Minimally Invasive Surgery for Metastatic Spine Disease

Abstract

Background Metastatic spine disease (MSD) is a new epidemic and it can lead to significant morbidities such as disabling pain and neurological deficits. A multidisciplinary approach including medical oncologists, radiation oncologists, and spinal surgeons is mandatory as the treatment options are constantly evolving and are of much debate. Current evidence shows that best clinical outcomes are achieved by surgery, especially when it is combined with postoperative radiotherapy. This winning combination, however, is only successful when the two modalities are appropriately timed. Minimally invasive approaches in MSD have been producing good outcomes in terms of pain reduction and neurological improvement, comparable to open surgery. To make surgical management an appealing choice in MSD, surgical morbidity needs to be kept as low as possible, especially when planning oncological treatment around surgery. Methods We discuss the “epidemiology and incidence”; “clinical presentation of MSD” and treatment modalities. We derive that radiotherapy was established as a treatment modality in the 1980's. In this review, we discuss main treatment modalities such as radiotherapy and chemotherapy in brief to improve the understanding of evolution of surgical treatment. Open surgery for MSD has evolved from a conservative destabilizing operation such as laminectomy to front and back open surgery with instrumentation. We then trace that minimally invasive surgery has slowly evolved to find its place in the management of MSD. Results A variety of minimally invasive approaches in MSD have shown encouraging results for early wound healing, reduced intraoperative blood loss, and shortened hospital stay while producing good outcomes in terms of pain reduction and neurological improvement, comparable to open surgery. Evolving from this review, we also provide our treatment algorithm to operate on patients with MSD, which keeps in view with the clinical presentation and radiological appearance of spinal cord compression. We would then discuss the advancement of surgery from open to minimal invasive approach. We finally establish a treatment algorithm, which encompasses both open and MIS surgery. Conclusion We believe that MIS is beneficial in well-selected group of patients suffering from clinically significant instability with intractable back pain or motor deficits. Our treatment algorithm for symptomatic MSD is suggested as a guideline as these are high-risk cases and treatments should be individualized with respect to prognosis, premorbidity, and patients' choice. We can improve patient's quality of life through minimally invasive intervention. The introduction of MIS can be a game changer in the treatment of MSD because of the less perioperative morbidity and allowing earlier radiotherapy and/or chemotherapy.