Modern oncologic treatments have resulted in an increase of the duration of life of patients with cancer; however the onset of a vertebral metastasis results in a decrease of the quality of life. The aim of surgery is to increase or restore the quality, but not the duration of life. The decision for surgery depends mainly on the functional impairment, and more incidentally on the primitive tumor, the metastatic diffusion, and the general status of the patient. Decision for operative technique depends on the anatomical patterns of the metastasis, considered with reference to the three columns classification of Denis.

The anterior column initial involvement results in instability with mechanical pain, increased by standing and coughing, decreased by supine position, similar to pain experienced with traumatic instability. The middle column involvement results in foraminal extension with radicular pain. The initial posterior column involvement is unfrequent and diagnosis is usually late as standard X-Rays are negative.

At a later stage, invasion of both anterior and middle column result in vertebral collapse with severe mechanical pain and cord compression. This is best treated by anterior approach, allowing a better tumoral resection and a better vertebral reconstruction using bone cement than by posterior approach. Middle and posterior column invasion result in canal invasion and cord compression, without vertebral collapse. Posterior column involvement requires a posterior approach, giving an easy access from C1 down to S1. In selected cases, a combined approach should be recommended because allowing a more complete resection, with less local recurrence rate.

Lastly diffuse lesions or multisegmental instability may require a posterior approach and an extensive stabilisation.