompression, and maintain spinal stability.

Several surgical approaches for the treatment of L5 vertebral body tumors were described in the recent literature, including posterior-only, anterior-only, and combined posterior- anterior techniques. Posterior-only approach allows adequate tumor removal in certain cases; however, they often require extensive muscle dissection and multilevel instrumentation, which may increase surgical morbidity ( 16 ). Conversely, combined approach provides improved access to the anterior spinal column ( 17 ). It also facilitates effective decompression and reconstruction ( 17 ). However, combined approaches are associated with longer operation duration and increased intraoperative blood loss ( 11 , 12 ).

The patient in our case had the diagnosis of hepatocellular carcinoma, with metastasis to the spine. A decision of a combined approach consisting of posterior minimally invasive percutaneous fixation followed by mini-open anterior L5 corpectomy was made by our team of neurosurgeons. The decision-making process was consistent with the NOMS framework: four fundamental assessments were made within it ( 27 ). Neurologically, the patient’s progressive motor deficit, severe pain (VAS = 8/10), and L5 nerve-root compression required direct decompression. Oncologically, surgery was not intended to achieve curative resection or oncological margins, and postoperative radiation remained part of the multidisciplinary treatment strategy. Mechanically, extensive destruction of the L5 vertebral body and a SINS score of 13 indicated instability that could not be adequately managed with radiotherapy alone. Thus, it required anterior-column reconstruction and posterior fixation. Systemically, the presence of metastatic disease (M1), a revised Tokuhashi score of 7, limited estimated survival, and poor preoperative functional status supported a surgical strategy aimed at rapid pain relief, stabilization, and early mobilization. For this reason, the purpose of surgery was decompressing the neural structures and restoring mechanical stability by the minimum intervention. The use of percutaneous short-segment fixation and a mini-open anterior approach was intended to reduce surgical morbidity while achieving these palliative objectives.

According to previous studies ( 12 , 18 – 21 ), posterior-only and combined approaches involving large muscle dissections and multilevel instrumentation are associated with increased blood loss and prolonged recovery. A systematic review, analyzing articles on corpectomy and spondylectomy of thoracolumbar metastasis, demonstrated that approaches that require posterior muscle dissection and significant bone work lead to more blood loss ( 22 ), which may reduce survival in oncological patients ( 23 ). In contrast, posterior minimally invasive percutaneous fixation followed by mini-open anterior corpectomy seems to reduce tissue trauma, decrease intraoperative bleeding, and facilitate earlier postoperative mobilization. In our case, total blood loss was 800 mL, which is lower compared to the volumes reported in several studies included in our literature review ( 12 , 18 – 21 ).

Another important step in the surgical treatment of the L5 vertebral body metastasis was the reconstruction of anterior column. In our case, anterior corpectomy contributed to sufficient decompression and immediate stabilization of the spinal column. Also, placement of the VLIFT titanium cage anteriorly maintained spinal alignment, provided adequate restoration of vertebral height, and stable support for the lumbosacral junction.

Short-segment fixation at L4–S1 may be associated with increased mechanical stress at the lumbosacral junction; however, in our case it was considered sufficient given the patient’s limited life expectancy.

Consistent with the WFNS Spine Committee recommendations, selection of the surgical strategy was based not solely on the SINS score but also on neurological status, tumor characteristics, systemic condition, functional status, and estimated survival ( 28 ).

Vertebroplasty with open decompression was considered during multidisciplinary planning. However, it was not selected because the patient had extensive destruction of the L5 vertebral body, disruption of the posterior vertebral wall, neural compression, and marked mechanical instability (SINS 13). Therefore, vertebroplasty has an increased risk of cement leakage into the spinal canal ( 24 ) and was not considered to provide sufficient restoration of anterior-column load-bearing capacity. Furthermore, open posterior decompression would require disruption of the posterior osseoligamentous structures, whereas preservation of the posterior column was one of the objectives of the selected approach.

Separation surgery combined with short-segment minimally invasive fixation and subsequent stereotactic radiotherapy was also considered. However, the main surgical problem was not limited to neural decompression. Extensive destruction of the L5 vertebral body had resulted in substantial loss of anterior-column support at the mechanically demanding lumbosacral junction. Therefore, separation surgery and posterior fixation alone were considered insufficient to provide immediate and reliable reconstruction of the anterior column. Anterior corpectomy and cage reconstruction were selected to restore load-bearing capacity, relieve neural compression, and permit early mobilization.

There are several advantages of a posterior minimally invasive fixation with mini-open anterior corpectomy. These are reduced surgical trauma, preservation of posterior spinal column, effective decompression, prevention of spinal instability, and early postoperative mobilization. The patient in our case was able to ambulate independently on the first postoperative day and demonstrated significant improvement in pain and functional status. Additionally, the patient reported significant improvement in quality of life and pain control after surgery.

Nevertheless, our study has several limitations. First, it describes a single clinical case, which limits the generalizability of the findings. Second, follow-up was limited to 11 weeks because the patient died from progression of hepatocellular carcinoma before the planned 3-month MRI examination. Consequently, long-term local tumor control, fusion, cage position, and construct durability could not be assessed. Third, postoperative improvement in quality of life was not evaluated using a validated patient-reported outcome measure. We recommend conducting research with larger patient cohorts to evaluate the effectiveness of this surgical treatment method.

A literature review was conducted by our team on the surgical removal of the lower lumbar spine tumors ( Table 2 ). A literature search was carried out of two electronic databases: Medline via Ovid and Pubmed for relevant studies published between 2000 and 2025. The main search terms involved “spinal cord tumors”, “lumbar vertebrae”, “corpectomy”, “spondylectomy”, and “surgical resection”. Case studies and case series examining adult patients who were surgically treated for lower lumbar spine tumors were included in the review. The other types of studies, studies investigating children, studies analyzing cervical, thoracic, upper lumbar, and sacral spine tumors, and studies investigating traumatic and degenerative spine disorders were excluded.

Six eligible studies were identified: four of them were case series ( 12 , 18 , 19 , 21 ), and two were case studies ( 20 , 25 ). The number of patients in the case series varied from 7 to 11. Tumors were located in the L4 in one study ( 12 ), in the L5 in three studies ( 19 – 21 ), and in both L4 and L5 in two studies ( 18 , 25 ). The giant cell tumor and breast cancer metastasis were the common types of cancer among patients included in six studies. It is important to mention that the surgical procedure performed in our case does not represent an en bloc resection but rather a palliative corpectomy.

Three studies utilized a posterior-only approach ( 12 , 20 , 21 ), two combined posterior-anterior approach ( 18 , 25 ), and one used both posterior-only and combined posterior-anterior approach ( 19 ). The posterior column was resected in five studies involving total en bloc spondylectomy ( 12 , 18 , 20 , 21 , 25 ). In Shousha et al. ( 19 ), it was preserved in the 10 patients treated using an anterior L5 corpectomy followed by posterior pedicle-screw fixation; preservation of the posterior column could not be determined in the single posterior-only case because posterior-element management was insufficiently described. A reconstruction of the vertebral body was carried out using a titanium cage ( 18 , 19 ), a titanium mesh cage ( 12 , 20 , 21 ), a VLIFT titanium cage ( 12 , 25 ), and an artificial vertebra ( 21 ). These constructions were filled with autogenous bone ( 12 , 18 , 20 ), allogenic bone ( 12 , 21 ), and bone cement ( 12 , 19 ). The amount of blood loss during the operation varied from 900 mL to 13460 mL. The duration of operation ranged between 140 and 1320 min.

14 patients demonstrated no evidence of disease, whereas 4 patients died of disease in studies that examined the combined approach. On the other hand, 9 patients showed no evidence of disease, and 5 died of disease in studies that explored the posterior-only approach. However, it is important to mention that the cases differed widely from one another. The essential factors such as gender, age, tumor type, and number of metastases which affect the outcome varied substantially among cases. For this reason, a great contrast in the operation time (140 vs. 1320 min) and amount of blood lost (900 vs. 13460 mL) can be observed, and no definitive conclusion can be drawn due to heterogeneity of the studies.

The surgical approach and surgery technique should be selected individually, considering the patient’s condition, their will, functional status, tumor type, number of metastases, life expectancy, and surgeon’s experience ( 26 ).

Conclusion

After careful multidisciplinary evaluation and discussion of our case, L5 corpectomy with posterior minimally invasive percutaneous short-segment transpedicular fixation may be a feasible technique for pain relief, mechanical stabilization, and preservation of neurological function. In conclusion, preservation of the posterior column was safe and effective in this case, enabling early mobilisation and improved functional recovery.

Acknowledgments

We thank the patient for agreeing to publish and share this study.

Funding Statement

The author(s) declared that financial support was not received for this work and/or its publication.

Footnotes

Edited by: Sidong Yang , Hebei International Joint Research Centre for Spinal Diseases, China

Reviewed by: Yuxuan Qian , Shanghai Cancer Institute State Key Laboratory of Systems Medicine for Cancer, China

Donika Vezirska , Military Medical Academy, Bulgaria

Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

Ethics statement

Ethical approval was not required for the study involving humans in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

TK: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing. MO: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing. MA: Conceptualization, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing – review & editing, Data curation, Formal analysis, Funding acquisition, Software, Visualization, Writing – original draft. AB: Data curation, Formal analysis, Methodology, Project administration, Resources, Software, Supervision, Visualization, Writing – original draft, Writing – review & editing. SA: Project administration, Supervision, Validation, Writing – review & editing.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

References

1. Rumgay H, Ferlay J, De Martel C, Georges D, Ibrahim AS, Zheng R, et al. Global, regional and national burden of primary liver cancer by subtype. Eur J Cancer. (2022) 161:108–18. 10.1016/j.ejca.2021.11.023

2. Ruatta F, Derosa L, Escudier B, Colomba E, Guida A, Baciarello G. Prognosis of renal cell carcinoma with bone metastases: experience from a large cancer centre. Eur J Cancer. (2019) 107:79–85. 10.1016/j.ejca.2018.10.023

3. Tahara RK, Brewer TM, Theriault RL, Ueno NT. “Bone metastasis of breast cancer”. In: Ahmad A, editor. Breast Cancer Metastasis and Drug Resistance: Challenges and Progress. Cham: Springer Nature Switzerland AG; (2019). p. 105–29. 10.1007/978-3-030-20301-6_7

4. Hernandez RK, Wade SW, Reich A, Pirolli M, Liede A, Lyman GH. Incidence of bone metastases in patients with solid tumors: analysis of oncology electronic medical records in the United States. BMC Cancer. (2018) 18(1):44. 10.1186/s12885-017-3922-0

5. Tanaka R, Yonemori K, Hirakawa A, Kinoshita F, Takahashi N, Hashimoto J, et al. Risk factors for developing skeletal-related events in breast cancer patients with bone metastases undergoing treatment with bone-modifying agents. Oncologist. (2016) 21(4):508–13. 10.1634/theoncologist.2015-0377

6. Guo Q, Zhang C, Guo X, Tao F, Xu Y, Feng G, et al. Incidence of bone metastasis and factors contributing to its development and prognosis in newly diagnosed renal cell carcinoma: a population-based study. Cancer Manag Res. (2018) 10:2935–44. 10.2147/CMAR.S170083

7. Nguyen Q-N, Chun SG, Chow E, Komaki R, Liao Z, Zacharia R, et al. Single-fraction stereotactic vs. conventional multifraction radiotherapy for pain relief in patients with predominantly nonspine bone metastases: a randomized phase 2 component of a phase 2/3 trial. JAMA Oncol. (2019) 5(6):872–8. 10.1001/jamaoncol.2019.0192

8. Zhao YJ, Cao HY, Zhu XD, Deng MM, Deng XQ, Sun S, et al. Epidemiology and surgical management of the lower lumbar spinal metastases in China: a multicenter retrospective study. Sci Rep. (2025) 15(1):31142. 10.1038/s41598-025-17125-8

9. Vazan M, Ryang Y-M, Gerhardt J, Zibold F, Janssen I, Ringel F, et al. L5 corpectomy—the lumbosacral segmental geometry and clinical outcome—a consecutive series of 14 patients and review of the literature. Acta Neurochir. (2017) 159(6):1147–52. 10.1007/s00701-017-3084-5

10. D’Aquino D, Tarawneh AM, Hilis A, Palliyil N, Deogaonkar K, Quraishi NA. Surgical approaches to L5 corpectomy: a systematic review. Eur Spine J. (2020) 29(12):3074–9. 10.1007/s00586-020-06617-y

11. Tomita K, Kawahara N, Baba H, Tsuchiya H, Fujita T, Toribatake Y. Total en bloc spondylectomy: a new surgical technique for primary malignant vertebral tumors. Spine. (1997) 22(3):324–33. 10.1097/00007632-199702010-00018

12. Huang W, Wei H, Cai W, Xu W, Yang X, Liu T, et al. Total en bloc spondylectomy for solitary metastatic tumors of the fourth lumbar spine in a posterior-only approach. World Neurosurg. (2018) 120:e8–16. 10.1016/j.wneu.2018.06.251

13. Kurisunkal V, Gulia A, Gupta S. Principles of management of spine metastasis. Indian J Orthop. (2020) 54(2):181–93. 10.1007/s43465-019-00008-2

14. Hage WD, Aboulafia AJ, Aboulafia DM. Incidence, location, and diagnostic evaluation of metastatic bone disease. Orthop Clin North Am. (2000) 31(4):515–28. 10.1016/s0030-5898(05)70171-1

15. Jacobs WB, Perrin RG. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. (2001) 11(6):1. 10.3171/foc.2001.11.6.11

16. Phelps BM, Gupta MC. A clinical practice review of optimizing the approach for correction of thoracolumbar deformity—when and how to perform anterior releases and fusion. AME Surg J. (2025) 5:17. 10.21037/asj-25-10

17. Fourney DR, Gokaslan ZL. Anterior approaches for thoracolumbar metastatic spine tumors. Neurosurg Clin N Am. (2004) 15(4):443–51. 10.1016/j.nec.2004.04.008

18. Kawahara N, Tomita K, Murakami H, Demura S, Yoshioka K, Kato S. Total en bloc spondylectomy of the lower lumbar spine: a surgical techniques of combined posterior-anterior approach. Spine. (2011) 36(1):74–82. 10.1097/BRS.0b013e3181cded6c

19. Shousha M, El-Saghir H, Boehm H. Corpectomy of the fifth lumbar vertebra, a challenging procedure. Clin Spine Surg. (2014) 27(6):347–51. 10.1097/BSD.0b013e318260dced

20. Li Z, Lv Z, Li J. Total en bloc spondylectomy for the fifth lumbar solitary metastasis by a posterior-only approach. World Neurosurg. (2019) 130:235–9. 10.1016/j.wneu.2019.07.054

21. Yang X, Yang J, Jia Q, Zhong N, Jiao J, Hu J, et al. A novel technique for total en bloc spondylectomy of the fifth lumbar tumor through posterior-only approach. Spine (Phila Pa 1976). (2019) 44(12):896–901. 10.1097/BRS.0000000000003003

22. Spiessberger A, Arvind V, Gruter B, Cho SK. Thoracolumbar corpectomy/spondylectomy for spinal metastasis: a pooled analysis comparing the outcome of seven different surgical approaches. Eur Spine J. (2020) 29(2):248–56. 10.1007/s00586-019-06179-8

23. Ito Y, Kanda M, Ito S, Mochizuki Y, Teramoto H, Ishigure K, et al. Intraoperative blood loss is associated with shortened postoperative survival of patients with stage II/III gastric cancer: analysis of a multi-institutional dataset. World J Surg. (2019) 43(3):870–7. 10.1007/s00268-018-4834-0

24. Meyer M, Farah K, Aurélie T, Graillon T, Dufour H, Fuentes S. Management of spinal metastasis by minimally invasive surgical techniques: surgical principles and indications—a literature review. J Clin Med. (2023) 12(16):5165. 10.3390/jcm12165165

25. Santiago-Dieppa DR, Hwang LS, Bydon A, Gokaslan ZL, McCarthy EF, Witham TF. L4 and L5 spondylectomy for en bloc resection of giant cell tumor and review of the literature. Evid Based Spine Care J. (2014) 5(02):151–7. 10.1055/s-0034-1387804

26. Tokuhashi Y, Matsuzaki H, Oda H, Oshima M, Ryu J. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine. (2005) 30(19):2186–91. 10.1097/01.brs.0000180401.06919.a5

27. Bilsky MH, Giantini-Larsen A, Kharas N, Newman WC, Yamada Y. “NOMS: roadmap to multidisciplinary metastatic spine tumor management”. In: Yamada Y, Bilsky MH, Lis E, editors. Multidisciplinary Spine Tumor Management: A Modern Approach. Cham: Springer Nature Switzerland; (2026). p. 3–16. 10.1007/978-3-032-07519-2_2

28. Zileli M, Zygourakis C, Niu T, Gokaslan Z, Peev N, Sharif S, et al. Surgical options for metastatic spine tumors: WFNS spine committee recommendations. Neurosurg Rev. (2024) 47(1):821. 10.1007/s10143-024-02949-1

Associated Data

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.