Use of “MAPS” for determining the optimal surgical approach to metastatic disease of the thoracolumbar spine: anterior, posterior, or combined

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

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✓ The surgical treatment of thoracolumbar metastases is controversial, and various approaches have been described. No single approach, however, is always applicable, and the optimal surgical strategy for any individual is determined by several interrelated factors. The authors have grouped these factors into four preoperative planning considerations that form the mnemonic “MAPS”: 1) method of resection; 2) anatomy of spinal disease; 3) patient's level of fitness; and 4) stabilization. The choice of approach is also considered in light of the goals of surgery, including the relief of pain, neurological palliation, spinal stabilization, and oncological control.

Article Information

Address reprint requests to: Ziya L. Gokaslan, M.D., Department of Neurosurgery, The Johns Hopkins University, Meyer 7–109, 600 North Wolfe Street, Baltimore, Maryland 21287. email: zgokasl1@jhmi.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Artist's illustrations of various approaches to the spine depending on the location of metastatic lesion within a given spinal segment.

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    A–C: Preoperative sagittal (A and B) and axial (C) MR images obtained in a patient with metastatic prostate carcinoma to T-1. Also noted are additional lesions in the more caudal levels. The patient presented with progressive lower-extremity weakness and gait deterioration. D: The patient underwent an anterior cervical approach, median sternotomy, T-1 corpectomy, and reconstruction with PMMA and plate fixation. Intraoperative photograph showing a left anterior cervical approach, median sternotomy, and plate fixation. E: Postoperatively, the patient recovered motor function.

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    A and B: Preoperative anteroposterior and lateral plain radiographs (A) and MR images (B) obtained in a 39-year-old woman with history of breast carcinoma. She presented with acute-onset low-back pain, bilateral lower-extremity weakness, and bowel and bladder dysfunction. The plain radiograph demonstrates complete collapse of L-2, whereas the MR image reveals severe compression of the cauda equina. The patient underwent a two-stage procedure: 1) a retroperitoneal approach, L-2 corpectomy, reconstruction with distractable cage, correction of kyphotic deformity, fixation with plate/screws, and fusion; 2) a posterior thoracolumbar pedicle screw fixation and fusion. C: Postoperative plain radiographs demonstrating the final construct. One year later, following additional local radiotherapy, the patient was neurologically intact and pain free.

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