Surgery of the tumors of the spine.

Introduction

Tumors involving the spine represent a complex and heterogeneous group of conditions that pose significant diagnostic and therapeutic challenges ( 1 , 2 ). They include both primary lesions arising within the spinal cord itself, or from adjacent spinal structures and secondary metastatic involvement, the latter being far more common in clinical practice. Although primary spinal tumors are rare, their clinical impact is considerable due to their potential to cause pain, neurological compromise, and spinal instability ( 3 ). In contrast, metastatic spine disease is highly prevalent, reflecting the spine’s rich vascular network and its role as a common site for hematogenous dissemination of malignancies ( 4 ).

Over the past decades, the management of spinal tumors has undergone a profound evolution ( 5 ). Historically considered largely incurable or managed with palliative intent, these lesions are now approached through multidisciplinary strategies combining surgery, radiotherapy, and systemic treatments. Advances in imaging, surgical planning, and intraoperative technologies have enabled more accurate diagnosis, improved surgical precision, and better oncological outcomes ( 6 ). At the same time, the introduction of stereotactic radiotherapy and minimally invasive surgical techniques has shifted the focus from extensive cytoreductive procedures toward less invasive, function-preserving approaches ( 7 ). Within this evolving landscape, surgery continues to play a central role. However, its indications, objectives, and techniques have significantly changed, requiring spine surgeons to integrate oncological principles with modern technological tools and multidisciplinary decision-making frameworks.

Tumor categories

Metastatic involvement of the spine represents the most frequent form of spinal tumors, accounting for the vast majority of cases encountered in clinical practice ( 4 ); however, this pattern differs in younger patients, where benign lesions predominate during the first two decades of life ( 8 ). The vertebral column is particularly susceptible to metastatic spread due to its extensive venous network, including the valveless Batson plexus, which facilitates hematogenous dissemination ( 4 ). Common primary malignancies that metastasize to the spine include lung, breast, prostate, renal, and gastrointestinal cancers ( 9 ). The thoracic spine is the most frequently involved segment (about 70%), followed by the lumbar region and sacrum (20%), whereas cervical involvement is less common ( 9 ). The clinical relevance of metastatic spine disease lies in its association with significant morbidity, including pain, mechanical instability, and neurological compromise, particularly in cases of metastatic epidural spinal cord compression (MESCC). As oncological treatments continue to improve survival, the incidence of spinal metastases is expected to increase, making their management an increasingly important aspect of modern spine oncology. Historically, treatment strategies were largely palliative ( 10 ). However, contemporary approaches emphasize functional preservation, local tumor control, and maintenance of quality of life, with surgery playing a key role in selected patients ( 11 , 12 , 13 ).

Primary tumors of the spine are uncommon, accounting for only 5% of all musculoskeletal neoplasms ( 1 , 2 ). They include a wide spectrum of benign and malignant lesions originating from osseous, cartilaginous, or neural elements of the spine. Benign tumors, such as osteoid osteoma, osteoblastoma, and aneurysmal bone cysts, are more frequent than malignant lesions but can exhibit locally aggressive behavior, particularly in the axial skeleton ( 8 , 14 , 15 ). Malignant primary tumors, including chordoma, chondrosarcoma, osteosarcoma, and Ewing sarcoma, are rare but pose significant therapeutic challenges due to their proximity to critical neurovascular structures ( 16 , 17 ). The clinical presentation is often nonspecific, with pain being the most common symptom. Neurological deficits may occur in advanced stages, frequently indicating tumor extension into the spinal canal.

Staging

Accurate diagnosis and staging of spinal tumors remain critical determinants of treatment feasibility and oncological outcomes ( 18 , 19 ). Delayed diagnosis remains a major issue, often related to insufficient imaging rather than misinterpretation. When neurological symptoms are present at initial evaluation, tumor progression into the spinal canal has often already occurred, significantly reducing the likelihood of achieving complete resection. Histopathological confirmation is mandatory and should be performed following strict oncologic principles, ideally within a multidisciplinary tumor board setting, as inappropriate biopsy techniques may compromise both oncological outcomes and limit surgical options ( 20 ).

Comprehensive staging is essential to assess the possibility of achieving tumor-free (R0) margins and define the extent and morbidity of the surgical procedure. Contraindications to radical resection include extensive involvement of critical adjacent structures and advanced epidural disease, which may necessitate intralesional or marginal approaches combined with adjuvant therapies. In selected cases, limited-margin resections may still be considered within a multimodal treatment strategy. Several classification systems have been developed to guide surgical planning and prognostic assessment ( 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ). While the Enneking system remains the foundation for defining tumor biology and surgical margins, its applicability to the spine is limited by anatomical complexity ( 21 ). The Weinstein–Boriani–Biagini (WBB) classification provides a more detailed anatomical framework, facilitating surgical planning based on tumor location and extension ( 22 , 23 ).

In metastatic disease, prognostic scoring systems, such as Tokuhashi ( 24 ) and Tomita ( 13 ), help stratify patients according to expected survival and guide the aggressiveness of surgical intervention. The classification systems incorporate multiple clinical and oncological parameters, including the patient’s general condition, the presence of extraspinal bone metastases, the number of spinal metastatic lesions, involvement of major visceral organs, the primary tumor origin, and the patient’s neurological status ( 25 ). In addition, the Spinal Instability Neoplastic Score (SINS) offers a standardized method to evaluate mechanical instability and determine the need for stabilization ( 26 , 27 , 28 ). The SINS system evaluates several key parameters, including pain characteristics, degree of vertebral body collapse, tumor biology (lytic versus blastic), involvement of the posterior elements, spinal level affected, and the presence of deformity such as kyphosis or translational instability. Based on these variables, lesions are categorized as stable, potentially unstable, or unstable, thereby guiding the indication for surgical stabilization. This framework assists spine surgeons in balancing the risks and costs of instrumentation against the expected benefits in terms of pain relief and mechanical stability.

Overall, optimal management of spinal tumors relies on the integration of accurate staging, appropriate classification systems, and multidisciplinary decision-making to balance oncological control with surgical morbidity ( 29 ).

Multidisciplinarity

The management of spinal tumors has become increasingly complex with the expansion of available therapeutic options, making effective coordination across multiple specialties essential. Multidisciplinary tumor boards represent the cornerstone of this integrated approach, providing a structured forum for regular interaction among specialists and enabling shared decision-making aimed at optimizing patient outcomes ( 30 ). Evidence across oncologic disciplines consistently supports their role in refining treatment strategies, improving coordination of care, and potentially enhancing survival. In spine oncology, these principles are particularly relevant given the rarity of primary tumors, the heterogeneity of metastatic disease, and the anatomical complexity of the spine ( 31 , 32 ). Dedicated spine tumor boards, involving spine surgeons, medical and radiation oncologists, radiologists, pathologists, and allied health professionals, are uniquely positioned to address these challenges through comprehensive case evaluation. Within this framework, tumors can be broadly stratified into those amenable to medical management alone (lymphoma, plasmacytoma, etc.), those requiring primarily surgical treatment (chondrosarcomas, etc.), and those necessitating combined multimodal approaches, including chemotherapy, surgery, and radiotherapy. For patients with metastatic spine disease, multidisciplinary discussion is essential to balance surgical indications against prognosis, systemic disease burden, and expected quality of life ( 33 , 34 ). Weekly tumor board meetings, complemented sometimes by urgent or virtual consultations, allow timely and individualized treatment planning. Each specialist contributes to different aspects of care, including prognostic assessment, evaluation of surgical risk-benefit, selection of systemic or radiation therapies, and interpretation of imaging and histopathological findings. This collaborative model not only improves clinical decision-making but also ensures a patient-centered approach that integrates oncologic control with functional outcomes and overall well-being.

Surgical strategies

The primary objectives of surgical management in spinal tumors differ according to disease context but generally include achieving local tumor control in primary lesions and maintaining functional status and survival in metastatic disease ( 35 ). Principal differences between the surgical management of primary and metastatic spinal tumors are summarized in Table 1 . Surgery plays a central role in the management of pain and neurological deficits associated with spinal instability ( 28 ). Common indications include mechanical instability, vertebral collapse with or without neurological compromise, tumors resistant to radiotherapy, intractable pain unresponsive to conservative treatment, and neurological deterioration occurring before, during, or after radiotherapy. Fundamental surgical principles include adequate neural decompression, restoration of spinal stability, and optimization of oncological margins while minimizing procedural morbidity.

From an oncological perspective, surgical strategies are defined according to the intended resection margins ( 21 ). Intralesional resection involves piecemeal tumor removal and is typically reserved for benign lesions or palliative indications, given the inability to achieve oncologically adequate margins. Marginal resection entails en bloc removal of the tumor along its pseudocapsule, whereas wide resection achieves en bloc excision surrounded by a continuous layer of healthy tissue. Radical resection, rarely feasible in the spine, involves removal of the tumor along with the entire anatomical compartment of origin.

To guide clinical decision-making in metastatic spine disease, integrated frameworks such as the neurologic, oncologic, mechanical, and systemic (NOMS) model have been developed ( 36 ). This approach incorporates neurological status, tumor biology and radiosensitivity, mechanical stability, and overall systemic condition to define the optimal therapeutic strategy ( 37 , 38 ). The NOMS framework also integrates the role of stereotactic radiotherapy, molecular and targeted therapy considerations, reflecting the growing impact of personalized oncology on surgical decision-making ( 39 ).

Palliative procedures

Decompression of spinal canal with posterior instrumentation

Posterior decompression has historically represented the cornerstone of surgical management for metastatic epidural spinal cord compression (SCC) since 1980 ( 40 ). Early surgical approaches, dating back to the late nineteenth century, relied primarily on laminectomy alone, which provided direct posterior decompression but failed to address anterior or lateral tumor components ( 41 , 42 ). This limitation, combined with the absence of stabilization, was associated with significant morbidity, including iatrogenic instability, progressive deformity, persistent pain, and potential neurological deterioration. In contemporary practice, isolated laminectomy is rarely indicated, except in selected cases such as targeted biopsy procedures when percutaneous sampling is not feasible ( 41 ). Even in these situations, surgical planning should be guided by preoperative imaging to minimize the extent of exposure and avoid unnecessary destabilization.

A major paradigm shift occurred following the landmark randomized trial by Patchell et al. , which demonstrated the superiority of surgical decompression combined with radiotherapy over radiotherapy alone in patients with SCC ( 42 ). This study established high-level evidence supporting the role of surgery in preserving ambulatory function, improving neurological recovery, and prolonging survival, without significantly increasing hospital stay. Consequently, surgical management evolved toward more aggressive decompressive and stabilizing procedures. However, the initial response to these findings led to the widespread adoption of extensive surgical approaches, including anterior and combined techniques, often associated with considerable morbidity. This highlighted the need for a more balanced strategy, integrating adequate neural decompression with mechanical stabilization while minimizing surgical burden ( 43 , 44 ). Modern approaches emphasize posterior decompression combined with instrumented stabilization as a standard strategy, allowing effective neural decompression and restoration of spinal stability ( 45 , 46 ). Advances in surgical techniques, including percutaneous instrumentation, have further reduced operative morbidity by preserving paraspinal musculature, decreasing blood loss, and shortening operative time, without compromising construct stability.

Separation surgery (piece-meal resection and curettage)

The introduction of stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) has profoundly transformed the management of metastatic spinal disease, challenging the traditional distinction between radioresistant and radiosensitive tumors ( 39 ). The ability to deliver high-dose, highly conformal radiation in a limited number of fractions has enabled effective local tumor control while minimizing damage to surrounding tissues and reducing treatment duration. These advances have shifted the surgical paradigm away from extensive cytoreductive resections toward more targeted procedures aimed at facilitating safe and effective radiation delivery.

Within this context, the concept of ‘separation surgery’ has emerged as a key strategy at the interface between surgery and radiotherapy ( 47 , 48 ) ( Table 2 ). Rather than pursuing maximal tumor debulking, the primary objective is to achieve circumferential decompression of the dural sac and re-establish a margin between the spinal cord and the tumor, thereby creating a safe target for ablative radiation within the limits of spinal cord tolerance. This approach, originally described by Benzel and Angelov ( 49 ), represents a paradigm shift toward function-preserving and less morbid surgical interventions ( 50 ). In practical terms, separation surgery is typically performed through a posterior approach and involves piecemeal tumor resection or curettage to decompress the neural elements ( 51 ). Circumferential decompression is achieved through removal of posterior elements and pedicles, allowing access to the ventral epidural space and enabling safe mobilization of the tumor away from the dura. Given the frequent compromise of spinal stability due to both tumor involvement and surgical resection, posterior instrumentation is commonly required, usually extending one or two levels above and below the affected segment ( 51 ) ( Fig. 1 ).

Hybrid treatment strategies combining separation surgery with SRS or SBRT have demonstrated durable local control across a wide range of tumor histologies, including those previously considered radioresistant ( 50 ). However, this approach is not without limitations, particularly the increased risk of wound complications in the setting of perioperative radiotherapy ( 52 , 53 , 54 ). Despite this, separation surgery has become a cornerstone of modern spine oncology, reflecting the shift toward multidisciplinary, less invasive, and biologically driven treatment strategies.

Cement augmentation techniques (vertebroplasty/kyphoplasty)

Percutaneous vertebral augmentation techniques, including vertebroplasty and kyphoplasty, have become integral components in the management of spinal tumors, particularly in the palliative setting ( 55 , 56 , 57 ). These minimally invasive procedures provide effective pain relief and mechanical stabilization in patients with pathological vertebral compression fractures, especially when disease is confined to the vertebral body without significant posterior wall disruption or high-grade epidural involvement. Vertebroplasty involves the direct injection of polymethylmethacrylate (PMMA) cement into the vertebral body, resulting in immediate structural reinforcement ( 55 ) ( Fig. 2 ). Kyphoplasty, in contrast, utilizes balloon expansion to create a cavity prior to cement injection, allowing for reduced injection pressure and potential restoration of vertebral height ( 58 ). Clinical evidence supports the efficacy of kyphoplasty in improving pain and functional outcomes compared to conservative management, highlighting its role in carefully selected patients ( 59 ). These techniques are particularly advantageous in oncologic patients due to their low morbidity profile, rapid recovery, and ability to facilitate early continuation of systemic or radiotherapy treatments. However, careful patient selection is mandatory. In the presence of significant epidural disease, cement injection may exacerbate neural compression and should, therefore, be approached with caution or avoided. Alternative strategies to address pathological vertebral wedging include mechanical endplate elevation using expandable devices, such as intravertebral jacks ( 60 ), and the deployment of expandable titanium mesh stents positioned over an inflatable balloon to restore vertebral body height and alignment ( 61 ).

Beyond standalone use, cement augmentation plays a critical role as an adjunct to posterior instrumentation ( 62 ). The use of fenestrated pedicle screws allows controlled delivery of PMMA through the implant, improving screw purchase in osteolytic or osteoporotic bone and reducing the risk of implant failure. This strategy enables the use of shorter fixation constructs without compromising stability, although distinct patterns of mechanical failure may occur ( 63 , 64 ). Overall, vertebral cement augmentation techniques represent a versatile and effective tool within the multidisciplinary management of spinal tumors, bridging the gap between purely conservative treatment and more invasive surgical interventions ( 65 ).

Minimally invasive approaches

Minimally invasive spine surgery (MISS) has emerged as a valuable adjunct in the surgical management of spinal tumors, expanding the armamentarium of the spine oncologic surgeon ( 66 , 67 ). However, its application must be individualized, as no single technique is universally applicable. The choice of approach depends on both surgeon-related factors, including technical expertise and familiarity with advanced technologies, and patient-related variables, such as surgical indication (pain control, mechanical instability, neural decompression, or separation surgery) and overall prognosis ( 68 ). In recent years, the role of MISS in spine oncology has grown substantially, driven primarily by the need to reduce surgical morbidity, particularly in patients with metastatic disease. Traditional open approaches, often requiring long-segment fixation and extensive soft tissue dissection, are associated with significant perioperative morbidity and increased risk of wound complications, especially in patients undergoing adjuvant chemotherapy or radiotherapy ( 69 , 70 , 71 ). The shift toward less aggressive cytoreductive strategies has favored approaches that minimize surgical footprint while achieving adequate neural decompression and stabilization ( 72 , 73 ).

In primary spinal tumors, the role of MISS remains more limited, particularly in malignant lesions where en bloc resection with oncologically adequate margins is required. Nevertheless, minimally invasive techniques have demonstrated efficacy in selected benign tumors, such as osteoid osteoma and osteoblastoma, and are increasingly being explored in hybrid strategies for malignant disease, particularly when combined with advanced radiotherapy modalities ( 74 , 75 , 76 ).

Technological advancements, including percutaneous instrumentation, tubular and expandable retractor systems, and intraoperative navigation, have further enhanced the feasibility and safety of MISS ( 72 , 73 , 77 , 78 ). These techniques allow targeted tumor resection and stabilization while preserving paraspinal musculature and spinal integrity, potentially reducing the need for extensive fusion procedures. Importantly, the reduced surgical burden associated with MISS facilitates earlier resumption of systemic therapies, which is a critical determinant of overall oncologic outcomes. For this reason, minimally invasive approaches are particularly advantageous in patients with limited physiological reserve or advanced disease, where the balance between surgical benefit and morbidity is crucial.

Percutaneous stabilization

The development of percutaneous pedicle screw instrumentation has emerged as a key minimally invasive strategy in the management of spinal tumors, expanding the indications for surgical stabilization, particularly in patients with mechanical instability, which may represent, according to SINS, an independent indication for surgery regardless of tumor histology or degree of epidural compression ( 79 , 80 ). In this setting, stabilization aims to reduce pathological motion and provide effective pain relief, particularly in cases of anterior column disruption, posterior element involvement, or pathological fractures, and in patients requiring rapid symptom control to enable early initiation or continuation of radiotherapy percutaneous posterior spinal instrumentation (PPSI) provides effective stabilization with minimal soft tissue disruption, resulting in reduced blood loss, lower wound complication rates, and faster postoperative recovery ( 81 ). It can be used as a standalone technique or combined with cement augmentation techniques. The use of fenestrated screws with PMMA augmentation further increases fixation strength in osteolytic bone, enabling shorter constructs without compromising mechanical integrity ( 79 ).

More recently, the introduction of carbon fiber-reinforced implants has added a new dimension to percutaneous stabilization in oncologic patients ( 82 ). These systems offer biomechanical properties comparable to titanium while significantly reducing imaging artifacts, thereby improving postoperative surveillance and facilitating more precise delivery of adjuvant radiotherapy, including proton therapy ( 83 ). However, their higher cost, limited intraoperative flexibility, and lack of long-term outcome data currently restrict widespread adoption.

Overall, percutaneous stabilization represents a paradigm shift toward less invasive, function-oriented surgical strategies, enabling effective palliation and integration with multimodal oncologic treatments.

‘Mini-open’ decompression

‘Mini-open’ and tubular minimally invasive decompression techniques have expanded the surgical options for neural element decompression in spine oncology, allowing effective treatment of both high-grade metastatic epidural spinal cord compression and selected cases of foraminal disease. In particular, targeted nerve root decompression may provide significant pain relief in patients with radiculopathy, especially in the lumbar spine below the level of the conus, where foraminal compromise related to posterior element involvement is common ( 84 ). These approaches utilize tubular or expandable retractor systems inserted through transmuscular corridors, enabling focused decompression via laminectomy, foraminotomy, or medial facetectomy while preserving surrounding soft tissues ( 72 , 73 , 84 ). Proper trajectory and positioning of the retractors are critical to ensure adequate exposure and safe tumor removal, particularly in the presence of lytic bone destruction where the risk of inadvertent canal violation is increased. Both intradural and extradural tumors can be addressed using these techniques, with outcomes comparable or superior to open surgery in terms of blood loss, operative time, and length of hospital stay ( Fig. 3 ).

Mini-open strategies can be combined with percutaneous instrumentation to create hybrid approaches that allow effective tumor resection and stabilization while minimizing muscle dissection ( 84 ). Limited midline or anterior exposures may be used for tumor removal or decompression, whereas posterior fixation is achieved through separate minimally invasive incisions. In selected cases, minimally invasive anterior or lateral approaches also permit corpectomy and reconstruction of the anterior column using expandable cages, offering reduced surgical morbidity compared to traditional open thoracic or retroperitoneal exposures ( 74 , 75 ). Although the current evidence is largely based on small series, these techniques have consistently demonstrated reduced perioperative morbidity, faster recovery, and decreased postoperative pain. Nevertheless, careful patient selection remains essential, as the complexity of tumor anatomy and oncologic goals may still necessitate more extensive open procedures.

Radiofrequency ablation

Percutaneous ablation techniques, particularly radiofrequency (RF) ablation, have emerged as minimally invasive options in the management of selected spinal tumors ( 85 , 86 ). Image-guided RF ablation allows targeted tumor destruction through thermal-induced coagulative necrosis and has demonstrated favorable outcomes in terms of pain control. The technique can be performed as a standalone procedure, especially in benign lesions such as osteoid osteoma ( Fig. 4 ) ( 87 , 88 ) or in palliative settings for metastatic disease in combination with vertebral cement augmentation, leveraging similar percutaneous access pathways to enhance both tumor control and mechanical stability ( 89 , 90 ). Despite its growing use, the application of RF ablation in the spine remains technically demanding and somewhat controversial due to the proximity of critical neural and vascular structures. Thermal injury to the spinal cord or nerve roots represents the main limitation, particularly for lesions located within close distance to the spinal canal. Strategies such as saline infusion, temperature monitoring, and advanced neuromonitoring have been proposed to mitigate these risks, although careful patient selection remains essential.

Beyond RF ablation, other modalities – including laser, microwave, and cryoablation – have been explored, often in combination with radiotherapy or cement augmentation, to improve pain control and local disease management ( 91 ). However, current evidence is largely based on small series, and the role of these techniques in achieving durable oncological control remains uncertain ( 86 ). Clinically, percutaneous ablation is best suited for patients with unresectable osteolytic lesions, limited life expectancy, or contraindications to surgery, as well as in cases where conventional therapies have failed or are not feasible. While early results are encouraging, further studies are required to better define long-term outcomes and optimal indications within the multidisciplinary treatment algorithm of spinal tumors.

Spinal laser interstitial thermal therapy (SLITT)

Spinal laser interstitial thermal therapy (SLITT) represents an emerging minimally invasive technique for the treatment of selected spinal tumors, particularly in the context of epidural disease ( 92 , 93 ). This approach involves the percutaneous insertion of a laser probe into the epidural space, delivering controlled thermal energy to induce tumor ablation under real-time magnetic resonance thermography. The primary objective is to reduce epidural tumor burden and restore a safe margin between the lesion and the spinal cord, thereby facilitating subsequent stereotactic body radiotherapy (SBRT), in a concept analogous to separation surgery but with a less invasive profile.

Early clinical experiences have demonstrated the feasibility and safety of SLITT, with reported improvements in pain control, neurological status, and quality of life ( 92 , 93 , 94 , 95 ). However, its widespread adoption has been limited by significant logistical and technical challenges, including the need for MRI-compatible instrumentation, dedicated intraoperative imaging resources, and specialized expertise in thermographic monitoring. Moreover, operative times may not be substantially reduced compared to alternative strategies, and its clinical utility appears confined to patients with low-grade epidural compression, who may also be candidates for upfront radiotherapy.

More broadly, thermal ablation technologies, including laser interstitial thermal therapy and RF ablation, have been explored as less invasive alternatives to open cytoreductive procedures in metastatic spinal disease ( 91 ). While initial results are promising – particularly when combined with SBRT – robust evidence supporting long-term oncological efficacy remains limited. Future prospective studies and technological refinements will be critical in defining the role of these techniques within the multidisciplinary management of spinal tumors.

Selective arterial embolization

Selective arterial embolization (SAE) plays an important role in the management of spinal tumors, primarily as an adjunct to surgery aimed at reducing intraoperative blood loss in highly vascular lesions ( 96 , 97 ). Preoperative embolization is particularly indicated in hypervascular primary tumors and metastatic lesions, including renal cell carcinoma, thyroid carcinoma, hepatocellular carcinoma, pheochromocytoma, melanoma, hemangiopericytoma, and selected sarcomas, where it can significantly improve surgical safety and facilitate tumor resection ( 96 ). Beyond its adjunctive role, SAE has also been explored as a definitive treatment modality in specific tumor types, most notably aneurysmal bone cysts (ABC) ( 98 , 99 ). While the traditional approach has combined preoperative embolization with intralesional curettage, concerns regarding recurrence and surgical morbidity have prompted interest in embolization as a standalone therapy. In selected cases, particularly in patients without significant neural compression or structural instability, SAE has demonstrated tumor regression and recurrence rates comparable to surgical treatment, while avoiding operative complications ( 96 ). However, this strategy often requires multiple treatment sessions to achieve adequate control, raising concerns regarding cumulative radiation exposure, especially in pediatric populations where ABCs are more prevalent.

Overall, arterial embolization represents a versatile tool in spine oncology, with applications ranging from surgical adjunct to primary therapy in selected indications, and its use should be tailored within a multidisciplinary treatment strategy based on tumor vascularity, location, and patient-specific factors.

En bloc resection

En bloc resection represents the cornerstone of surgical management for selected primary spinal tumors, with the objective of achieving oncologically sound margins through removal of the tumor as a single specimen ( 100 , 101 , 102 ). An R0 resection is defined by histologically negative margins and remains the most important predictor of local control and long-term survival. Vertebrectomy encompasses a spectrum of resections involving partial or complete removal of one or more vertebral segments, with different techniques tailored to tumor location and extent.

Several subtypes of en bloc resection can be distinguished ( 103 , 104 , 105 ). - Hemivertebrectomy involves a sagittal resection of the vertebra, including the pedicle, facet joint, and a variable portion of the vertebral body, while preserving contralateral structural continuity. - Vertebrectomy (or total en bloc spondylectomy) entails removal of the entire vertebral body, often combined with en bloc excision of adjacent pedicles, with the posterior elements removed separately, resulting in complete disruption of spinal continuity. - Posterior arch resection includes en bloc removal of the spinous process, lamina, facet joints, and portions of the pedicles ( Fig. 5 ). - The concept of ‘total en bloc vertebrectomy’ is largely theoretical, as true radical resection would require sacrifice of the spinal cord and nerve roots, a strategy associated with prohibitive morbidity and, therefore, reserved for exceptional salvage situations.

Vertebrectomy, considered the standard wide resection technique for malignant spinal tumors, can be performed through single-stage posterior-only approaches or combined anterior–posterior procedures ( 103 ). In the classical two-stage approach, posterior instrumentation and decompression are first achieved, followed by anterior vertebral body resection and reconstruction. Alternatively, the posterior-only technique described by Tomita allows en bloc removal of the vertebral body through a bilateral posterolateral approach, with careful dissection of surrounding structures, including pleura and major vessels, and subsequent stabilization using pedicle screw constructs ( 106 ). The choice of surgical approach is dictated by tumor extent, anatomical location, and staging. A key technical prerequisite for achieving marginal or wide en bloc resection is the presence of at least one uninvolved pedicle; otherwise, the resection becomes intralesional. Combined anterior and posterior approaches are often required in cases of significant extraosseous extension to achieve adequate margins. In selected cases, sacrifice of nerve roots may be necessary to obtain oncological clearance ( 107 , 108 ).

Despite its oncological advantages, en bloc resection remains technically demanding and associated with substantial morbidity. Therefore, careful patient selection and multidisciplinary planning are essential to balance oncological benefit against surgical risk.

Bone loss reconstruction

Reconstruction following en bloc resection of spinal tumors is a critical step aimed at restoring spinal stability and enabling early mobilization ( 109 ). In most cases, stabilization begins with posterior fixation, often performed prior to vertebral osteotomy to provide a stable construct during resection and facilitate controlled deformity correction maneuvers. The choice of reconstruction strategy depends on the level of the spine and the extent of resection, with particular attention to the balance between mechanical stability and biological integration ( 109 ).

At the thoracic level, hemivertebrectomy can often be adequately stabilized with posterior instrumentation combined with autologous bone grafting of the residual posterior elements. However, special caution is required at the cervicothoracic junction, where additional anterior support may be necessary to prevent junctional instability, particularly in cases involving extensive resections such as those associated with apical thoracic tumors ( 110 ).

In the thoracolumbar and lumbar spine, posterior fixation alone may be sufficient for limited resections, such as partial hemivertebrectomy (up to one third of the body), whereas more extensive resections involving a larger portion of the vertebral body require additional anterior column reconstruction ( 91 ). In cases of total vertebrectomy, circumferential stabilization is mandatory due to the high risk of mechanical failure and nonunion, typically achieved through combined anterior and posterior reconstruction. Anterior column reconstruction can be performed using structural allografts or expandable cages, with the choice influenced by surgeon preference and specific biomechanical considerations ( 111 ). Structural allografts may provide favorable long-term stability, while expandable cages offer intraoperative flexibility and immediate load-bearing capacity. In selected cases, minimally invasive anterior approaches, including thoracoscopic techniques, can be utilized to reduce surgical morbidity.

Innovative tools

Surgical navigation and robotics

The integration of surgical navigation and robotic technologies has significantly enhanced the precision and safety of spinal tumor surgery, particularly in complex oncological procedures requiring millimetric accuracy. Navigation systems are especially valuable in scenarios involving extensive or circumferential tumor spread, where precise osteotomies are critical to achieving adequate resection margins while preserving adjacent neural structures ( 112 , 113 ). They also reduce the risk of wrong-level surgery, which is particularly relevant in cases of purely intraosseous lesions located in anatomically challenging regions such as the mid-thoracic spine. Beyond accuracy, navigation has contributed to improving surgical efficiency and reducing radiation exposure for both patients and operating room personnel. Modern systems, based on intraoperative computed tomography or fluoroscopic imaging, allow real-time guidance and adaptability during surgery ( 114 , 115 ) ( Fig. 6 ). Key technical differences among platforms include image quality, the extent of anatomical coverage per acquisition, and the type of reference tracking system employed, all of which may influence workflow and accuracy.

Robotic assistance further complements these technologies by enabling highly controlled and reproducible instrument placement, particularly in minimally invasive procedures ( 116 ). While its application in posterior spinal tumor surgery remains limited, robotic systems have shown promise in selected cases, including the resection of paraspinal and presacral tumors, where enhanced visualization and instrument precision are advantageous.

Endoscopy

Endoscopic techniques represent a further evolution in MISS, aiming to reduce surgical morbidity through subcentimeter access corridors and targeted tissue dissection ( 117 ). In spine oncology, endoscopic tumor resection has been described in two main forms: fully endoscopic procedures and endoscope-assisted techniques. Current evidence remains limited, largely consisting of small case series demonstrating the feasibility of complete resection in selected benign tumors, such as osteoblastoma, as well as extradural lesions treated with decompressive intent, including separation surgery ( 118 , 119 ). Despite these promising early experiences, fully endoscopic tumor surgery remains technically demanding and is currently restricted to highly selected cases. Limitations include restricted visualization, challenges in achieving adequate hemostasis, and the potential risk of incomplete tumor resection, particularly in more complex or vascular lesions. These factors, combined with the absence of widely available intraoperative adjuncts, such as ultrasound, may increase the risk of neurological complications depending on tumor location and degree of neural compression. Endoscopic approaches may also be integrated into hybrid strategies, including transtubular techniques or combined with percutaneous instrumentation, providing minimally invasive options for decompression and tumor removal. Overall, while endoscopy represents a promising step toward further reducing the invasiveness of spinal tumor surgery, its current role remains limited. Ongoing technological improvements, particularly in visualization and bleeding control, together with increasing surgical experience, are expected to expand its indications in the future.

Electrochemotherapy

Electrochemotherapy (ECT) has emerged as a novel locoregional treatment modality combining the administration of cytotoxic agents, most commonly bleomycin, with the application of electric pulses to increase cell membrane permeability and enhance intracellular drug uptake ( 120 ). In spine oncology, ECT has been explored primarily as a palliative option for patients with unresectable lesions or those unfit for extensive surgery, particularly in metastatic disease ( 120 , 121 ). Preliminary studies have demonstrated its feasibility and safety in the treatment of spinal and paraspinal tumors, with reported benefits in terms of local tumor control and pain relief. The technique can be applied percutaneously under imaging guidance or during open surgery, allowing targeted treatment while sparing surrounding critical structures ( 121 ). However, its use in proximity to the spinal cord requires careful planning due to the potential risk of neurological injury. Although early clinical results are encouraging, current evidence remains limited to small series, and further studies are needed to better define indications, long-term outcomes, and its role within multimodal treatment strategies.

Conclusion

Spinal tumor surgery has undergone a profound evolution over recent decades, shifting from aggressive cytoreductive approaches toward more tailored, multidisciplinary, and biology-driven strategies. While en bloc resection remains the gold standard for selected primary tumors, modern management of metastatic disease increasingly relies on integrated approaches combining separation surgery, advanced radiotherapy, and minimally invasive techniques. The expanding surgical armamentarium has improved patient outcomes by reducing morbidity and facilitating early continuation of oncologic treatments; however, these complex conditions should be managed in highly specialized centers with dedicated multidisciplinary teams. Ultimately, optimal outcomes depend on careful patient selection, adherence to oncological principles, and continuous integration of emerging technologies with evolving systemic therapies.

ICMJE Statement of Interest

The authors declare that there are no relationships/conditions/circumstances that present a potential conflict of interest with the present manuscript. P Ruggieri is an editor of EFORT Open Reviews ; however, he was not involved in the peer-review process or in any editorial decision regarding this manuscript.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Ethical review committee statement

This research project, conducted with anonymous biological material and associated anonymous health-related personal data, does not require a research ethics committee approval in our institutions.

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