Management of metastatic spinal disease in low- and middle-income countries: an international survey of practices and challenges in Latin America

Abstract

Spinal metastases impose urgent diagnostic and therapeutic demands; however, evidence from low- and middle-income countries (LMICs) in Latin America is sparse. We aimed to characterize real-world practices, access gaps, and priorities to in-form context-adapted guidelines. We conducted a multinational, cross-sectional online survey (September–October 2025) of licensed clinicians managing spinal metastases across 20 Latin American countries. A validated multilingual instrument (60 items; Cronbach’s α = 0.87) assessed practice patterns, diagnostic and therapeutic resources, perceived complications and outcomes, and barriers to care. Because this was a clinician-reported survey rather than a patient-level registry, estimates of survival, complications, neurological or ambulatory recovery, length of stay, and reintervention were considered perceptions of local practice and were not interpreted as objective clinical outcomes or measures of treatment effectiveness. A total of 1,318 complete responses were analyzed using descriptive and nonparametric comparative statistics. Respondents were predominantly neurosurgeons (63.4%) and orthopedic spine surgeons (34.3%); most practiced in tertiary centers (88.0%) and managed 10–50 spinal metastasis cases annually (76.6%). Diagnostic capacity was uneven: MRI was the preferred initial study (69.9%), yet round-the-clock availability existed in only 40.5%; advanced imaging was routine in 20.9% and unavailable in 30.1%. Symptom-to-diagnosis intervals were 1–3 months in 56.9% and > 6 months in 13.7%, with longer delays in public and lower-middle-income settings (p ≤ 0.041). Biopsy access was present in 90.9%, but pathology turnaround exceeded two weeks in 26.1%. Surgical access was always selected in 86.3%; open surgery predominated (56.9%), combined approaches 29.4%, and minimally invasive surgery 8.5%. Time-to-surgery exceeded two weeks for 26.8% of cases. Stereotactic body radiotherapy was available in 14.4%, and initiation of radiotherapy occurred > 1 month after indication in 62.7%. Economic cost (46.7%), limited instrumentation (19.7%), and delayed diagnosis (19.1%) were leading barriers. Multidisciplinary tumor boards were routine in 35.3%. Reported survival exceeded one year in 59.3% of practices; common complications included infection (33.8%), implant failure (25.0%), and pulmonary events (22.3%). Standardized outcome scales were used routinely by 79.6%. In Latin America, clinicians demonstrate broad expertise but face systemic constraints (diagnostic delays, restricted advanced imaging/navigation, limited SBRT, and high out-of-pocket costs), that blunt timely, integrated care. Priority actions include accelerating diagnostic pipelines, expanding radiotherapy and navigation assisted capacity, strengthening multidisciplinary pathways, and implementing financial protection. Regionally coordinated registries and targeted training are essential to narrow equity gaps in metastatic spine care.