VA provides analgesia and structural reinforcement more rapidly than other treatment measures [149]. Certain newer variants of VA have been shown to be comparable to standard methods, such as BK, in decreasing pain scores and functional improvement [17]. VCFs following SBRT are also amenable to VA. Typically followed VA procedure patients should still be considered for radiation. Surgical Consultation Surgery is the standard of care for pathologic VCF complicated by frank spinal instability and/or neurologic deficits. The SINS can be used to categorize the metastatic spinal segment as stable, potentially unstable, or unstable based on anatomic and clinical factors [150] and can guide surgical referral [14,150]. In the setting of metastatic spinal cord compression, mainly because of osseous compression, surgery is more likely to allow recovery compared to RT alone [151]. Observational studies suggest that surgical decompression, tumor excision, and stabilization improve neurological status from nonambulatory to ambulatory and provide pain relief [137]. Decompressive surgery followed by RT may benefit symptomatic spinal cord compression in patients who are <65 years of age, in the setting of a single level of compression, in patients with neurologic deficits for <48 hours, and in those patients with a predicted survival of at least 3 months [152]. The combination of a spine stabilization procedure and RT may also help manage axial pain and aid in neurologic recovery [153]. A large prospective randomized trial shows that patients with metastatic epidural spinal cord compression treated with direct decompressive surgery plus postoperative radiotherapy retain the ability to walk for longer and regain the ability more often than patients treated with radiotherapy alone. Surgery allows most patients to remain ambulatory for the remainder of their lives, whereas patients treated with radiation alone spend a substantial proportion of their remaining time paraplegic.
Management of Vertebral Compression Fractures PCAs. VA provides analgesia and structural reinforcement more rapidly than other treatment measures [149]. Certain newer variants of VA have been shown to be comparable to standard methods, such as BK, in decreasing pain scores and functional improvement [17]. VCFs following SBRT are also amenable to VA. Typically followed VA procedure patients should still be considered for radiation. Surgical Consultation Surgery is the standard of care for pathologic VCF complicated by frank spinal instability and/or neurologic deficits. The SINS can be used to categorize the metastatic spinal segment as stable, potentially unstable, or unstable based on anatomic and clinical factors [150] and can guide surgical referral [14,150]. In the setting of metastatic spinal cord compression, mainly because of osseous compression, surgery is more likely to allow recovery compared to RT alone [151]. Observational studies suggest that surgical decompression, tumor excision, and stabilization improve neurological status from nonambulatory to ambulatory and provide pain relief [137]. Decompressive surgery followed by RT may benefit symptomatic spinal cord compression in patients who are <65 years of age, in the setting of a single level of compression, in patients with neurologic deficits for <48 hours, and in those patients with a predicted survival of at least 3 months [152]. The combination of a spine stabilization procedure and RT may also help manage axial pain and aid in neurologic recovery [153]. A large prospective randomized trial shows that patients with metastatic epidural spinal cord compression treated with direct decompressive surgery plus postoperative radiotherapy retain the ability to walk for longer and regain the ability more often than patients treated with radiotherapy alone. Surgery allows most patients to remain ambulatory for the remainder of their lives, whereas patients treated with radiation alone spend a substantial proportion of their remaining time paraplegic.