Transpedicular approach for circumferential decompression and separation surgery as a safe and effective way to maximize surgical treatment for spinal metastases: a multicentric study.

Objective: Surgery for spinal metastases has undergone multiple transformations in operative technique, with the goal of enhancing local disease control and facilitating adjuvant therapies. The transpedicular approach offers a minimally invasive strategy for achieving circumferential spinal cord decompression, optimizing conditions for high-dose radiation therapies such as stereotactic body radiation therapy and safe cytoreduction. This study aimed to assess the safety and effectiveness of the transpedicular approach in achieving 360° spinal cord decompression.

Methods: In this multicentric retrospective observational study, the medical records of symptomatic patients who underwent circumferential decompression of the dural sac for spinal metastases between January 2018 and June 2023 were analyzed. Assessed data included perioperative complications and clinical outcomes in terms of neurological function and axial pain. Neurological status was evaluated using the American Spinal Injury Association Impairment Scale and modified Medical Research Council scale. Radiological assessments included epidural spinal cord compression grading and the Spine Instability Neoplastic Score. Statistical analyses were conducted to identify predictors of outcomes.

Results: Circumferential decompression was successfully achieved in all cases. Neurological improvement was observed in 76.3% of patients at discharge, with sustained functional benefits at a mean follow-up of 19.2 months. Postoperative pain improved in 84.2% of patients. A significant association was found between immediate postoperative neurological improvement and long-term outcomes (p = 0.004). Univariate logistic regression analysis indicated that immediate postoperative improvement significantly reduced the likelihood of deterioration at the last follow-up [Nagelkerke R2 = 0.135, Exp(B) = 0.208; p = 0.004]. The total complication rate was 9.8%. Complications included CSF leaks (2.8%), wound infections (1.9%), and low rates of neurological deterioration (0.9%).

Conclusions: The transpedicular approach provides a safe and effective route for circumferential spinal cord decompression in metastatic spinal disease. It minimizes perioperative risks, facilitates high-dose radiation therapy, and achieves favorable neurological and pain outcomes in thoracic and lumbar locations.