CHALLENGES IN REVISION SURGERY FOR RECURRENT METASTATIC SPINAL TUMORS

Spinal metastases are among the most common sites of bone involvement in systemic malignancies and are characterised by pain, neurological dysfunction, and mechanical instability, all of which con-tribute to significant morbidity in affected patients. In cases of recurrence, surgical treatment consti-tutes a complex process that requires multidisciplinary evaluation due to the anatomical and biological challenges posed by prior interventions and the high risk of complications. The primary objectives of the surgical approach are decompression of neural elements, restoration of spinal stability, and improvement of the patient’s quality of life.Among the surgical techniques applied in recurrent spinal metastases, posterolateral approaches are most frequently employed. Anterior and combined approach-es are less commonly used due to their higher complication risks. En bloc resection provides long-term local control in selected patients, but its indications remain limited due to high morbidity rates. Separation surgery aims to create a safe margin between the epidural tumour tissue and the spinal cord suitable for radiosurgery; when combined with adjuvant stereotactic body radiotherapy (SBRT), high local control rates have been reported. Minimally invasive techniques (percutaneous pedicle screw placement, vertebroplasty, kyphoplasty) are increasingly preferred in recurrent cases, as they offer low surgical morbidity, rapid postoperative mobilisation, and effective pain management. Furthermore, combining tumour ablation techniques such as radiofrequency ablation with cement augmentation has shown promising results in terms of palliative local control and analgesia.The surgical decision-mak-ing process should take into account the patient’s performance status, life expectancy, tumour histolo-gy, prior treatment history, and systemic disease burden-prognostic tools such as the NOMS algorithm and Tokuhashi scoring system guide in determining surgical indications. Current literature reports that, when appropriate patient selection is performed, revision surgery after recurrence can result in signifi-cant neurological improvement and enhanced quality of life; however, complication rates vary between 20% and 40%.In conclusion, surgical strategy in recurrent spinal metastasis should be individualised, evidence-based, and planned within a multidisciplinary framework. The fundamental goal must be to preserve the patient’s functional capacity, achieve pain control, and improve overall quality of life.