The role of surgical timing in survival of patients with spinal metastases

BACKGROUND: Spinal metastases commonly cause pain, neurological deterioration, and instability. Surgery is palliative, aiming to relieve symptoms and maintain oncologic treatment eligibility. Optimal surgical timing, however, remains debated. METHODS: We retrospectively analyzed 664 patients who underwent 760 operations for spinal metastases at Semmelweis University (2008-2022). Clinical data included demographics, comorbidities, primary tumor, neurological status, surgical approach, and timing of surgery relative to the symptom onset. Survival was assessed with both Kaplan-Meier and log-rank testing, with subgroup analyses by surgical timing and operative hours. RESULTS: Pain (83%) and motor deficits (46%) were the most frequent symptoms. Lung, renal, breast, and hematologic cancers predominated. Median survival was 294 days; 30% exceeded two years. No survival advantage was detected for conventional acute surgical thresholds (≤ 48 h, ≤ 72 h, ≤ 1 week). Delays beyond one week correlated with reduced survival. Pain improved postoperatively in ~ 90% of cases, independent of timing. Severe preoperative motor dysfunction predicted poor survival and recovery, emphasizing the need for urgent surgery in this subgroup. Procedures during working hours were associated with superior postoperative symptom control (OR 3.3, p = 0.003), though survival outcomes were unchanged. CONCLUSIONS: Surgical management of spinal metastases provides consistent pain relief. Urgent intervention is critical in patients with progressive motor deficits, whereas multidisciplinary preoperative optimization is preferable in others. Operations during working hours yield better symptomatic outcomes, but survival remains primarily determined by the oncologic disease burden. Prospective multicenter studies are warranted to refine timing guidelines.