capability of these implants allows optimization of diameter and length for the reconstruction. The goal is to be compatible with the host tissue and act harmoniously with bone graft packing. Anterior column reconstruction with a cage is effective in preventing the progression of a kyphotic deformity.

Bone cement is not only a replacement material but also reinforces strength. For example, after hardening, Norian non-exothermic hydroxyapatite cement had a compressive strength of 20–55MPa. Though weaker than autogenous cortical bone (50–200 MPa), it was stronger than autogenous cancellous bone (2–20 MPa). Other allogeneic bone grafts have compressive strengths of 4–13MPa. Bone cement can be injected into a ver­tebral body percutaneously [10, 11] or in an open fashion. It can also be used to augment screws when the bone is weak, injected into a screw tract or around a screw via a Jamshidi needle [12]. Cement can also serve as a substitute for a cage when placed from a posterior direction [13].

Though the basic reconstruction techniques for spinal metastasis are similar to the trauma or degenerative disorders, extra deliberation is needed in this patient population. Many of these patients do not have a long life expectancy and may have many medical comorbidities, which make surgery a dangerous endeavor and decrease postoperative fusion rates. Consideration of the patient’s condition such as degree of tumor spread, speed of disease progression, prognosis, and surgical tolerance must be taken into account. The Tokuhashi index considers the patient’s Karnofsky index, neurological status, metastatic type, and lesion resectability to help determine surgical candidacy [16]. The Tokuhashi score cor­related well with life expectancy (0–4<3months, 5–8 < 6 months, 9–12 > 6 months) and is also useful in determining the extent of spinal recon­struction as only patients with reasonable life expectancies should be candidates for aggressive reconstructive procedures [17]. The Tomita clas­sication of metastatic stages based on tumor intracompartmental or extracompartmental inva­sion can also be used in surgical determination [18]. Despite this, recent advances in cancer immunotherapy, particularly clinical trials aimed at blockade of programmed death receptor 1 (PD-

CT and MRI scans have become the standard imaging modalities used to determine the location and extent of tumor burden. MRI provides power­ful tissue resolution and can discriminate with the use of gadolinium, tumor from surrounding soft tissue anatomy. CT scans are often used in con­junction with MRI, and their utility is often used

surgical planning and decision-making regarding management. Histopathological examination is most commonly achieved via CT-guided biopsy. This procedure has become safe, economical, and reasonably reliable as percutaneous CT-guided biopsy of spinal lesions is diagnostically accurate 93% of the time, with higher rates of success associated with high-grade lesions versus low­grade lesions. Once all of this data is acquired, the decision to manage and treat these patients is complex and relies on a multidisciplinary team that includes spine surgeons, oncologists, radia­tion oncologists, access surgeons, and neurovas­cular surgeons. Compelling arguments for surgery include palliation, decompression, and/or cure with some rare primary lesions; however all of this is factored in the context of the patient’s over­all survival, prognosis, and extent of disease burden making the decision to operate a very difcult one.