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Hindawi Publishing Corporation International Journal of Surgical Oncology Volume 2011, Article ID 598148, 9 pages doi:10.1155/2011/598148 Review Article A Systematic Review of the Current Role of Minimally Invasive Spine Surgery in the Management of Metastatic Spine Disease Camilo A. Molina, Ziya L. Gokaslan, and Daniel M. Sciubba Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Meyer Building 5-185a, Baltimore, MD 21287, USA Correspondence should be addressed to Daniel M. Sciubba, firstname.lastname@example.org Received 19 February 2011; Accepted 30 March 2011 Academic Editor: Charles Fisher Copyright © 2011 Camilo A. Molina et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Although increasingly aggressive decompression and resection methods have resulted in improved outcomes for patients with metastatic spine disease, these aggressive surgeries are not feasible for patients with numerous comorbid conditions. Such patients stand to beneﬁt from management via minimally invasive spine surgery (MIS), given its association with decreased perioperative morbidity. We performed a systematic review of literature with the goal of evaluating the clinical eﬃcacy and safety of MIS in the setting of metastatic spine disease. Results suggest that MIS is an eﬃcacious means of achieving neurological improvement and alleviating pain. In addition, data suggests that MIS oﬀers decreased blood loss, operative time, and complication rates in comparison to standard open spine surgery. However, due to the paucity of studies and low class of available evidence, the ability to draw comprehensive conclusions is limited. Future investigations should be conducted comparing standard surgery versus MIS in a prospective fashion. 1. Introduction Ideal management is multidisciplinary and involves vari- ous medical specialties such as neurosurgery, surgical oncol- It is estimated that nearly 10 million people worldwide were ogy, medical oncology, radiation oncology, interventional diagnosed with cancer in 2000, with the incidence expected radiology, pain specialists, and rehabilitation therapy [4, 5]. to increase to 15 million by 2020 . The most commonly Management strategies involve a combination of surgery diagnosed neoplasms are breast, lung, and prostate cancers (for candidate patients), radiotherapy, and pharmacotherapy [2, 3]. Metastatic invasion of the spinal column can occur [4, 5, 11]. Due to both the short life expectancy of aﬄicted via various mechanisms that are dependent on both the bio- patients and high systemic tumor burden [8, 9, 12–14], logical behavior and physical location of the primary tumor with the exception of solitary metastatic lesions such as . Given the predilection of the breast, prostate, and lung in the setting of renal cell carcinoma, treatment regimens neoplasms to metastasize to bone, it is not surprising that are most often palliative rather than curative . Aﬄicted spinal metastases occur in 30–90% of patients, with 10% of patients frequently present with inﬁltration of the spinal such patients experiencing symptomatic metastatic epidural column with tissues that lack weight bearing properties spinal cord compression (MESCC) [4, 5]. The most common resulting in spinal instability, particularly ventral column symptom at presentation is pain that can be both radicular instability given that most metastatic lesions localize to the (exaggerated by percussion or palpation) and/or mechanical anterior elements . Optimal treatment of such patients (exacerbated by movement) [6, 7]. Neurological dysfunction requires stabilization in addition to traditional (surgical or including motor, sensory, and autonomic dysfunction is nonsurgical) decompression [4, 15]. The most eﬃcacious the second most common presentation modality and is modality for restoring column instability is reconstructive indicative of metastatic epidural spinal cord compression surgical intervention. Unfortunately, numerous patients are (MESCC) [3, 8–10]. not considered candidates for surgical intervention due to 2 International Journal of Surgical Oncology neoplasm-associated comorbidities such as malnourishment (ii) Criteria for exclusion were the following: and diminished immune system that make extensive surgical procedures unfeasible . Such patients can be managed (a) iontradural spine tumors, with vertebral augmentation, as it can provide some degree (b) primary spine tumors, of restabilization . However, surgical advances in the ﬁeld (c) pediatric age groups, of minimally invasive spine surgery (MIS) have opened the door for not only extended surgical candidacy to patients (d) articles with no extractable data speciﬁc to who were previously ineligible, but it has also established the metastatic spine disease. setting for surgical intervention with minimal perioperative morbidity such as decreased pain, less blood loss, and shorter 2.3. Study Eligibility and Quality Assessment. Abstracts were hospital stays [11, 15–23]. This paper aims to describe the screened by two independent reviewers using the above- current role of MIS in the treatment of metastatic spine stated inclusion and exclusion criteria. Cases of reviewer disease. The overall objectives of this paper are to present a disagreement were resolved by a third reviewer. Full-text systematic review of literature with regard to the following versions of acceptable article were gathered and subjected clinical questions: to more detailed screening for inclusion. After ﬁnalizing a collection of eligible studies, the studies were analyzed in detail, and the data pertaining to the research questions was (1) the eﬃcacy of MIS in improving neurological and extracted and tabulated by one reviewer. The second reviewer pain-associated outcomes in the setting of metastatic checked the extracted information. spine disease; (2) the incidence of complications associated with MIS in the setting of metastatic spine disease. 3. Results A total of eleven publications were ultimately found eligible to evaluate the clinical outcomes associated with MIS as 2. Methods a treatment for metastatic spine disease. All of the publi- 2.1. Search Strategy. A systematic review of literature was cations available were retrospective in nature. Nine of the performed employing Pubmed and a review of bibliogra- publications were retrospective case series, and two of the phies of reviewed articles. The search query was broad publications were case reports. Although case reports are and formulated to combine a number of subheadings and normally excluded in systematic reviews, they were included keywords that included the therapies and pathology of in this review due to the paucity of evidence evaluating MIS interest. The search string employed was the following: in the setting of metastatic spine disease. The main outcomes (“Minimally Invasive Surgery” OR “MIS” OR “VAST” extracted from the selected publications included mean OR “endoscopic thoracoscopy” OR “mini-open spine operating time (MOT), mean blood loss (MBL), hospital surgery” OR “minimal access spine surgery” OR “MASS”) length of stay (LOS), rate of neurological improvement AND ((“bone neoplasms” (Mesh) OR “spinal neoplasms” (NI), pain alleviation rate (PA), and complication rate (CR). ∗ ∗ (Mesh)) OR (“spin ”AND “metasta ”) OR (“Spinal Cord Collected outcomes are tabulated in Tables 1 and 2. Compression” (Mesh) OR “spinal cord compression”) OR (“epidural neoplasms” (Mesh) OR “epidural neoplasm”)). 3.1. Video-Assisted Thoracostomy (VAST). There were a total of ﬁve publications addressing the use of VAST or endoscopy-assisted posterior decompression to manage 2.2. Eligibility Criteria patients with metastatic spine lesions. Four of the publica- tions were retrospective case series, and one was a case report. (i) Criteria for possible inclusion were the following: The earliest description of VAST for managing metastatic vertebral was published by Rosenthal et al.  in 1996. (a) articles published between 1980 and 2011, The authors described the development of an endoscopic (b) all articles in English or with an English trans- procedure to achieve anterior vertebrectomy, reconstruction, lation, and stabilization of the thoracic spine in 4 patients aﬄicted with metastatic spine lesions. All patients were in good health (c) adult age group (18 years and older), condition but were experiencing progressive neurological decline and radiological evidence of bone destruction and (d) articles describing the use of minimally invasive cord compression. The study reported a 6.5 hr MOT, 7.5 day spine surgery modalities in the treatment of LOS, and 1450 mL MBL. The authors found that MBL was metastatic disease, correlated to MOT and extent of vertebrectomy. Addition- (e) fully published peer reviewed studies including ally, all of the patients were ambulatory with assistance on RCTs, nonrandomized trials, cohort studies, postoperative day 1, ambulatory with a Jewett brace during case control studies, case series, and case the ﬁrst 4 weeks, and independently ambulatory at 11-month reports. Both prospective and retrospective followup (NI: 100%). Patients were pain-free following chest studies were considered. drain removal on day 3 or 4 and remained pain-free at International Journal of Surgical Oncology 3 Table 1: Endoscopic video-assisted thoracoscopy (VAST) outcomes. MOT: Mean operating time; LOS: Length of stay; NI: Neurological improvement rate; PA: Pain alleviation rate; CR: Complications rate; MBL: Mean blood loss. Study Design and procedure Outcome results MOT: 6.5 hours LOS: median 7.5 days NI: All patients experienced neurological improvement; Retrospective analysis (n = 4) of outcomes associated in addition, all were independently ambulatory at time Rosenthal et al. ; with VAST MIS management of thoracic metastatic discharge and followup (mean 11 mo.) spine disease PA: All patients free of pain at time of discharge and followup (mean 11 mo) CR: none MBL = mean 1450 mL MOT: 3.1 hours Retrospective analysis (n = 41) to analyze the Huang et al.  CR: 54% complication rate in VAST MIS MBL: mean 775 mL MOT: 2.6 hours NI: Both patients experienced neurological improvement and were independent at followup (mean Case series (n = 2) to report outcomes associated with 9.5 mo) Le Huec et al. , the use of VAST to manage spinal metastases at the PA: Both patients experienced pain relief and only one cervicothoracic junction required narcotics postoperatively CR: 1 patient suﬀered a progressive recurrent laryngeal nerve palsy MBL: 350 mL MOT: 6 hours LOS: 6.5 days NI: All 8 patients experienced neurological Retrospective case series (n = 8) to evaluate outcomes improvement McLain , 2001 of endoscopy-assisted posterolateral approach to PA: All 8 patients experienced pain relief. Additionally manage thoracic metastatic spine disease 63% of patients experienced complete pain relief CR: none MBL: 1677 mL NI: Patient was neurologically intact at two-month Case report (n = 1) of endoscope-assisted posterior Mobbs et al. , followup. Patient initially presented with hyperreﬂexia decompression of a solitary renal cell carcinoma 2002 PA: Patient was pain-free at two-month followup metastatic lesion CR: Patient experienced no procedural complications 11-month followup (PA: 100%). The study reported no superﬁcial wound infection (7%),atelectasis (5%),pericar- complications (Table 1). dial penetration (2%), implant failure (2%), and death (2%). Huang et al.  published a retrospective case review Notably, none of the complications occurred due to injury to of 90 patients who had undergone VAST for various spinal the spinal cord, a great vessel, or internal organ (Table 1). pathologies, of which 41 cases were due to metastatic Le Huec et al.  published a small case series of two lesions. The main goal of the study was to evaluate MIS patients in which VAST was used to manage metastatic spine complication rates. Procedures performed for the metastatic disease encompassing the cervicothoracic junction. The goal lesion aﬄicted subgroup included biopsy only, corpectomy of the authors was to develop an alternative approach to for decompression, and corpectomy with interbody fusion. the traditional lateral approach that requires mobilization Although the study did not stratify MOT (3.1 h) or MBL of the scapula to visualize the T1, T2, and T3 spinal (775 mL) according to neoplastic or nonneoplastic etiologies, levels. The technique was technically feasible and allowed the study did stratify complication rates. The authors for ample access to achieve corpectomy and visualization reported a total of 30 complications in 22 patients (overall of the posterior longitudinal ligament, thereby allowing for CR: 33%) for the 90 procedures performed. Importantly, complete release of the cord. MOT was 2.6 hours, MBL was 22 of those complications occurred among the 41 patients 350 mL, and mean LOS was 6.5 days. Both patients presented treated for metastatic spine disease (CR: 54%). Additionally, with progressive neurological decline but were independently the authors also noted that the most common complication ambulating at last followup (7 and 12 months) (NI: 100%). was excessive intraoperative bleeding, with all 5 instances Both patients experienced substantial pain relief (PA: 100%), occurring in patients with metastatic disease. The additional but one required narcotics at the followup due to having complications encountered were intercostals neuralgia (7%), undergone additional surgeries for other metastases. One 4 International Journal of Surgical Oncology patient acquired a progressive recurrent laryngeal nerve palsy tumor recurrence (1), implant failure (1), and metastasis (CR: 50%) (Table 1). (1). Complications encountered from ST included sepsis (1), postoperative pneumonia (1), pneumothorax (1), GI bleeding (1), and UTI (1). Additionally, 2 year survival 3.2. Endoscopy-Assisted Posterior Decompression. McLain rates were also not signiﬁcantly diﬀerent (MASS: 24% versus  reported a retrospective case series of 8 patients aﬄicted ST: 29%, P = .69). However, the authors found that the with metastatic spine lesions to demonstrate the feasibility of percentage of patients requiring at least a 2-day postoperative endoscopically assisted (transpedicular) decompression and admission to the intensive care unit (ICU) was signiﬁcantly stabilization through a single, extrapleural, and posterolat- diﬀerent when comparing MASS to ST, with MASS resulting eral approach. MOT was 6.5 hours, and MBL was 1677 mL. in signiﬁcantly less admissions (MASS 6.9% versus ST: 88%, All 6 of the patients that presented with neurological deﬁcit P ≤ .001) (Table 2). recovered completely and maintained neurological integrity Deutsch et al.  reported a retrospective case series until the last followup or terminal care (3–36 months) (NI: of 8 patients undergoing MASS posterolateral vertebrectomy 100%). The other 2 patients not presenting with neurologic and decompression to treat symptomatic thoracic MESCC. compromise retained neurological function until the last The patient population was compromised of patients not followup or terminal care (3–36 months). All 8 patients deemed candidate for conventional open thoracotomy due experienced pain relief (PA: 100%), and 5 patients (62.5%) to age (mean 74 y), limited life expectancy, and/or systemic did not require any analgesics at the last followup. The metastatic burden. MOT was2.2 hoursand MBLwas authors concluded that endoscopy augmented the eﬃcacy of 227 mL. All patients presented with substantial neurologic the posterolateral approach by improving the visualization of deﬁcit (mean Nurick grade: 4.35 (range 3–5)) and pain structures that were traditionally diﬃcult to access through a (mean numerical pain score (NPS) 5.5 (range 3–8)). Post- standard posterolateral approach (Table 1). operatively, 5 patients experienced neurologic improvement Mobbs et al.  published a case report of endoscope- (NI: 62.5 %), and the mean Nurick grade of all patients assisted posterior decompression of a solitary renal cell decreased to 3.13. 5 patients experienced pain alleviation carcinoma metastatic lesion. The patient initially presented (PA: 62.5%), with the group mean NPS decreasing to 3.10. with hyperreﬂexia and back pain but was neurologically There was no incidence of complications reported (Table 2). intact and pain-free at two-month postoperative followup. Kan and Schmidt  published a retrospective case The patient’s course was uncomplicated throughout the series of 5 patients with metastatic disease of the thoracic procedure and postoperative recovery (Table 1). spine who underwent ventral decompression via MASS. The procedure included a corpectomy, interbody fusion, 3.3. Minimal Access Spine Surgery (MASS). There were a expandable cage-mediated reconstruction, and stabilization total of six publications addressing the use of MASS to via anterior plating through MASS techniques. MOT was manage patients with metastatic spine lesions. Muhlbauer et 4.3 hours, MBL was 610 mL, and mean LOS was 6.25 days. al.  published the ﬁrst description of MASS for managing All patients who presented with neurological deﬁcits were metastatic spine disease in 2000. The authors reported a neurologically intact at 6-month followup (NI: 100%). The preoperating mean VAS score for the group was 6.8, and it small retrospective case series regarding the management of 5 patients with compression fractures from osteoporosis or decreased to 3 at 6-month followup. Additionally, all patients metastatic lesions. Reported MOT was 6 hours, and MBL experienced some degree of pain relief (PA: 100%) (Table 2). Payer and Sottas  published a case series of 37 was 1120 mL. All 5 of the patients presented preoperatively with both pain and neurological dysfunction. At followup, patients, 11 of which were aﬄicted with thoracic metastasis all patients had experienced neurological improvement (NI: to the spine and managed via MASS using the SynFrame 100%) characterized by either progressing from ambulating (Stratec Medical; Obendorf, Switzerland) table mounted with a cane to ambulating unassisted, or from being retractor. The authors stratiﬁed results according to tumor and nontumor etiology. MOT for tumor patients was 188 nonambulatory to ambulating with a cane. Additionally, all patients experienced signiﬁcant pain relief (PA: 100%) with minutes versus 178 minutes for nontumor patients. MBL 40% of the patients not utilizing analgesics at followup (6–12 for tumor patients was 711 mL versus 598 mL for nontumor patients. There were 4 complications (15%) in the nontumor months) (Table 2). Huang et al.  published a retrospective analysis of group and 2 complications in the tumor group (18%). Neu- 46 patients to compare outcomes in MASS (n = 29) rological outcomes were not stratiﬁed according to etiology. However, it was reported that of the 22 patients presenting and standard thoracotomy (ST, n = 17) in the setting of metastatic spine disease. There was no signiﬁcant diﬀerence with neurological deﬁcits, 20 patients demonstrated recovery in MOT, MBL, NI, or CR. MOT for MASS was 179 minutes (NI: 92%). Preoperative and postoperative pain outcomes versus 180 minutes for ST (P = .54). MBL for MASS was were not compared (Table 2). 1,100 mL versus 1,162 mL for ST (P = .63). Neurological Taghva et al.  published a case report describing a T4 and T5 vertebrectomy with expandable cage placement outcome was reported as the postoperative reacquisition of ambulation. NI for MASS was 70.8% versus 69.2% for coupled with T1–T8 screw ﬁxation and fusion using MASS. ST (P = .6). CR for MASS was 24% versus 29% for ST The patient was aﬄicted with metastatic adenocarcinoma of the lung and presented with back pain for more than 4 (P> .05). Complications encountered from MASS included dural tears (2), femoral fracture (1), pneumothorax (1), months. On neurological examination, the patient was found International Journal of Surgical Oncology 5 Table 2: Minimal access spine surgery outcomes. MOT: Mean operating time; LOS: Length of stay; NI: Neurological improvement rate; PA: Pain alleviation rate; CR: Complications rate; MBL: Mean blood loss, SVR: 2-year survival rate. Study Design and procedure Outcome results MOT: 6 hours NI: All patients experienced neurological improvement Retrospective case series (n = 5) of patients undergoing and were ambulatory at followup (6 mo to 1 yr) Muh ¨ lbauer et al. , lumbar corpectomy and anterior reconstruction via PA: All patients experienced pain relief. 40% of patients 2000 MASS in the setting of osteoporotic or did not utilize analgesics at 1-year followup malignancy-related compression fractures CR: Segmental vessel nick via a high-speed drill. Bleeding was adequately controlled MBL: 1120 mL MOT: MASS = 179 mins versus ST = 180 mins; P = .54 %Requiring 2-dayICU stay: MASS = 6.9% versus ST = 88%, P ≤ .001 Retrospective analysis (n = 46) comparing MASS Huang et al. , NI: Reacquisition of ambulation postoperatively; MASS (n = 29) to standard thoracotomy (ST) (n = 17) in the 2006 = 70.8% versus ST = 69.2%, P = .6 management of thoracic spinal metastasis SVR: MASS = 27.4 mo versus ST = 24.8 mo, P = .68 CR: MASS = 24% versus ST = 29% MBL: MASS = 1,100 mL versus ST = 1,162 mL, P = .63 MOT: 2.2 hours LOS: 4 days Retrospective case series (n = 8) of patients undergoing Deutsch et al. , NI: 62.5% of patients MASS posterolateral vertebrectomy and decompression 2008 PA: 62.5% of patients for the management of thoracic spinal metastasis CRs: none MBL: 227 mL MOT: 4.3 hours LOS: 6.25 Retrospective case series (n = 5) of patients undergoing Kan and Schmidt NI: All patients experienced neurological improvement MASS anterior corpectomy and decompression for the , 2008 PA: All patients experienced pain alleviation management of thoracic spinal metastasis CR: none MBL: 610 mL MOT: 188 mins Retrospective case series (n = 11) analyzing operative NI: All patients neurologically intact, at presentation outcomes of MASS conducted with the SynFrame remained intact and 91% of patients with preoperative Payer and Sottas , (Stratec Medical, Obendorf, Switzerland) table deﬁcit experienced neurological improvement mounted retractor in the setting of thoracic metastatic CR: 18% (2/11; one dural tear and one superﬁcial spine disease wound infection) MBL: 711 mL MOT: 7 hours LOS: 5 days Case report of a man undergoing vertebrectomy and NI: Patient experienced myelopathy relief and was Taghva et al. , expandable cage reconstruction for the management of ambulatory on postoperative day 1 2010 metastatic lung adenocarcinoma localized to the PA: at 9-month followup, patient remained back thoracic spine pain-free with no use of analgesic medications CR: none MBL: 1200 mL to have decreased strength and sensation. Operative time was outcomes of VAST and endoscopy-assisted posterior decom- 7 hours, and blood loss was 1200 mL. The patient was dis- pression in the setting of metastatic spine disease. Data was charged 5 days following surgery. Neurological outcome was compiled and yielded a median MOT of 4.6 hours (2.6– positive, with the patient being ambulatory postoperatively 6.5 hours), a median MBL of 1113 mL (350–1677 mL), 7- on day 1 and completely recovering strength and sensory day median LOS (6.5–7.5 days), 100% median NI (92%– function at 9-month followup. Similarly, pain alleviation was 100%), 100% median PA (94%–100%), and 0% median CR satisfactory with the patient reported to be pain-free at 9- (0%–54%) (Table 3) Data gathered from the 6 publications, month followup (Table 2). totaling 76 patients, to evaluate MASS outcomes in the setting of metastatic spine disease yielded similar results with 3.4. Summary. There were a total of 5 publications, encom- a median MOT of 3.7 hours (2.2–7 hours), a median MBL passing a total of 105 patients, selected to review the of 905 mL (227–1200 mL), 5-day median LOS (4–6.25 days), 6 International Journal of Surgical Oncology Table 3: Minimally invasive spine surgery outcomes summary. rates. In 2004, Klimo Jr. et al.  published a meta-analysis VAST: Video-assisted thoracoscopy; MASS: Minimal access spine comparing outcomes of surgery and radiotherapy manage- surgery; mMOT: Median mean operating time; mLOS: Median ment compared to radiotherapy alone and reported superior mean length of stay; NI: Median neurological improvement rate; outcomes for patients who underwent surgery in addition PA: Median pain alleviation rate; mCR: Median complication rate; to radiotherapy. In 2005, Patchell et al.  conducted mMBL: Median mean blood loss. the ﬁrst randomized control study comparing the eﬃcacy VAST (median (range)) MASS (median (range)) of radiotherapy and surgery to that of radiotherapy alone. Similar to the results of Klimo Jr. et al. , the study not N = 105 patients 76 patients only found functional and survival outcomes to be superior mMOT 4.6 hours (2.6–6.5 hours) 3.7 hours (2.2–7 hours) in the surgery plus radiotherapy group but also reported that mLOS 7 days (6.5–7.5 days) 5 days (4–6.25 days) surgical intervention was cost eﬀective, cementing the role mNI: 100% (92%–100%) 95% (62.5%–100%) of surgery in the management of metastatic spine disease for mPA: 100% (94%–100%) 100% (62.5%–100%) candidate patients. mCR: 0% (0%–54%) 9% (0%–24%) Although surgery plus radiation has been shown to mMBL 1113 mL (350–1677 mL) 905 mL (227–1200 mL) be superior to radiation alone in a class I study, the role of surgical intervention remains controversial due to the diﬃculty of appropriate patient selection. Numerous factors 95% median NI (62.5%–100%), 100% median PA (62.5%– such as tumor type, extent of metastatic disease, spinal 100%), and 9% median CR (0%–24%) (Table 3). In com- stability, neurologic status, comorbid conditions, and life paring VAST to MASS (Table 3), the data suggests that expectancy are considered when evaluating a patient for VAST was associated with longer operative times, increased potential surgical candidacy [4, 15]. Furthermore, numerous hospital length of stay, and increased blood loss. However, scoring systems such as that of Tokuhashi et al. and VAST compared favorably when looking at median neuro- Tomita et al.  have been created to guide patient selection logical improvement and median complication rates. Despite and dictate the aggressiveness of the respective surgical inter- appearing clinically signiﬁcant, it is uncertain whether these vention. Unfortunately, the advances in surgical technique diﬀerences are statistically signiﬁcant. that improved surgical outcomes in patients with metastatic lesions required aggressive methods such as circumferential decompression or combined (anterior, posterior, and lateral) 4. Discussion approaches that were only feasible in healthier patients Surgical intervention in the setting of metastatic spine disease with respective longer life expectancies and thus were not commenced prior to the advent of radiotherapy, and the feasible for patients with numerous comorbid conditions or initial goals of treatment were to achieve decompression of contraindications such as ongoing chemotherapy . the spinal cord. This was most commonly performed via a Minimally invasive spine surgery was created with the dorsal laminectomy, as it was believed that this would relieve purpose of minimizing soft tissue surgical trauma and the pressure on the cord resulting in a reversal of neurologic thereby accelerating postoperative care [16, 18, 43, 44], with- out a loss of surgical eﬀectiveness, and was thus applicable deﬁcits. However, the majority of metastatic neoplasms aﬀect the anterior column and thus when combined with to the management of metastatic spine disease in patients destabilization of the posterior column via a laminectomy, not candidate for conventional surgical intervention. More speciﬁcally, patients with single or adjacent level involvement patients experienced rapid destabilization of the entire spinal column along with both cord vascular insuﬃciency and with neurologic symptoms from spinal instability or neuro- radicular compression due to the loss of spinal column logical structure compression and a life expectancy of at least integrity [2, 32]. 3 months are considered candidate for MIS [15, 16, 18]. With the advent of radiotherapy, evidence accrued There are two main modalities of minimally inva- sive spine surgery: endoscopic video-assisted thoracoscopic demonstrating no neurological beneﬁt to surgical inter- vention, speciﬁcally laminectomy alone, in comparison to surgery (VAST) and mini-open surgeries otherwise known radiotherapy alone, and thus surgery as a primary treatment as minimal access spine surgery (MASS) . VAST, ﬁrst described in 1993 , allows for the visualization and modality was abandoned [33–36]. However, spine surgery in the setting of the metastatic spine disease continued magniﬁcation of the entire ventral spine from T1 to T12, to advance as surgeons continued to operate in patients thereby allowing for decompression, reconstruction, and sta- bilization similar to an open thoracotomy. However, unlike whose neurological function was not improved following radiotherapy . During the 1980s, rapid advances in both an open thoracotomy, VAST has the advantage of decreased surgical technique and advances in spinal instrumentation pulmonary morbidity, preservation of chest wall motion, resulted in the publication of the studies that re-established decreased intercostal neuralgia, and avoidance of scapular a role for surgical intervention as an addition to radio- dysfunction . Furthermore, VAST can be combined with laparoscopic techniques to permit similar visualization and therapy [37, 38]. In 1983, Constans et al.  published a retrospective case series of 600 patients with symptomatic manipulation of the lumbar spine [15, 29]. Despite advan- MESCC and reported a neurological stabilization rate of tages, VAST has not become a widely adopted procedure due to practical limitations such as a steep learning curve, 41% and a neurological improvement rate of 44%, both of which were rates considered to be superior to prior reported increased surgical time, relative diﬃculty in controlling International Journal of Surgical Oncology 7 intraoperative bleeding, and expensive equipment needed to performed in the setting of thoracolombar spine pathology. perform the procedure [15, 47]. One of the limitations commonly associated with MIS proce- MASS was ﬁrst described in 1997  as a microsurgical dures is prolonged operative time. Data gathered contradicts approach for performing an anterior lumbar fusion, covering this notion and suggests that both VAST and MASS collective all levels from L2 to S1. It has since become more popular median operating times (mMOT) compare favorably to open than VAST as an MIS modality as it is easier to learn, is standard thoracotomy (ST) operating times collected by a more familiar exposure to most spine surgeons, permits Smith et al.  (VAST: 4.6 hours (2.6–6.5 hours); MASS: faster decompression of the spinal canal [23, 30, 49], 3.7 hours (2.2–7 hours); ST: 4.65 hours (2.3–10.2 hours)). potentially allows for safer mobilization of neurovascular Decreased complication rates, blood loss, and length of structures, and provides three-dimensional direct vision stay are considered to be among the beneﬁts of MIS. This allowing for easier reconstruction of the anterior column was conﬁrmed by outcomes data compiled in our study . Since its introduction, the procedure has been modiﬁed when compared to gathered data outcomes for ST . to permit access from T2 to S1 via a combination of mini- Median mean complication rates (mCR) for VAST (0% (0%– open thoracotomy and/or retroperitoneal miniapproach [30, 54%)) and MASS (9% (0%–24%)) compared favorably to 49]. those of ST (30.5% (15%–94.4%)). Similarly, median mean In this study, we performed a systematic review of blood loss (mMBL) and median mean length of stay (mLOS) published literature to date with the goal of evaluating the for both VAST (mMBL: 1113 mL (350–1677 mL); mLOS: clinical eﬃcacy and safety of MIS in the setting of metastatic 7 days (6.5–7.5 days)) and MASS (mMBL: 905 mL (227– spine disease. A total of 11 studies speciﬁcally reporting 1200 mL); mLOS: 5 days (4–6.25 days)) was decreased in outcomes of metastatic spine cases managed via MIS were comparison to data gathered for ST  (mMBL: 2100 mL gathered. 5 of the studies, totaling 105 patients employed (460–3136 mL); mLOS: 14.6 days (7.2–35.5 days)). It should VAST, and 6 of the studies, totaling 76 patients, employed be noted that the paper by Huang et al.  included in MASS. All of the collected studies were retrospective (Class this review performed a direct retrospective comparison of IV evidence), and two of the studies were case reports. MOT, MBL, LOS, and CR for MASS versus ST and found no Although traditionally excluded from systematic reviews, the signiﬁcant diﬀerence in rates for any of the latter. However, two case reports collected were included in our study due to the study did ﬁnd a signiﬁcant diﬀerence in the incidence the scarcity of published studies reporting on the use of MIS of patients that required at least a two-day admission to the to treat metastatic spine lesions. ICU postoperatively (MASS: 6.9% versus ST: 88%). If there We evaluated the clinical eﬃcacy of MIS for the treatment truly is not a diﬀerence in these operative variables, it is of metastatic vertebral lesions via neurological improvement possible that the potential beneﬁt of MIS is counteracted by rate and pain alleviation rate outcome data. Collected data the more complicated nature of operating in patients with from each study was compiled to yield median mean metastatic spine disease . This observation was present neurological improvement (mNI) and median mean pain in the study included by Payer and Sottas in which alleviation rate (mPA). mNI for VAST was 100% (92%– mean blood loss, operative time, and complication rates 100%) and 95% (62.5%–100%) for MASS. mPA for VAST were higher in patients being operated for spinal tumors was 100% (94%–100%) and 100% (62.5%–100%) for MASS. versus those operated on the spine for pathology other than The neurological improvement and pain alleviation rates are tumor. similar to those provided by the Class I study conducted by Patchell et al. that evaluated surgery plus radiotherapy 5. Conclusions outcomes . Given the high rates of neurological dys- function and pain alleviation, the results suggest that both A systematic review of the literature yielded Class IV data VAST and MASS are eﬃcacious means of achieving pain and suggesting that both VAST and MASS MIS modalities are neurological dysfunction relief through decompression and eﬃcacious means of achieving neurological improvement stabilization. and alleviating pain in the treatment of metastatic spine Operative variables such as operative time, blood loss, disease. However, the magnitude of neurological improve- complication rate, and hospital stay are considered markers ment and/or pain alleviation cannot be accurately quantiﬁed of safety and practicality. Prolonged operating times are by such retrospective studies. Such studies suggest that associated with an increased amount of complications (i.e., minimally invasive surgery for metastatic spine disease oﬀers higher wound infection rate) and costs . High blood loss decreased blood loss, operative time, and complication rates leading to perioperative anemia leads to increased morbidity in comparison to standard open spine surgery. Furthermore, (i.e., surgical site infections), mortality, length of stay, and these studies also suggest that MIS implementation was not readmission rates . Furthermore, patients with high limited by increased operative times. Nonetheless due to blood loss often require transfusions which are associated the paucity of studies and low class of available evidence, with higher risks of infection, acute immune-mediated the ability to draw comprehensive conclusions is limited. hemolytic reactions, and gastrointestinal complaints . Minimally invasive surgery thus remains a viable option Longer hospital stays result in higher costs and are indicative for the treatment of spinal metastases. Future investiga- of increased patient morbidity . 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