title: Optimal approach to circumferential decompression and reconstruction for thoracic spine metastatic disease.
abstract: BACKGROUND
  Circumferential decompression has been demonstrated to be the first-line therapy for patients with metastatic tumors in the thoracic spine requiring surgical intervention. However, there is significant debate regarding whether these tumors are best accessed anteriorly utilizing a thoracotomy or posteriorly. We used decision analysis to determine which approach yields greater health-related quality of life (QOL).
  
  
  METHODS
  We searched Medline, Embase, and the Cochrane Library for relevant articles published between 1990 and 2011 on anterior and posterior approaches to metastatic disease in the thoracic spine. QOL values for major treatment outcomes were determined using the existing literature. Separate models were created for ambulatory and nonambulatory patients. A Monte Carlo simulation and sensitivity analyses were used to determine which treatment strategy resulted in the highest QOL.
  
  
  RESULTS
  For ambulatory patients, an anterior approach resulted in a slightly higher QOL, and for nonambulatory patients, a posterior approach was favored, but these differences were not statistically significant.
  
  
  CONCLUSIONS
  Using a decision-analytic model, we found no significant difference in QOL resulting from anterior versus posterior approaches to metastatic lesions in the thoracic spine. Decisions should instead be based on surgeon comfort, tumor characteristics, anatomy of the lesion, patient-related factors, and goals of the operation.
authors.affiliation: Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA, neil.malhotra@uphs.upenn.edu.
authors.forename: Neil R
authors.initials: NR
authors.lastname: Malhotra
authors.forename: Jennifer
authors.initials: J
authors.lastname: Kosty
authors.forename: Matthew
authors.initials: M
authors.lastname: Sanborn
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Bekisz
authors.forename: Theodore W
authors.initials: TW
authors.lastname: Mooncai
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Neustein
authors.forename: Jessica
authors.initials: J
authors.lastname: Ou
authors.forename: Anna
authors.initials: A
authors.lastname: Zhu
authors.forename: Ali
authors.initials: A
authors.lastname: Bernstein
authors.forename: Sherman C
authors.initials: SC
authors.lastname: Stein
mesh_terms: D003661:Decision Support Techniques; D019299:Decompression, Surgical / Q000379:methods*; D006801:Humans; D015201:Meta-Analysis as Topic; D011379:Prognosis; D019651:Plastic Surgery Procedures / Q000379:methods*; D013125:Spinal Neoplasms / Q000556:secondary* / Q000601:surgery*; D013904:Thoracic Vertebrae / Q000601:surgery*; D013908:Thoracotomy / Q000379:methods*