Embolize, Resect, Irradiate

Given the high-grade epidural spinal cord compression, we would recommend urgent surgical decompression (1). Separation surgery for metastatic renal cell carcinoma is challenging given its highly vascular nature. As such, provided that the patient is not acutely symptomatic from spinal cord compression or overt mechanical instability, we would perform preoperative embolization of the segmental arterial feeders to improve hemostasis and visualization of the neural elements during the operation. Surgery would include a right costotransverse approach to tumor resection with likely sacrifice of the right T7 and possibly T8 nerve roots, with posterior instrumented fusion from T5 to T10.

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