Asian Journal of Orthopaedic Research

Spinal metastases are common in advanced cancer and cause pathological vertebral fracture, mechanical pain and metastatic epidural spinal cord compression. Two therapeutic traditions address this burden. Antiresorptive therapy with bisphosphonates or denosumab aims to prevent skeletal complications across the whole skeleton, whereas early surgical management aims to decompress the spinal cord and restore stability before neurological function is lost. These traditions have developed through separate trial programmes, guidelines and specialties, and the evidence linking them is fragmented. This critical narrative review appraises the evidence for antiresorptive therapy and early surgery in adults with spinal metastases from solid tumours, examines the tools used to select and time intervention, and evaluates how the two approaches interact with radiotherapy within multimodal care. Randomised trials, meta-analyses, prospective cohorts, retrospective series, guidelines and trial registry records were identified through biomedical and multidisciplinary scholarly databases and citation tracking, and were appraised qualitatively for design, endpoint validity and applicability to the spine. Antiresorptive agents consistently delay composite skeletal-related events, and denosumab is modestly more effective than zoledronic acid, but no randomised comparison has shown that either agent, or one agent over the other, reduces spinal cord compression specifically. Extended dosing intervals for zoledronic acid are supported by randomised evidence, whereas hypocalcaemia, osteonecrosis of the jaw and rebound bone loss after denosumab withdrawal require planned monitoring. Decompressive surgery with radiotherapy improves ambulatory outcomes in carefully selected patients, and observational data favour operating within hours to two days of neurological deterioration, yet the benefit is attenuated in older patients and remains contested in matched comparisons. Instability and compression scores are reliable, but survival prediction models are poorly calibrated in contemporary cohorts. Evidence for combining antiresorptives with surgery or stereotactic radiotherapy, for example to reduce radiation-induced vertebral fracture or improve fixation, is limited to retrospective and non-oncological studies. Priorities include spine-specific endpoints, pragmatic trials of integrated pathways and prospective studies of perioperative bone-targeted therapy. Antiresorptive therapy and early surgery are best regarded as complementary components of a coordinated pathway whose integration remains insufficiently tested.