Review Evolution in treatment strategy for metastatic spine disease: Presently evolving modalities N. Kumar a, * , R. Malhotra a , A.S. Zaw a , K. Maharajan a , N. Naresh b , A. Kumar c , B. Vellayappan d a Department of Orthopaedic Surgery, University Spine Centre, National University Health System, 1 E Kent Ridge Road, Singapore b School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne NE2 4BW, United Kingdom c Department of Orthopaedic Surgery, Khoo Teck Puat Hospital, Singapore d Department of Radiation Oncology, National University Cancer Institute of Singapore, National University Health System, Singapore Accepted 5 May 2017 Available online --- Abstract The advent of minimally invasive surgery (MIS) in the surgical management armamentarium and stereotactic radiosurgery in the domain of radiotherapy, has led to a major evolution in treatment of metastatic spine disease (MSD). We reviewed the recent literature to discuss evolution from open to MIS approaches in MSD and the concurrent evolution in radiotherapy. This will provide a sound base for further development and understanding of treatment paradigms in MSD. Literature review showed that evolution of surgery can be traced from inappropriate open surgery (i.e. laminectomy) to appropriate open (i.e. posterior instrumentation and decompression) and further to mini- mally invasive surgery. This transition was concurrent with the introduction of radiotherapy and its evolution in management of MSD. Ev- idence shows that presently, the best clinical outcomes are achieved by surgery with timely postoperative radiotherapy. To make surgery an appealing choice in MSD, surgical morbidity needs to be minimized when planning postoperative oncological treatment. MIS approaches have advantages such as early wound healing enabling early introduction of radiotherapy, reduced intraoperative blood loss and shortened hospital stay. Pain reduction and neurological improvement are comparable to open surgery. A multidisciplinary team approach including spinal surgeons, medical & radiation oncologists is mandatory, as the treatment options are constantly evolving. Advancement in radio- therapy with introduction of MIS can be a game-changer in MSD due to reduced peri-operative morbidity, allowing earlier postoperative radiotherapy/chemotherapy. We also provide our treatment algorithm which relies on clinical presentation and radiological appearance of spinal cord compression, providing an overview of treatment strategy. Ó 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved. Keywords: Spinal metastasis; Open surgery; Minimally invasive surgery; Radiotherapy; Chemotherapy Introduction The spine is the most common site for osseous metas- tasis from systemic neoplasia. 1,2 Metastatic Spine Disease (MSD) can be regarded as a new ‘epidemic’. It can lead to significant morbidities e namely pain and/or neurolog- ical deficits. Traditionally, surgery has been indicated in conjunction with medical treatment in specific situations or when radiotherapy (RTx) and/or chemotherapy (CTx) have failed. It is also commonly employed in emergent sit- uations such as rapid neurological deterioration or patho- logical fracture. Measures to reduce surgical morbidity in these high-risk patients should be taken. Minimally inva- sive surgery (MIS) seems to be a logical solution to reduce * Corresponding author. Department of Orthopaedic Surgery, National University Health System, 1 E Kent Ridge Road, 119228, Singapore. Fax: þ65 67780720. E-mail address: dosksn@nus.edu.sg (N. Kumar). http://dx.doi.org/10.1016/j.ejso.2017.05.006 0748-7983/Ó 2017 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved. Available online at www.sciencedirect.com ScienceDirect EJSO xx (2017) 1e18 www.ejso.com Please cite this article in press as: Kumar N, et al., Evolution in treatment strategy for metastatic spine disease: Presently evolving modalities, Eur J Surg Oncol (2017), http://dx.doi.org/10.1016/j.ejso.2017.05.006