The transformative role of SBRT in the management of spinal metastases

Spinal metastases can cause disabling pain and neurological deterioration and have historically been treated with palliative intent and conventional external beam radiotherapy (cEBRT). A fundamental shift away from the short-term palliative goals associated with cEBRT has taken place over the past two decades following the availability of stereotactic body radiotherapy (SBRT). This technique has enabled durable pain relief and local control owing to the ability to precisely deliver high radiation doses across typically up to five fractions, with level 1 evidence supporting superior complete pain response rates and local tumour control compared with cEBRT. The development of spinal SBRT has also resulted in greater multidisciplinary collaboration, with neuroradiologists, spinal surgeons, interventional radiologists, biomechanical engineers, medical physicists, medical oncologists and radiation oncologists working together with the common goal of improving our understanding of the pathophysiology and treatment of spinal metastases. As a result, substantial gains have been realized in refining patient selection and treatment sequencing, and particularly the development of less-invasive surgical procedures. In this Review, we summarize the development and role of SBRT in the management of spinal metastases.