Preoperative embolization of spinal metastatic disease: rationale and technical considerations

The spine is the most common site of bony metastatic disease, with the incidence of spinal metastatic disease increasing, likely as a result of improved survivorship in patients with cancer. Although occasionally incidentally identified through cancer screening/staging or studies done for other reasons, spinal metastatic disease often is symptomatic. The three key points to consider when devising a treatment algorithm are neurological compromise, spinal instability, and individual patient factors. Because the goal of treatment is almost always palliation, a multidisciplinary approach is taken to offer the best chance at alleviating the patient's symptoms. Consideration is given to various treatment choices, such as radiation therapy, chemotherapy, as well as locoregional management strategies, such as thermal ablation (radiofrequency and cryoablation). However, the mainstay of accepted management, especially in those whose life expectancy is > 12 weeks where other strategies have failed, is surgical resection and local stabilization. In this article we review the role and rationale for preoperative embolization of spinal metastatic disease and discuss various related issues, including determining who is most likely to benefit from preoperative embolization, important anatomical considerations, and other technical points, such as timing of surgery and accepted methods of achieving effective local tumor devascularization.