20 Quality of Life in Advanced Tumors: Can Minimally Invasive Surgery Techniques Improve the Quality of Life of Patients with Advanced Oncologic Disease to Allow for Decreased Pain or Should Traditional Techniques of Palliation Be Used? Metastatic cancer causes approximately 500,000 deaths every year.1 Moreover, metastatic epidural spinal cord compression (MESCC) is an increasingly common and debilitating process associated with cancer where compression of the spinal cord causes neurological deficit.1,2 There were a projected 1.5 million new cases of cancer in the United States in 2010,3 with MESCC occurring in 5 to 10% of patients with cancer. The most common primary tumors that metastasize to the spine consist of lung, breast, prostate, melanoma, gastrointestinal (GI), and kidney.4,5 The prognosis of these individual metastatic cancers is variable. In a retrospective review of MESCC at Johns Hopkins University from 1996 to 2006, the mean survival after surgery was 10.8 months with the median survivals at the following: lung (4.3 months), breast (21 months), prostate (3.8 months), melanoma (40.9 months), GI (5.1 months), and kidney (19.8 months).6 Management of spinal metastases is undergoing an exciting transition given patients are living longer with improved medical therapies and the operative management is transitioning toward minimally invasive approaches. As with every paradigm shift, a critical view of this transition must be taken to weigh the advantages and disadvantages for patients. Minimally invasive surgery (MIS) aims to decrease the morbidities associated with open surgeries by reducing tissue damage. In the context of spinal metastases, MIS encompasses a variety of techniques, such as endoscopy video-assisted thoracoscopic surgery (VATS),7 mini-open decompression,8 minimal access spine surgery (MASS),9 and percutaneous pedicle screw placement.10 Vertebral augmentation procedures such as vertebroplasty and kyphoplasty are also considered “minimally invasive,” albeit not surgical.10 In order to keep our discussion focused, we hereby constrain MIS studies for spinal metastases to those involving minimally invasive retractors and/or the mini-open technique. We compare MIS to open surgeries, which consist of corpectomies utilizing posterior, anterior, or mixed approaches, followed by stabilization. The evidence we provide is restricted to studies that provide statistical outcomes specific to patients with spinal metastases. In general, patients with metastatic spine disease presenting with mechanical instability, radioresistant tumors, medically intractable pain, and/or progressive neurological deficits resulting from spinal cord compression are candidates for surgery, given that they have sufficient life expectancy and health status.11,12,13 With regard to the life expectancy, the literature suggests a predicted survival of at least 3 months from open surgeries.8 MIS is suitable for candidates with less favorable characteristics, such as high systemic tumor burden, aggressive tumor pathology, shorter expected survival (less than 6–12 months), and old age.14,15,16 Because MIS in the field of spinal metastases has expanded significantly only in the past decade, various exclusion guidelines for MIS are accruing based on the approach used.17 MIS is becoming increasingly popular because it provides patients with the desired outcomes associated with open surgery ( From a financial perspective, a relatively recent study suggests that newer MIS and mini-open techniques significantly lower acute and subacute costs relative to open techniques due to potential decreased complication rates, length of stay (LOS), and blood loss, as well as fewer discharges to rehab. However, these results are based on low-class evidence that does not have long follow-up periods and includes patients of pathologies other than metastasis.24 Open surgical techniques are more familiar to spine surgeons and are not associated with as many inherent limitations of MIS. For example, the restricted operating view in MIS can impede upon the ability to effectively identify anatomical structures and resect tumor; surgeons must be careful not to overuse cauterizing tools when clearing their working window, which can inadvertently lead to muscle and ligament damage.20 Furthermore, multiple-level lesions and kyphotic deformities are more effectively treated using open surgery, as certain MIS techniques using tubular retractors expose only one vertebral body level.16 With regard to cost, equipment for open surgeries is cheaper than that needed for thoracoscopic or laparoscopic MIS procedures.8 Finally, open surgeries are generally reported to have an easier learning curve.14,25 A 75-year-old male patient with a history of colon cancer complained of upper back pain beginning weeks before his recent admission. Magnetic resonance imaging (MRI) demonstrated a metastatic lesion at T3, with epidural spinal cord compression ( Fig. 20.1 Preoperative T2-weighted sagittal magnetic resonance imaging demonstrates cord-compressing metastatic lesion at the T3 vertebral body with compromised integrity. The patient was brought to the operating table and intubated after induction. The patient was then placed prone on a Jackson table; the head is fixed into a Mayfield head holder. Antiseptics were then applied to the patient’s lower neck and upper back. The surgeon was standing on the left of the patient. A line was drawn along the midline of the patient’s back. The level of operation was located by counting the number of ribs down from the cephalad, as well as by checking aspects of the pedicles, which appear loose or absent on the AP (anteroposterior) projection. Upon identifying the tumorous vertebral level, small 3-cm incisions are made off the midline to allow for a trajectory conducive to a bilateral costotransversectomy. These areas are infiltrated with about 10 mL of lidocaine each. DuraPrep was applied in two applications over the patient’s back and a timeout is done. The patient is then draped in a sterile fashion and the fluoroscope was brought in and draped sterilely as well At this point, two surgeons began operating in tandem; the dermis was cut through using bipolar and unipolar cautery, and the trapezius and paraspinal muscles are separated using a muscle-splitting approach until the transverse process of the metastatic level was reached. Another X-ray was taken to confirm the level. Bilateral pipeline distractible tubular retractors are positioned to dock upon the transverse processes. Using subperiosteal dissection, the entirety of the affected level, as well as top of the level below and the bottom of the level above, is exposed. With high-speed drill, rongeurs, and curettes, bilateral laminectomy is performed at the affected level, and partial laminectomies are performed at the level above and the level below. Then, a bilateral costotransversectomy was conducted by taking the transverse process and rib off at the affected level and the one above it, allowing for a transpedicular vertebrectomy at the affected level. The cord was completely decompressed from any tumor or bone. Nerve roots (in our case, T2 and T3) are tied using double ligature ties, bipolared, and cut lateral to the ties. Using high-speed drill, curettes, and Kerrison punches, the entirety of the affected vertebral body was removed, as well as the discs above and below. Throughout this time, the patient’s evoked potentials are monitored, as motor evoked potentials may return following decompression (in our case, they did not). A mesh titanium cage filled with allograft bone (to facilitate arthrodesis) was placed in the vertebral body defect and checked for correct alignment via fluoroscopy. Small incisions are made through skin and fascia, so that Jamshidi needles can be placed in alignment with the pedicles at two levels above and below the resected vertebral body. Once placement was confirmed with fluoroscopy, Kirschner’s wires are inserted into each of the areas. The patient underwent serial tapping and placement of mesh premeasured screws. Then, a minimally invasive rod was anchored and clamped down into all screws. Fluoroscopic shots are taken again to confirm adequate placement. The fascia and skin are then closed, with a drain inserted into one of the larger incisions. The patient was brought to the operating table and intubated after induction. The patient was then placed prone and all pressure points were padded. The patient’s back was scrubbed down to sterilize, and an incision was planned at the site of the lesion using external landmarks on the skin. Needles for electrophysiologic monitoring were placed, a time-out was done, and antibiotics were administered. After marking the patient’s back, an incision was made with subperiosteal dissection from two levels above to two levels below the site of metastasis. The pedicles at the two levels above and below the site of tumor were cannulated using a pedicle finder and a ball pit sound. An X-ray is taken to ensure that the markers in the pedicles show adequate placement. Pedicle screws are inserted appropriately to ensure stability during the vertebrectomy. Laminectomies are done from one level above to one level below the metastatic site. The ribs are removed bilaterally with careful dissection of the pleural cavity using subperiosteal dissection. Afterward, a bilateral costotransversectomy is conducted, followed by vertebrectomy of the affected level, as well as removal of adjacent discs. To complete the vertebrectomy, the right-sided T3 nerve root was double ligated and cut. At this point, a distractible cage packed with allograft was inserted into the void. The cage was distracted and the rods and screws were retightened. Then, allograft was packed along the edges of the decorticated posterolateral compartments to facilitate arthrodesis. Once hemostasis was obtained, the layers of tissue were closed to ensure there was no tension on the wound. Additionally, drains are placed subfascially and superficially. Though decompressive surgery for metastatic spinal tumors has been conducted since the early 1900s,26 it was not until 2005 that a randomized, multicenter study demonstrated a significant superiority of direct decompressive surgery with radiation over radiation alone.27 Now that surgery is a clearly accepted treatment modality, efforts are being made to minimize incidental damage on paraspinal muscles and joints inherent to open approaches, which as aforementioned, yield many advantages. Therefore, MIS is a promising field for those with spinal metastases. Unfortunately, due to the relative novelty of the field, there are only a handful of studies with a low level of evidence. There are no level I studies available. There are no level II studies available. In 2011, Chou et al retrospectively compared the results of five patients treated with mini-open transpedicular corpectomy, circumferential decompression, and expandable cage reconstruction with percutaneous screws to five patients treated with an open approach. The MIS cohort had a mean blood loss (MBL) of 1,320 mL and operative time of 7.8 hours, while the open cohort had an MBL of 3,120 mL and operative time of 6.8 hours. Partial and full neurological recovery was noted in three of three MIS patients with preoperative deficit, while full neurological recovery was observed in three of three open patients with preoperative deficit. No instrumentation failure was noted in either group. The authors reported no statistically significant differences with respect to blood loss, operative time, or complication rate, though this analysis included three other patients with traumatic and primary spinal tumors per surgical cohort.28 In 2012, Fang et al retrospectively compared the results of 24 mini-open anterior corpectomy patients to those of 17 posterior total en bloc spondylectomy (TES) patients operated in between 2004 and 2010 for solitary metastases of the thoracolumbar spine. MBL and mean operative time were significantly less for the MIS cohort (p < 0.05). Improvements in visual analog scale (VAS) scores were comparable, as were neurological improvement rate, 2-year survival rate, and complication rate (p > 0.05). Neither group had hardware failure or loss of sagittal Cobb angle. Slight subsidence (< 3 mm) of the mesh cage was observed in 17.6% of the TES group, while no subsidence of the polymethyl methacrylate block/autograft was observed in the MIS group.8 An overwhelming majority of the current literature regarding MIS techniques for spinal metastases presents a patient or series of patients treated with a certain approach. As a result, a direct comparison to a cohort treated with an open technique cannot be made. In 2000, Mühlbauer et al treated one patient with metastatic disease using a minimally invasive retroperitoneal approach for lumbar corpectomy and reconstruction, consisting of methyl-methacrylate (MMA) packed Harms’ cage, modular segmental spinal system (MOSS) screws, and variable screw placement (VSP) plates. At 1-year follow-up, the 59-year-old patient improved from having pain and bilateral sensorimotor deficit, as well as being ambulatory with assistance to requiring no analgesics and being ambulatory without assistance. Radiographs at this time point also demonstrated a stable compound union. There were no complications.29
20.1 Introduction
20.2 Indications of Minimally Invasive Surgery
20.3 Advantages of Minimally Invasive Surgery
Table 20.1), but with less medical comorbidities.18 Since operative management of spinal metastases functions as a palliative measure as opposed to a curative one, MIS may provide a more advantageous approach in the patient’s and surgeon’s perspective. With an experienced surgical team, MIS can compare favorably to open surgery with regard to operative time.16,19 More significantly, muscle-splitting retractor technology causes less muscle damage, and consequently reduces the duration of postoperative back pain and axial instability.20,21 Secondary to reduced soft-tissue trauma are the potential advantages of decreased blood loss, shorter hospitalization stay, and earlier mobilization. The ability to engender faster wound healing rates is critical to the survival of the patient given that it allows for a shorter delay between surgery and an adjuvant therapy regimen.21,22,23 Because of these advantages, MIS has the potential to treat a wider range of patients with metastatic disease, especially those who were not previously qualified for surgery.21
20.4 Advantages of Open Technique
20.5 Case Illustration
20.5.1 Minimally Invasive Surgery
Fig. 20.1). The patient developed some slight paresthesias in his lower extremities and on neurological examination he demonstrated full strength on his motor exam. A costotransversectomy approach with transpedicular vertebrectomy of T3 for the tumor resection was done with posterior stabilization with percutaneous screws. Especially considering the patient’s age, an MIS approach was chosen to expedite healing and reduce time until radiation therapy.
20.6 Surgical Technique in Minimally Invasive Surgery
20.7 Surgical Technique in Open Surgery
20.8 Discussion of Minimally Invasive Surgery
20.8.1 Level I Evidence in Minimally Invasive Surgery
20.8.2 Level II Evidence in Minimally Invasive Surgery
20.8.3 Level III Evidence in Minimally Invasive Surgery
20.8.4 Level IV Evidence in Minimally Invasive Surgery
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