title: When Less Is More: The indications for MIS Techniques and Separation Surgery in Metastatic Spine Disease.
abstract: METHODS
  Systematic review.
  
  
  OBJECTIVE
  The aim of this study was to review the techniques, indications, and outcomes of minimally invasive surgery (MIS) and separation surgery with subsequent radiosurgery in the treatment of patients with metastatic spine disease.
  
  
  BACKGROUND
  The utilization of MIS techniques in patients with spine metastases is a growing area within spinal oncology. Separation surgery represents a novel paradigm where radiosurgery provides long-term control after tumor is surgically separated from the neural elements.
  
  
  METHODS
  PubMed, Embase, and CINAHL databases were systematically queried for literature reporting MIS techniques or separation surgery in patients with metastatic spine disease. PRISMA guidelines were followed.
  
  
  RESULTS
  Of the initial 983 articles found, 29 met inclusion criteria. Twenty-five articles discussed MIS techniques and were grouped according to the primary objective: percutaneous stabilization (8), tubular retractors (4), mini-open approach (8), and thoracoscopy/endoscopy (5). The remaining 4 studies reported separation surgery. Indications were similar across all studies and included patients with instability, refractory pain, or neurologic compromise. Intraoperative variables, outcomes, and complications were similar in MIS studies compared to traditional approaches, and some MIS studies showed a statistically significant improvement in outcomes. Studies of mini-open techniques had the strongest evidence for superiority.
  
  
  CONCLUSIONS
  Low-quality evidence currently exists for MIS techniques and separation surgery in the treatment of metastatic spine disease. Given the early promising results, the next iteration of research should include higher-quality studies with sufficient power, and will be able to provide higher-level evidence on the outcomes of MIS approaches and separation surgery.
  
  
  METHODS
  N/A.
authors.affiliation: Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, TN.
authors.forename: Scott L
authors.initials: SL
authors.lastname: Zuckerman
authors.affiliation: Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Ilya
authors.initials: I
authors.lastname: Laufer
authors.affiliation: Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
authors.forename: Arjun
authors.initials: A
authors.lastname: Sahgal
authors.affiliation: Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Yoshiya J
authors.initials: YJ
authors.lastname: Yamada
authors.affiliation: Department of Neurological Surgery, University of Utah, Salt Lake City, UT.
authors.forename: Meic H
authors.initials: MH
authors.lastname: Schmidt
authors.affiliation: Department of Neurological Surgery, University of San Francisco California, San Francisco, CA.
authors.forename: Dean
authors.initials: D
authors.lastname: Chou
authors.affiliation: Department of Neurosurgery, Massachusetts General Hospital, Boston, MA.
authors.forename: John H
authors.initials: JH
authors.lastname: Shin
authors.affiliation: University Spine Centre, University Orthopaedics, Hand & Reconstructive Microsurgery Cluster, National University Hospital, Singapore.
authors.forename: Naresh
authors.initials: N
authors.lastname: Kumar
authors.affiliation: Department of Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, MD.
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Sciubba
mesh_terms: D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D013123:Spinal Fusion / Q000379:methods*; D013125:Spinal Neoplasms / Q000556:secondary / Q000601:surgery*