Surgery for Spine Tumors: What to Expect

In November 2023, Bob Wagner—a first assistant director on well-known Hollywood movies such as Babylon, Fight Club, The Social Network, Casino, Public Enemies and The Girl With the Dragon Tattoo—was preparing to leave L.A. to start work on a new film when he got an unwelcome surprise: evidence of a cancer recurrence.

“I didn’t have any symptoms at all,” he said. “I walked 2-5 miles every morning. I was feeling fine. But whenever I’m getting ready to work on a film, I go to the dentist, I go to the doctor for a physical—blood test, all of that.”

They found the tumor deep in the base of my spine.

Wagner had gone through a bout of testicular cancer in 2005. He had what’s called a germ-cell tumor. Since then, he’d been living cancer-free, as far as he knew. But the new blood test came back with a very high score for alpha-fetoprotein, a marker for germ-cell cancer.

“I got referred to a urologist and oncologists and got scans, and they found the tumor deep in the base of my spine,” said Wagner.

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Spine Tumors Are Not All the Same

About 90% of tumors in the spine are metastases, which are cancers that have spread from another part of the body, such as the breast, lung or prostate. Tumors that originate in the spine—called primary spinal tumors—are rare, and they generally fall into two categories:

• Tumors of the vertebra (the bones in the spine), such as chordoma, chondrosarcoma and osteosarcoma
• Tumors in the spinal cord or its surrounding tissues, including astrocytoma, ependymoma and meningioma

How Are Spine Tumors Treated?

Treatment is different for the various tumor types.

Most tumors that originate in the spine are benign. Benign spinal tumors can often be left alone and just watched. They only need to be treated if they grow and cause pain or other symptoms.

Metastatic spinal tumors are malignant and require medical treatment to control the cancer and prevent further spread. The most common treatments for these tumors are chemotherapy, radiation therapy and surgery. Oncologists may also treat them with tumor ablation, a minimally invasive technique that destroys tumor tissue by applying heat, cold or other agents through a thin probe placed directly into the tumor.

“In spine tumors that have spread from elsewhere, if we’re treating with surgery, usually we’re not trying to remove the tumor all the way,” explained Cedars-Sinai orthopedic spine surgeon Joseph Schwab, MD, director of Spine Oncology. “We’re just trying to stabilize the spine and/or remove enough tumor to be able to treat it with specialized radiation therapy.”

If you remove these tumors in pieces, they often come back, so we try to take the whole tumor out at once.

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Malignant tumors that have not spread from elsewhere but originate in or around the spinal cord can also often be removed in pieces. That’s not true, however, of the rare malignant tumors that originate in the bone—the kind that was found at the base of Bob Wagner’s spine.

“With this surgery, we’re generally trying to make the patient disease-free,” said Schwab. “If you remove these tumors in pieces, they often come back, so we try to take the whole tumor out at once, which can make for a significant surgery.”

Expertise Matters When Choosing a Spine Tumor Surgeon

After his diagnosis, Wagner met with multiple orthopedic surgeons who all said the same thing: This tumor is really deep. Trying to remove it with surgery would be really complicated.

“Finally, at Cedars-Sinai, I met with Dr. Schwab, and he was fantastic,” said Wagner. “He’s like the guy for these kinds of spine tumor surgeries, and he really took the time to explain my treatment options and the surgery in detail. He said he’d performed similar surgeries in the past, and he thought it was the right approach for my situation.”

Wagner said he didn’t want a long, drawn-out treatment with chemotherapy.

When I heard that word curative, I was just like, ‘OK, let’s do this!’

“I didn’t want that sword of Damocles hanging over my head, with months or years of visiting the doctor, getting blood tests and hoping the tumor’s shrinking,” he explained. “Dr. Schwab said surgery had the potential to be curative. When I heard that word curative, I was just like, ‘OK, let's do this!’”

“My team at Cedars-Sinai agreed this tumor could not be treated effectively with just chemotherapy,” said Schwab. “But it’s vital that patients understand their options and what they’re getting into. These are very large operations. They usually take at least two full days. Patients are in the hospital for weeks, and then, ideally, they go to rehab for an extended period of time.”

The surgeries are so long and complex, they are broken up into stages—or days of surgery—in order to give the surgeons and patients a chance to recover.

For his part, Wagner said he had a good mindset going into the surgery.

“The first time you hear the word cancer, it's frightening. But this being my second go-round, I felt like, ‘It’s all right. I know I can do this.’”

What Happens During Spine Tumor Surgery?

Surgery to remove a tumor in the bones of the spine sometimes involves accessing the spine from the front and back in order to reach the whole cancer. This means moving or working around major blood vessels and delicate nerves. Missteps in this area can result in serious complications.

In Wagner’s case, Schwab said access was complicated by the earlier operation he’d undergone to remove his previous tumor.

“We found that his previous surgery really made our surgery very complex,” Schwab said. “The vascular surgery team had a very difficult time moving the big blood vessels in his pelvis because they had been operated on before and they were completely scarred in. So instead of taking two days, we ended up needing four stages—so four days of surgery—to come at the spine from different angles.”

Once the surgical team had made all the cancerous vertebra accessible, Schwab was able to remove the whole tumor. One nerve root—the L5, which controls feeling and movement in the foot and lower leg—had to be cut in the process.

“That nerve root went right through the tumor. So, I talked to Bob in between stages and said we're probably going to have to resect that nerve root,” said Schwab. “We did. And as a result, he’s ended up having a foot drop—difficulty lifting the front part of his foot—which is the kind of outcome we try to avoid.”

Once the tumor was out, there was a hole in the spine where those missing cancerous bones used to be. Schwab filled the hole with a piece of Wagner’s fibula—the thin bone that runs alongside the tibia, or shin bone. To strengthen Wagner’s fibula, he spliced it to an allograft—a femur harvested from a human donor. This new bone combination was then grafted into the spinal column, and a microsurgeon connected the blood vessels in the fibula to existing vessels in Wagner’s spine.

Spine Tumor Surgery Takes a Team

Surgery of this magnitude is best handled by a dedicated, multidisciplinary team of experienced surgeons and support staff.

“Having experience and having a team is just absolutely paramount,” said Schwab. “I have a lot of experience, but I can’t do these surgeries on my own. We’ve established a world-class team here at Cedars-Sinai, with access to the latest technology and tools.”

Schwab ticks off a list of specialist surgeons that are often needed to assist in these surgeries, including colorectal surgeons, plastic surgeons, vascular surgeons, microsurgeons, urologic surgeons, neurosurgeons, and for tumors in the chest area, thoracic or cardiac surgeons.

Equally important, he said, are anesthesiologists and the operating room staff, including the nurses and surgical technicians.

“All the members of this team that we’ve put together at Cedars-Sinai are at the top of their field, and they do an incredible job. There are very few medical centers in the country that can provide this level of care, but it’s what you want as a patient if you’re faced with this kind of operation.”

Recovering From Spine Tumor Surgery

Patients generally need to recover in the hospital for two to four weeks after spinal tumor surgeries.

“It’s really hard on the body, obviously,” said Wagner. “Those first weeks and months after the operation were miserable and painful.”

After four weeks in the hospital, Wagner spent two months at the California Rehabilitation Institute—a partnership of Cedars-Sinai, UCLA Health and Select Medical. He was not allowed to put any weight on his legs for three months, and he used a wheelchair for six months.

“I remember when I was in the rehab hospital, Dr. Schwab came back and told me the tumor margins were all clear. Like, OK, we got all that cancer. That was a really emotional thing.”

Almost two years out from the operation, Wagner said he’s still walking with a cane and wearing a brace for his foot drop. He said he’s continuing to get stronger with physical therapy, and he’s back at work, recently completing a challenging six-month film shoot.

“I can’t say enough good things about Dr. Schwab. I really feel blessed to have found him,” Wagner said. “Not only is he an incredible surgeon—one of the few that could have done this surgery—but he really cares. He went out of his way to be available to me and my partner, Ashley. Every day I was in surgery, after 10 hours in the operating room, he’d come find her in the hospital and let her know everything that was going on. He and the whole team at Cedars-Sinai were fantastic!”

Wagner said the best news is that since the operation, the blood tests and scans have all come back NED: no evidence of disease.

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