When Less Is More

Abstract

Study Design Systematic review. Objective The aim of this study was to review the techniques, indications, and outcomes of minimally invasive surgery (MIS) and separation surgery with subsequent radiosurgery in the treatment of patients with metastatic spine disease. Summary of Background Data The utilization of MIS techniques in patients with spine metastases is a growing area within spinal oncology. Separation surgery represents a novel paradigm where radiosurgery provides long-term control after tumor is surgically separated from the neural elements. Methods PubMed, Embase, and CINAHL databases were systematically queried for literature reporting MIS techniques or separation surgery in patients with metastatic spine disease. PRISMA guidelines were followed. Results Of the initial 983 articles found, 29 met inclusion criteria. Twenty-five articles discussed MIS techniques and were grouped according to the primary objective: percutaneous stabilization (8), tubular retractors (4), mini-open approach (8), and thoracoscopy/endoscopy (5). The remaining 4 studies reported separation surgery. Indications were similar across all studies and included patients with instability, refractory pain, or neurologic compromise. Intraoperative variables, outcomes, and complications were similar in MIS studies compared to traditional approaches, and some MIS studies showed a statistically significant improvement in outcomes. Studies of mini-open techniques had the strongest evidence for superiority. Conclusions Low-quality evidence currently exists for MIS techniques and separation surgery in the treatment of metastatic spine disease. Given the early promising results, the next iteration of research should include higher-quality studies with sufficient power, and will be able to provide higher-level evidence on the outcomes of MIS approaches and separation surgery.

Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review

“…Studies comparing minimally invasive surgery and open surgery showed that minimally invasive surgery provided equivalent or superior outcomes with reduced surgical morbidity and complications in spinal metastasis patients [ 70 - 72 ]. However, because the quality of evidence is deemed low in the current literature, no definite conclusion regarding the superiority of minimally invasive surgery over open surgery can be derived, and no strong recommendations have been made at this point [ 73 ].…”

Diagnostic algorithm, prognostic factors and surgical treatment of metastatic cancer diseases of the long bones and spine

“…Use of minimally invasive surgical techniques, such as percutaneous stabilisation, use of tubular retractors and mini-open approaches as well as percutaneous cement augmentation of pathological, stable but painful vertebral body fractures, are strongly advised to reduce the peri-operative complication rate. 73 The last element of the NOMS framework is the systemic assessment which means the prediction of the patient’s ability to tolerate the proposed intervention. Comorbidities, general health status and tumour burden have to be assessed.…”

“…Therefore, the minimally invasive separation of the tumour tissue from the dural sac (separation surgery) with post-operative SRS radiotherapy would be the optimal treatment choice in a high number of cases, providing safe and effective local control. 73 …”

Decision Making in Patients With Metastatic Spine. The Role of Minimally Invasive Treatment Modalities

“…Differently from open surgical treatments, MISS allows earlier post-surgical irradiation (i.e., 1 week after), with patients anecdotally treated as early as 3 days after surgery using a stereotactic technique (94). The efficacy of a combination of MISS and stereotactic body radiotherapy has been adopted also in patients with malignant primary tumors of the spine, for whom en bloc resection was not considered because of the encasement of the spinal cord or vascular structures (95).…”