**2.7. Discussion**

incontinence (ASIA C, KPS 60, mBS 2), after a one-month history of severe thoracic spinal pain (VAS 90/100), unresponsive to common analgesics. Imaging showed a lesion which substituted the T12 body and its right pedicle, with initial invasion of the spinal canal. He then underwent a pure percutaneous short fixation with transpedicular screws at T11, L1, and at the left pedicle of T12, followed by a mini-open access, centered at the level of T12, with a

The patient was mobilized in the first post-operative day, with an almost complete resolu‐ tion of thoracic pain (VAS 20/100). Intraoperative blood loss was 200 cc, and RBC transfu‐ sion was not necessary. No opioids were administered in the post-operative period, and the patient was discharged on the fourth post-operative day. A post-operative CT scan showed the complete decompression of the spinal cord, with segmental fixation. At the follow-up, the patient presented a complete restoration of neurological deficit (ASIA E), and antalgic therapy with non-steroidal anti-inflammatory drugs (NSAID) was only administered ad libitum

**Figure 3.** Clinical case 2. Pre-operative MRI sagittal scan and coronal thoraco-lumbar X-ray (A and B images) showed diffuse spinal metastatic localizations with pathologic fractures of T9, T10 and T11, severe kyphosis and medullary compression in patient with a previous right partial T10 corpectomy with T9-T11 antero-lateral fixation. In the C and D images it is shown the postoperative CT scan 3D reconstruction which documented the percutaneous fixation with transpedicular screws at T7, T8, left pedicle of T9, L1 and L2, followed by a mini-open access, centered at the level of

T10-T11, with a decompressive laminotomy and double cross-link. Skin incisions in the F image.

decompressive laminotomy.

430 Neurooncology - Newer Developments

(**Figure 2**).

**2.6. Illustrative case 2**

Results of our comparative study demonstrate that standard open techniques and the MISS techniques are equivalent, in terms of the ability to achieve an early neurological improve‐ ment in patients with acute myelopathy due to spinal cord compression. Nevertheless, MISS approach has a clear and significant advantage over standard open techniques, in terms of blood loss, operation length, and hospital stay; they also confirm its safety, with no patients presenting peri-operative surgical-related complications.

The study consisted of 48 patients with advanced cancer from different primary tumors, presenting a low Karnowsky score and acute myelopathy due to spinal-cord compression; All of them had low modified Bauer scores, which indicate only a short or middle term surgical palliation through posterior decompression and spinal segmental fixation [18]. Surgery was instrumented in all patients, to treat a preoperative instability or to prevent post-surgical instability. A gross total or complete resection of metastases was never attempted because clearly not indicated for any of the patients in the series.

According to the biological behavior of the lesion (i.e., osteolytic or osteoblastic), the number of segments involved, and the columns involved for each segment, the implant for fixation was as shortest as possible, and, in cases where the lesion was partially invading the verte‐ bra, pedicle screws are also inserted in the fractured vertebrae.

We have been interested in comparing the quality of life at an early follow-up, since, in patients with advanced metastatic cancer, the late follow-up is generally conditioned by the progres‐ sion of the primary disease, and this can produce a bias when evaluating the surgical results for neurological restoration alone or the quality of life. Considering an equivalent neurologi‐

cal recovery, at 30 days follow-up, patients in the MISS group presented a better outcome in terms of quality of life: in our opinion this is the final aim of surgical treatment in case of patients with short- to mid-term life expectancy.

Interestingly some patients of our series aged over 60 years presented an early worsening of neurological symptoms, confirming that age is a key prognostic factor which must to be considered before choosing the surgical strategy in treating advanced cancer patients.

Finally, MISS seem to significantly reduce the post-operative pain. In fact, in our series, VAS reduced and the need for opioids was significantly lower in patients of the MISS group. The reduction in opioids administration improves the quality of life of such patients, avoiding severe constipation or alterations in consciousness.

In our experience, metastatic patients operated with MISS techniques, compared to those operated with traditional open surgery techniques, presented a significant 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 post-operative pain and the need of opioids administration were also significantly less pronounced, and these effects appear to translate to a better quality of life of such patients, which is a primary aim in case of patient with a short life expectancy.
