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Lecture · Neurosurgery & Radiation Oncology

Spinal Metastases

Surgical and Radiation Treatment

  • October 14, 2026
  • Maimonides Health, Brooklyn, NY
  • Radiation Oncology and Hematology-Oncology residents and fellows
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In the online version, figures from published articles are replaced by a citation and a link to the original paper. All cases shown are published cases.

About this lecture

A case-based review of how neurosurgery, radiation oncology and medical oncology decide together for patients with spinal metastases. The lecture follows one patient with a compressed thoracic cord from first presentation to postoperative radiosurgery, and uses that case to walk through the assessments, the operative concepts and the trials that shape current practice.

Thank you to Dr. Alexis Narvaez-Rojas and the Radiation Oncology program at Maimonides Health for the invitation.

What it covers

  • First actionsNew weakness or sphincter change, imaging, steroids and coordinating the team
  • Anatomy to contoursVertebral landmarks, ligaments and the six-sector scheme for spine SBRT
  • AssessmentEpidural spinal cord compression (ESCC) grading, SINS, Denis columns and the NOMS framework
  • SurgeryPatchell trial, separation surgery, percutaneous fixation, kyphoplasty and implant choice for radiation planning
  • Radiation evidenceSC.24, RTOG 0631, SCORAD, SCORE-2, DOSIS and the 2024 ASTRO and ESTRO guidelines
  • Safety and sequencingFracture risk, spinal cord constraints, postoperative SBRT timing and systemic therapy

Take-home points

  1. ESCC and the neurologic examination assess the threat to the cord; SINS guides the stability assessment.
  2. Decompress the actual anatomy. Separation surgery can make postoperative radiosurgery possible.
  3. Fixation treats the mechanics; radiation treats the residual tumor.
  4. Match the benefit and burden of treatment to the patient's systemic reserve and goals.

Key references

  1. Patchell RA, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366:643–648. PubMed
  2. Laufer I, et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 2013;18:744–751. PubMed
  3. Laufer I, et al. Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery. J Neurosurg Spine. 2013;18:207–214. PubMed
  4. Barzilai O, et al. Hybrid therapy for metastatic epidural spinal cord compression: technique for separation surgery and spine radiosurgery. Oper Neurosurg. 2019;16:310–318. PubMed
  5. Bilsky MH, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13:324–328. PubMed
  6. Fisher CG, et al. A novel classification system for spinal instability in neoplastic disease (SINS). Spine. 2010;35:E1221–E1229. PubMed
  7. Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine. 1983;8:817–831. PubMed
  8. Berenson J, et al. Balloon kyphoplasty versus non-surgical fracture management for painful vertebral body compression fractures in patients with cancer (CAFE). Lancet Oncol. 2011;12:225–235. PubMed
  9. Rades D, et al. Radiotherapy with 4 Gy × 5 versus 3 Gy × 10 for metastatic epidural spinal cord compression (SCORE-2, ARO 2009/01). J Clin Oncol. 2016;34:597–602. PubMed
  10. Hoskin PJ, et al. Effect of single-fraction vs multifraction radiotherapy on ambulatory status among patients with spinal canal compression from metastatic cancer (SCORAD). JAMA. 2019;322:2084–2094. PubMed
  11. Sahgal A, et al. Stereotactic body radiotherapy versus conventional external beam radiotherapy in patients with painful spinal metastases (CCTG SC.24). Lancet Oncol. 2021;22:1023–1033. PubMed
  12. Ryu S, et al. Stereotactic radiosurgery vs conventional radiotherapy for localized vertebral metastases of the spine: phase 3 results of NRG Oncology/RTOG 0631. JAMA Oncol. 2023;9:800–807. PubMed
  13. Guckenberger M, et al. Dose-intensified stereotactic body radiotherapy for painful vertebral metastases: a randomized phase 3 trial (DOSIS). Cancer. 2024;130:2713–2722. PubMed
  14. Sahgal A, et al. Vertebral compression fracture after spine stereotactic body radiotherapy: a multi-institutional analysis. J Clin Oncol. 2013;31:3426–3431. PubMed
  15. Alcorn S, et al. External beam radiation therapy for palliation of symptomatic bone metastases: an ASTRO clinical practice guideline. Pract Radiat Oncol. 2024;14:377–397. PubMed
  16. Guckenberger M, et al. ESTRO clinical practice guideline: stereotactic body radiotherapy for spine metastases. Radiother Oncol. 2024;190:109966. PubMed

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