This article explores the classification of spinal tumors and highlights new therapeutic approaches such as separation surgery and stereotactic radiotherapy, emphasizing the need for multidisciplinary collaboration.

Spinal Tumors: Classification and General Definition

Spinal tumors are classified into two main groups: metastatic spinal tumors and primary spinal tumors.

• Metastatic spinal tumors are those that spread to the spine from another organ or tissue in the body.
• This group represents the most common type of spinal tumors.

Tumors are also generally divided into two major categories as benign and malignant:

• Benign tumors are often monitored radiologically at regular intervals and do not usually require surgical intervention.
• However, some benign tumors with aggressive characteristics may cause compression of the spinal cord or severe pain, leading to the need for surgical treatment.

Treatment Approaches in Primary and Metastatic Spinal Tumors

In malignant spinal tumors — whether primary or metastatic — treatment approaches can vary significantly.

• Primary spinal tumors originate from the tissues of the spine itself.
• These types of tumors typically require complete surgical removal.

The primary surgical goal in these tumors is to remove the tumor in one piece, without entering the tumor itself, while preserving the spinal cord and vital surrounding structures.

Thanks to advancements in technology and surgical techniques in recent years, such complete removals have become much more feasible. However, due to the high risk and technical complexity of the procedure, it must be performed by experienced spine surgeons.

Failure to remove the tumor in this manner (en bloc resection) significantly increases the risk of recurrence in the future.

Separation Surgery in Metastatic Spinal Tumors

In metastatic spinal tumors, the treatment approach differs from that of primary tumors. In these cases, complete removal of the cancerous tissue from the spine is not always necessary, provided that spinal cord function is preserved.

Thanks to recent advancements in radiotherapy — especially in stereotactic radiotherapy techniques — partial debulking of tumor masses compressing the spinal cord can reduce tumor burden. This is followed by highly precise radiotherapy, achieving a high rate of local tumor control.

This modern surgical approach is referred to in the medical literature as “separation surgery.”

→ In separation surgery, unlike primary tumors, complete circumferential removal of the tumor is usually not required.

Advantages of this method include:

• Lower risk of surgical complications
• Minimal trauma to the patient
• With the help of evolving technologies, implants can be placed using minimally invasive techniques under navigation or fluoroscopic guidance. Only the compressive area is accessed through small incisions, relieving pressure on the spinal cord.

Separation surgery is successfully applied in a majority of metastatic spinal tumor cases. However, this approach should not be performed based solely on the surgeon’s decision; it must be coordinated with other specialties such as medical oncology and radiation oncology.

• Not every spinal metastasis requires surgical intervention.
• However, in cases where there is a risk of neurological deterioration due to tumor compression, prompt and accurate decision-making is critical for successful treatment.

Objective and Scope of Separation Surgery

Over the past decade, separation surgery has become increasingly common. It involves the meticulous removal of tumor tissues compressing the spinal cord with the assistance of a surgical microscope. The primary goal of this procedure is to create a safe anatomical margin around the spinal cord that permits the administration of high-dose stereotactic radiotherapy.

A critical aspect that must be considered in separation surgery is as follows:

→ If the tumor tissue adhering to the spinal cord is not fully removed or if the mass requiring excision is left partially intact, stereotactic radiotherapy cannot be applied effectively.

Stereotactic Radiotherapy: High-Intensity and Targeted

Stereotactic radiotherapy (SRT) is a treatment method that delivers significantly more intense and precise radiation doses compared to conventional radiotherapy.

→ Its greatest advantage lies in its ability to destroy cancerous tissue with high efficacy while aiming to spare surrounding healthy tissue.

However, this intensity also introduces a substantial risk:
If the surgeon fails to establish a safe anatomical buffer away from the spinal cord and surrounding vital structures, stereotactic radiotherapy may cause permanent damage to these sensitive areas during treatment.