An analysis of decision making and treatment in thoracolumbar metastases.

STUDY DESIGN: Systematic review of literature. OBJECTIVE: To determine whether surgical approach and technique to be used in thoracolumbar metastases is influenced by anatomic region of the spine. SUMMARY OF BACKGROUND DATA: There is a significant debate about the best surgical approach for the treatment of thoracolumbar metastasis. METHODS: Two research questions below were determined through a consensus among a panel of spine experts. A systematic review of literature was conducted using Pubmed. The search terms included "spin*" and "metasta*." This was to include the terms, "metastatic," "metastasis," "metastases," "spinal," and "spine." 1. In the T2 to T5 region, what is the impact of different surgical approaches (anterior, posterior, combined anteroposterior [AP]) on local recurrence, adverse events, pain alleviation, and neurologic recovery? 2. Within the thoracolumbar spine (T6-T10; T11-L2; and L3-L5) what is the impact of different surgical approaches on outcomes as per question one. The results of the systematic review were discussed with spine oncology experts through a modified Delphi technique to arrive at treatment recommendations. RESULTS: From the search terms used 5176 abstracts were found. Based on the review of these abstracts, 161 were deemed acceptable. These abstracts were reviewed according to an inclusion and exclusion criteria, leaving 60 articles. These 60 articles were reviewed in detail leaving 32 articles for inclusion. There was no level I study. There was 1 level II study, 5 level III studies, and 26 level IV studies. Most of these studies selected their approach by tumor topography. The quality of evidence was very low. CONCLUSION: There is very low quality evidence to support the superiority of one approach over another. There is a strong recommendation for posterior or posterior-lateral approach from T2 through T5. For the T6-L5 regions of the spine we recommend either anterior, posterior, or combined anterior and posterior surgery depending on the clinical presentation, surgeon and patient preference.