Key points for aggressive surgery in MST

Aggressive resection in Metastatic spinal tumors (MST) includes three main en bloc techniques: vertebrectomy, hemivertebrectomy, and corpectomy. En bloc excision aims to remove the tumor in one piece without violation, ensuring appropriate pathological margins. Vertebrectomy (marginal or wide en bloc excision) is indicated when the tumor is centrally located with at least one uninvolved pedicle. Thoracic lesions are often managed in a single stage, whereas lumbar lesions usually require a two-stage approach to reduce neurological risk. Posterior mobilization precedes anterior tumor delivery, with careful neural decompression. Hemivertebrectomy is used for eccentrically located tumors involving part of the vertebral body, pedicle, or transverse process. It preserves uninvolved structures and may reduce morbidity compared with total vertebrectomy. Lastly, corpectomy can be performed via anterior, posterior, or combined approaches to remove tumor and reconstruct the anterior column. Indications for aggressive surgery depend on multidisciplinary evaluation, life expectancy, functional status, tumor biology, and mechanical instability. While isolated metastasis may justify radical resection, prognosis and systemic disease burden must guide decisions. Despite favorable long-term outcomes in selected patients, en bloc vertebrectomy carries high morbidity and frequent revision surgery. Careful patient selection, embolization, vascular support and experienced surgical teams are essential to optimize management.