Timing of stereotactic radiosurgery and surgery and wound healing in patients with spinal tumors: A systematic review and expert opinions

Background and Purpose: Stereotactic radiosurgery (SRS) and surgery may be used in combination to manage cord compression due to spinal tumors. Procedure sequence and interval affect wound healing. We aimed to review the evidence on effects of timing and sequence of surgery and SRS on wound healing and bone fusion in patients with spine tumors. Materials and Methods: We performed a comprehensive literature search (Medline, Embase, Google Scholar, Cochrane Database of Systematic Reviews) to identify relevant studies published in 2000-2011. Additional reports were identified in reference lists from relevant papers. Case reports and series discussing patients aged ≥18 with primary or metastatic tumors to the spine who underwent surgical excision with/without instrumentation and SRS before or after surgery were included. The apparent relationship of procedure sequence and interval on wound healing and bone fusion was assessed. Results: Evidence on outcomes following treatment with SRS and surgery was provided in 31 studies; neither wound healing nor bone fusion were endpoints in any study. Wound healing complications were discussed in six studies (20%) including 88 patients treated with both modalities. Animal studies and limited evidence in humans suggest that at least 1 week is indicated between SRS and surgery or surgery and SRS. Conclusions: Evidence to guide decisions regarding the sequence and timing of surgery and SRS with respect to wound healing is limited. Consistent reporting of wound healing complications will improve ability to develop guidelines for optimal treatment of spinal tumors.