Minimally Invasive Approach to Spinal Tumors

Vertebral metastases and other spinal tumors may be complicated by pathological fracture and compression of neural structures. The vital prognosis of the patient and his general health condition is the common criteria used to decide whether the patient is a candidate for surgery. It is known that surgical decompression, stabilization, and radiation therapy have better functional outcome than the use of radiotherapy alone in selected patients. In this sense, denying surgery for patients based on their shortened life expectancy may negate real benefit for some of them, especially considering inherent inaccuracy in survival estimations. This must be balanced with the potential complications of proposed procedures that may also compromise their remaining quality of life. Therefore, the possibility to use minimal invasive surgery (MISS) to stabilize and decompress a metastatic spine can be an alternative to resolve these cases without increased patient morbidity.Objectives This is a retrospective analysis of a multicenter database of patients with spinal metastases treated with MISS techniques from 2005 to 2014. We discuss the indications for surgery, the decision making process, analyze the influence of the Tomita and SINS scoring systems, and study the clinical and surgical outcomes and access to radiotherapy.Results A total of 39 patients with an average age of 62 years (range, 32–82 years) were included in the study. Overall, 23 males and 16 females. Primary tumor included pulmonary (eight), breast cancer (eight), multiple myeloma (eight), pancreatic (three), prostate (two), melanoma (two), renal cell carcinoma (two), Pnet (one), parotideal (one), escamous carcinoma (one), bladder (one), uterine (one), and colorectal (one). The indication for surgery was painful pathological fracture in all patients and in six patients it was associated with radicular impairment, one patient had both radicular and thoracic myelopathy. Overall, 17 patients underwent vertebroplasty or kyphoplasty. About, 11 patients underwent percutaneous fixation. Six patients underwent percutaneous fixation and vertebroplasty in different levels. Four patients underwent percutaneous fixation and miss spinal decompression. One patient underwent percutaneous fixation and miss spinal decompression and vertebroplasty in others levels. With regards to survival scores (Tomita), 6 patients in long-term local control recommendation group, 5 patients in middle-term local control recommendation group, 15 patients in palliative surgery recommended recommendation group, and 13 patients in only palliative care recommendation group. With regards of the SINS scoring system there were 32 patients in 7 to 12 points: probable instability and 7 patients in 13 to 18 points: unstable. Clinical Outcomes: All patients had postoperative alleviation of mechanical pain with no neurological complications. All patients with preoperative neurological impairment, recovered after surgery. No major complications were observed and only two patients showed vertebroplasty cement leakage without neurologic or pulmonary consequences. One patient presented transient radicular pain because of dorsal kyphoplasty. Only 6 of 13 patients in the Tomita score palliative care group died before 3 months. Overall, 17 patients had an indication of postoperative radiotherapy (RT); mean time between surgery and RT was 19 days (range, 6–30 days). In six patients, RT was initiated before 2 weeks. There were no complications related to RT.Discussion MISS techniques in vertebral metastasis are valid alternatives for axial mechanical pain alleviation and neural decompression. A low risk of complications may prove these techniques to be more adequate for this group of patients with limited life expectancy and thus, very sensible to quality of life impairment.