Surgical management of metastatic spinal tumors: a narrative review emphasizing patient selection, operative timing, minimally invasive approaches, and precision oncology

Abstract

Purpose: Metastatic spinal tumors (MSTs) develop in 30%–40% of all patients with cancer and are a leading cause of cancer-related neurological impairment. Metastatic epidural spinal cord compression (MESCC) occurs in 5%–14% of patients during their lifetime and constitutes an oncological emergency because it can cause rapid and often irreversible motor loss. The management of MSTs was transformed by a randomized controlled trial that established direct decompressive surgery as the standard of care for selected patients with MESCC. Since then, targeted immunotherapy and molecular oncology have substantially prolonged survival across several malignancy subtypes, further reshaping the field. In this setting, durable preservation of ambulatory function has become a central therapeutic objective.Current concepts: Spine oncology practice has responded through more refined patient-selection tools, improved operative techniques, and technologically driven enhancements in surgical precision. This review examines the current evidence base for surgical intervention in MSTs, including structured patient selection with the spine instability neoplastic score and the Neurologic, Oncologic, Mechanical, and Systemic framework; the effect of surgical timing; comparisons of morbidity and efficacy between open surgery and minimally invasive spine surgery; advances in robotic-assisted navigation and carbon fiber-reinforced polymer implants; the role of separation surgery in enabling adjuvant stereotactic body radiotherapy; and the incorporation of next-generation sequencing into postoperative oncological planning.Discussion and conclusion: Contemporary surgical management of MSTs is increasingly integrated with radiotherapy, systemic therapy, and multidisciplinary planning to preserve function, support local control, and allow timely systemic treatment.