Spine

Primary spine tumors require multidisciplinary management at specialized centers. En bloc resection with appropriate margins (Enneking principles) remains standard for most tumors, associated with better local control and survival. Emerging options include denosumab for GCTs, percutaneous ablation for osteoid osteomas, and advanced radiation techniques for chordomas. Treatment decisions must balance oncologic control with morbidity and quality of life.

This trial is straightforward: adding fusion to decompression for lumbar spinal stenosis did not improve disability or walking outcomes, but it did make surgery bigger, longer, and more expensive. Unless a patient has a separate structural reason to need fusion, decompression alone should usually remain the default.

NOMS framework uses neurologic (ESCC grade), oncologic (radiosensitivity), mechanical (instability), and systemic (comorbidities/survival) assessments to guide spinal metastasis treatment. Radiation (cEBRT for sensitive, SRS for resistant tumors) is primary; surgery reserved for instability or to create tumor-cord separation for safe SRS dosing in high-grade ESCC.

SPORT 4-year results show surgery for lumbar disc herniation leads to greater improvements in pain, function, and disability compared to non-operative care. However, high crossover from non-operative to surgery (45% in randomized cohort) complicates interpretation. The as-treated analysis demonstrates clinically meaningful benefits of surgery, but work status was similar between groups.

This SPORT trial compared surgery versus nonsurgical care for lumbar spinal stenosis without spondylolisthesis. Despite high crossover (67% surgery, 43% nonsurgical groups), as-treated analysis showed surgery provided significantly greater improvement in pain and function by 3 months sustained to 2 years. Intention-to-treat analysis showed benefit only for bodily pain. Consider surgical referral for appropriate candidates after failed conservative management.

This multicenter RCT compared surgery vs. nonsurgical care for degenerative spondylolisthesis. Intention-to-treat analysis was negative due to 40% crossover, but as-treated analysis showed surgery improved SF-36 scores by ~18 points and Oswestry by -16.7 at 2 years. Consider surgery for motivated patients, but discuss crossover risks and lack of definitive RCT evidence.

This SPORT observational cohort of 743 patients with lumbar disk herniation found that those choosing surgery had greater improvements in pain, function, and disability at 3 months and 2 years compared to usual care. However, as a nonrandomized study, treatment effects may be confounded by selection bias. Use this to inform shared decision-making while awaiting higher-level evidence.

In patients with single-level metastatic epidural cord compression from solid tumors who are surgical candidates, direct decompressive surgery followed by radiotherapy provides significantly better ambulatory outcomes than radiotherapy alone, with 27% more patients walking and maintaining ambulation 4 months longer, without increased short-term mortality.