Sequence of surgery, radiotherapy, and stereotactic radiosurgery in the treatment of metastatic spine disease: Effects on wound healing

Treatment for patients with epidural cord compression from spinal metastases continues more than a decade of evolution. The standard of care is shifting to surgery and external beam radiation therapy (EBRT) in combination, rather than EBRT alone. New surgical techniques are enabling effective cord decompression, more extensive tumor excision, and spine stabilization, even in patients who present with significant pain and reduced ambulation. Excellent preliminary results have been shown from stereotactic radiosurgery (SRS) as adjuvant or even primary treatment in these patients. A change in the interval between radiation-based treatment and surgery, or between surgery and subsequent EBRT or SRS has the potential to significantly impact wound healing. We reviewed the literature to present the available evidence on wound complications and on the timing of surgery and radiation in these patients. Based on animal studies and the few patient series bringing specific evidence in humans, it would appear that an interval of at least 1 week is indicated between EBRT or SRS and surgery, and between surgery and radiation-based treatment. An interval of 2–4 weeks or longer reduces the risk of wound healing complications, facilitates increased tensile strength in surgical wounds, and allows better bone fusion. Consistent reporting of wound healing complications and additional research is needed.