MISS in Patients with Acute Mielopathy from Thoracic Vertebral Metastases: A Prospectical Comparison with Open Surgery

Presented at SMISS Annual Forum 2013
By Massimo Miscusi MD, PhD
With Filippo Polli MD, PhD, Alessandro Frati MD, Marco Cimatti MD, PhD, Luca De Martino MD, Stefano Forcato MD, Sokol Trungu MD, Luca Ricciardi MD, Antonino Raco MD,

Disclosures: Massimo Miscusi MD, PhD None Filippo Polli MD, PhD None, Alessandro Frati MD None, Marco Cimatti MD, PhD None, Luca De Martino MD None, Stefano Forcato MD None, Sokol Trungu MD None, Luca Ricciardi MD None, Antonino Raco MD None,

Introduction: Spinal metastasis is common in patients with cancer. About 70% of symptomatic lesions are found in the thoracic region of the spine and 5-10% of patients presents with cord compression as initial symptom. MISS procedures have been recently advocated as a useful approach for spinal metastases, seeking to decrease the morbidity of more traditional open spine procedures; furthermore they would reduce the recovery time and the interval to start the post-operative chemotherapy and radiotherapy.

Methods: From May 2009 to March 2013, a series of 42 patients (29 women and 13 men, with a mean age of 56 years), have been prospectively enrolled in this study. They presented with acute mielopathy due to vertebral thoracic metastases. They were divided in two groups according to the surgical treatment. They were treated with laminectomy and stabilization both with traditional open surgery (n=18) or MISS (n=22). MISS procedure was based on purely percutaneous pedicle screws placement and mini-open laminectomy, without exposure of posterior joints. Patients with complete paraplegia from more then 24 hours and with life expectancy less then three months were excluded. Patients groups were homogeneous for neurological impairment.
Results have been analyzed in term of neurological recovery (Frenkel scale), pain relief (VAS) and complications avoidance, at 15 days and 1 month follow-up. Operation time length, post-operative bed-rest time, duration of hospitalization, intraoperative blood loss, the need and the length of post-operative opioid administration were also evaluated.

Results: There were no significant differences between two groups in term of neurological recovery and complications. Nevertheless, in MISS group we have a clear and significative improvement in term of blood loss, operation time, and bed rest length, which is associated to a more rapid functional recovery and discharge from hospital. The postoperative pain and the need of opioid administration were also significantly less pronounced in MISS group.

Conclusion: In our opinion MISS techniques are the first choice treatment for spine metastatic patients with mielopathy, because they may obtain a safe and affective spinal cord decompression and spine fixation, as traditional surgery, but reducing the impact of surgery in critical patients.