HE modern concept of surgery for spinal metastasis involves radical excision with the primary goal of local cure and secondary goals of alleviating pain, preserving neurological status, and stabilizing the spine. 42,45 The surgical approach that best accomplishes these goals remains uncertain. Anterior and lateral ap- proaches directed at the site of primary tumor encroach- ment on neural elements have achieved good results, superseding those of laminectomy alone; 4,8,11–14,19,27–29,33–35, 43,46,48 however, they may not be ideal in all situations. 31 These procedures require entering either the thorax or the retroperitoneum in which concomitant parenchymal pul- monary or retroperitoneal disease may make surgery more risky and damage to viscera more likely. Such approaches may not achieve complete removal of tumor or adequate stabilization if the posterior elements are disrupted by tumor infiltration, a situation that may necessitate a sec- ond, posterior operation. Posterolateral vertebral body re- section combined with stabilization avoids some of the pitfalls of anterior and lateral procedures while providing adequate circumferential decompression of the neural ele- ments. 29,31 The few surgeons who use the posterolateral approach have achieved good success. 2,6–9,16–18,21,23,24,29,31,36 In this study we evaluated the feasibility and safety of one particular posterolateral approach for radical resection of vertebral metastasis when combined with reconstruc- tion and stabilization and applied in a uniform fashion. We present a series of patients with locally extensive vertebral metastases treated with radical decompression and resec- tion (“spondylectomy”) via a posterolateral approach, ver- tebral body reconstruction, and posterior segmental spinal stabilization in a single-stage operation. Patient selection, operative technique, complications, outcome of this treat- ment with respect to pain, neurological status, local con- trol, and spinal alignment are presented in detail in this report. This information should assist the surgeon in the quest for optimal surgical treatment for patients suffering from vertebral metastases and it provides a viable alterna- tive to transcavitary and lateral extracavitary procedures. Clinical Material and Methods Patient Population From 1989 to 1995, 110 patients underwent surgery for spinal metastasis via a variety of posterior approaches at the M. D. Anderson Cancer Center. Treatment consisted of laminectomy alone or in conjunction with posterior in- strumentation in 34 cases, laminectomy and partial verte- brectomy via a posterior approach in 11 cases, and subto- tal posterior vertebrectomy and posterior instrumentation without vertebral reconstruction in 31 cases. Surgery in J. Neurosurg. / Volume 85 / August, 1996 J Neurosurg 85:211–220, 1996 Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis EDWARD W. AKEYSON, M.D., PH.D. , AND IAN E. MCCUTCHEON, M.D., F.R.C.S.(C) Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas  The authors present a series of 25 patients who underwent single-stage complete spondylectomy, vertebral body reconstruction, and posterior segmental spinal stabilization for malignant metastatic disease involving multiple col- umns of the thoracolumbar spine. Patients were selected for this approach primarily because they were poor candidates for a transcavitary or lateral extracavitary approach or because the tumor involved both anterior and posterior columns of the spine. The operative approach used combines radical local resection of tumor via a bilateral transpedicular route, methylmethacrylate vertebral body reconstruction, and Luque rectangle stabilization in a single operation. Following surgery, the majority of patients experienced improvement in their neurological status, reduction in pain, or both. Most patients were functionally improved, or at least no worse, and spinal alignment was maintained in all. There was one local recurrence in a long-term survivor. Complications included cerebrospinal fluid fistulas, migrating graft material, and wound healing problems. The authors conclude that this surgical approach is safe and feasible for the radical resec- tion of vertebral metastasis when combined with reconstruction and stabilization. This technique represents a useful alternative to other commonly used surgical approaches for the treatment of spinal metastases, and it should aid sur- geons in selecting the optimum approach for individual patients. KEY WORDS • spinal metastasis • posterolateral approach • vertebrectomy • spinal instrumentation T 211