Posterior-only total en bloc spondylectomy of L4 for solitary bladder cancer metastasis – An illustrative case

Background: Total en bloc spondylectomy (TES) is a well-established surgical technique for complete resection of vertebral tumors. While traditionally performed through combined anterior-posterior approaches, a posterior-only approach may reduce operative time, blood loss, and morbidity in selected patients. Case Description: We report a 57-year-old male with a solitary L4 vertebral metastasis from previously treated bladder cancer, presenting with low back pain and neurogenic claudication. Imaging confirmed a hypermetabolic lesion isolated to L4 without systemic spread. A two-stage posterior-only TES was performed using careful gauze dissection for anterior vertebral release and en bloc removal. The patient was discharged neurologically intact but experienced two episodes of proximal junctional failure at 4 and 7 months, ultimately requiring extension of fusion to T4. At 14-month follow-up, he remained ambulatory without recurrent failure. Conclusion: Posterior-only TES at L4 is feasible in carefully selected patients. Success requires meticulous surgical planning, multidisciplinary coordination, and thorough patient counseling regarding the risk of mechanical complications and the potential need for revision surgery.