Annals of Surgical Oncology

, Volume 21, Issue 9, pp 2864–2872 | Cite as

Optimal Approach to Circumferential Decompression and Reconstruction for Thoracic Spine Metastatic Disease

  • Neil R. Malhotra
  • Jennifer Kosty
  • Matthew Sanborn
  • Jonathan M. Bekisz
  • Theodore W. Mooncai
  • Thomas M. Neustein
  • Jessica Ou
  • Anna Zhu
  • Ali Bernstein
  • Sherman C. Stein
Thoracic Oncology



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).


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.


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.


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.


Thoracic Spine Posterior Approach Anterior Approach Spinal Cord Compression Posterior Decompression 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors declare no conflict of interest.


  1. 1.
    Harrington KD. Metastatic tumors of the spine: diagnosis and treatment. J Am Acad Orthop Surg. 1993;1:76–86.Google Scholar
  2. 2.
    Gokaslan ZL, York JE, Walsh GL, et al. Transthoracic vertebrectomy for metastatic spinal tumors. J Neurosurg. 1998;89:599–609.PubMedCrossRefGoogle Scholar
  3. 3.
    Byrne TN. Spinal cord compression from epidural metastases. N Engl J Med. 1992;327:614–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Fourney DR, Gokaslan ZL. Spinal instability and deformity due to neoplastic conditions. Neurosurg Focus. 2003;14:e8.PubMedCrossRefGoogle Scholar
  5. 5.
    Black P. Spinal metastasis: current status and recommended guidelines for management. Neurosurgery. 1979;5:726–46.PubMedCrossRefGoogle Scholar
  6. 6.
    Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978;3:40–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Young RF, Post EM, King GA. Treatment of spinal epidural metastases. Randomized prospective comparison of laminectomy and radiotherapy. J Neurosurg. 1980;53:741–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Constans JP, de Divitiis E, Donzelli R, et al. Spinal metastases with neurological manifestations. Review of 600 cases. J Neurosurg. 1983;59:111–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Stark RJ, Henson RA, Evans SJ. Spinal metastases. A retrospective survey from a general hospital. Brain. 1982;105 Pt 1:189–213.PubMedCrossRefGoogle Scholar
  10. 10.
    Steinmetz MP, Mekhail A, Benzel EC. Management of metastatic tumors of the spine: strategies and operative indications. Neurosurg Focus. 2001;11:e2.PubMedCrossRefGoogle Scholar
  11. 11.
    Rodriguez M, Dinapoli RP. Spinal cord compression: with special reference to metastatic epidural tumors. Mayo Clin Proc. 1980;55:442–8.PubMedGoogle Scholar
  12. 12.
    Findlay GF. Adverse effects of the management of malignant spinal cord compression. J Neurol Neurosurg Psychiatry. 1984;47:761–8.PubMedCentralPubMedGoogle Scholar
  13. 13.
    Sorensen S, Borgesen SE, Rohde K, et al. Metastatic epidural spinal cord compression. . Results of treatment and survival. Cancer. 1990;65:1502–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Perrin RG, McBroom RJ. Anterior versus posterior decompression for symptomatic spinal metastasis. Can J Neurol Sci. 1987;14:75–80.PubMedGoogle Scholar
  15. 15.
    Siegal T, Siegal T, Robin G, et al. Anterior decompression of the spine for metastatic epidural cord compression: a promising avenue of therapy? Ann Neurol. 1982;11:28–34.PubMedCrossRefGoogle Scholar
  16. 16.
    Harrington KD. Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine. J Neurosurg. 1984;61:107–17.PubMedCrossRefGoogle Scholar
  17. 17.
    Sundaresan N, Galicich JH, Bains MS, et al. Vertebral body resection in the treatment of cancer involving the spine. Cancer. 1984;53:1393–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Overby MC, Rothman AS. Anterolateral decompression for metastatic epidural spinal cord tumors. Results of a modified costotransversectomy approach. J Neurosurg. 1985;62:344–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Siegal T, Tiqva P, Siegal T. Vertebral body resection for epidural compression by malignant tumors. Results of forty-seven consecutive operative procedures. J Bone Joint Surg Am. 1985;67:375–82.PubMedGoogle Scholar
  20. 20.
    Fourney DR, Gokaslan ZL. Anterior approaches for thoracolumbar metastatic spine tumors. Neurosurg Clin North Am. 2004;15:443–51.CrossRefGoogle Scholar
  21. 21.
    Sundaresan N, Galicich JH, Lane JM, et al. Treatment of neoplastic epidural cord compression by vertebral body resection and stabilization. J Neurosurg. 1985;63:676–84.PubMedCrossRefGoogle Scholar
  22. 22.
    Sundaresan N, Shah J, Foley KM, Rosen G. An anterior surgical approach to the upper thoracic vertebrae. J Neurosurg. 1984;61:686–90.PubMedCrossRefGoogle Scholar
  23. 23.
    York JE, Walsh GL, Lang FF, et al. Combined chest wall resection with vertebrectomy and spinal reconstruction for the treatment of Pancoast tumors. J Neurosurg. 1999;91 Suppl l:74–80.PubMedCrossRefGoogle Scholar
  24. 24.
    Cybulski GR, Stone JL, Opesanmi O. Spinal cord decompression via a modified costotransversectomy approach combined with posterior instrumentation for management of metastatic neoplasms of the thoracic spine. Surg Neurol. 1991;35:280–5.PubMedCrossRefGoogle Scholar
  25. 25.
    Cahill DW, Kumar R Palliative subtotal vertebrectomy with anterior and posterior reconstruction via a single posterior approach. J Neurosurg. 1999;90 Suppl 1:42–7.PubMedGoogle Scholar
  26. 26.
    Weller SJ, Rossitch E Jr. Unilateral posterolateral decompression without stabilization for neurological palliation of symptomatic spinal metastasis in debilitated patients. J Neurosurg. 1995;82:739–44.PubMedCrossRefGoogle Scholar
  27. 27.
    Shaw B, Mansfield FL, Borges L. One-stage posterolateral decompression and stabilization for primary and metastatic vertebral tumors in the thoracic and lumbar spine. J Neurosurg. 1989;70:405–10.PubMedCrossRefGoogle Scholar
  28. 28.
    Akeyson EW, McCutcheon IE. Single-stage posterior vertebrectomy and replacement combined with posterior instrumentation for spinal metastasis. J Neurosurg. 1996;85:211–20.PubMedCrossRefGoogle Scholar
  29. 29.
    Muhlbauer M, Pfisterer W, Eyb R, Knosp E. Noncontiguous spinal metastases and plasmocytomas should be operated on through a single posterior midline approach, and circumferential decompression should be performed with individualized reconstruction. Acta Neurochir. 2000;142:1219–30.PubMedCrossRefGoogle Scholar
  30. 30.
    Bilsky MH, Boland P, Lis E, et al. Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases. Spine. 2000;25:2240–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Cho DC, Sung JK. Palliative surgery for metastatic thoracic and lumbar tumors using posterolateral transpedicular approach with posterior instrumentation. Surg Neurol. 2009;71:424–33.PubMedCrossRefGoogle Scholar
  32. 32.
    Wang JC, Boland P, Mitra N, et al. Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004. J Neurosurg Spine. 2004;1:287–98.PubMedCrossRefGoogle Scholar
  33. 33.
    Davis C. Partial posterior vertebrectomy for anterior thoracic cord compression. Br J Neurosurg. 1987;1:277–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Abel R, Keil M, Schlager E, Akbar M. Posterior decompression and stabilization for metastatic compression of the thoracic spinal cord: is this procedure still state of the art? Spinal Cord. 2008;46:595–602.PubMedCrossRefGoogle Scholar
  35. 35.
    Klimo P Jr, Dailey AT, Fessler RG. Posterior surgical approaches and outcomes in metastatic spine-disease. Neurosurg Clin North Am. 2004;15:425–35.CrossRefGoogle Scholar
  36. 36.
    Klimo P Jr, Thompson CJ, Kestle JR, Schmidt MH. A meta-analysis of surgery versus conventional radiotherapy for the treatment of metastatic spinal epidural disease. Neurooncology. 2005;7:64–76.Google Scholar
  37. 37.
    Patchell RA, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet. 2005;366(9486):643–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Lu DC, Lau D, Lee JG, Chou D. The transpedicular approach compared with the anterior approach: an analysis of 80 thoracolumbar corpectomies. J Neurosurg Spine. 2010;12:583–91.PubMedCrossRefGoogle Scholar
  39. 39.
    Xu R, Garces-Ambrossi GL, McGirt MJ, et al. Thoracic vertebrectomy and spinal reconstruction via anterior, posterior, or combined approaches: clinical outcomes in 91 consecutive patients with metastatic spinal tumors. J Neurosurg Spine. 2009;11:272–84.PubMedCrossRefGoogle Scholar
  40. 40.
    Shehadi JA, Sciubba DM, Suk I, et al. Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients. Eur Spine J. 2007;16:1179–92.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Hal Sox, Marshal A. Blatt, Michael C. Higgins, Keith I. Marton. Medical decision making. Burlington: Butterworth-Heinemann; 1988.Google Scholar
  42. 42.
    Einarson TR. Pharmacoeconomic applications of meta-analysis for single groups using antifungal onychomycosis lacquers as an example. Clin Ther. 1997;19:559–69.PubMedCrossRefGoogle Scholar
  43. 43.
    Concato J, Feinstein AR. Monte Carlo methods in clinical research: applications in multivariable analysis. J Invest Med. 1997;45:394–400.Google Scholar
  44. 44.
    Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ. 2001;323 7308:334–6.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Lega BC, Danish SF, Malhotra NR, et al. Choosing the best operation for chronic subdural hematoma: a decision analysis. J Neurosurg. 2010;113:615–21.PubMedCrossRefGoogle Scholar
  46. 46.
    Aoki N, Kitahara T, Fukui T, et al. Management of unruptured intracranial aneurysm in Japan: a Markovian decision analysis with utility measurements based on the Glasgow Outcome Scale. Med Decis Making. 1998;18:357–64.PubMedCrossRefGoogle Scholar
  47. 47.
    The World Health Organization Quality of Life assessment (WHOQOL): position paper from the World Health Organization. Soc Sci Med. 1995;41:1403–9.Google Scholar
  48. 48.
    Pettiford BL, Schuchert MJ, Jeyabalan G, et al. Technical challenges and utility of anterior exposure for thoracic spine pathology. Ann Thorac Surg. 2008;86:1762–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Hall DJ, Webb JK. Anterior plate fixation in spine tumor surgery. Indications, technique, and results. Spine. 1991;16 Suppl 3:S80–3.PubMedCrossRefGoogle Scholar
  50. 50.
    Ikard RW. Methods and complications of anterior exposure of the thoracic and lumbar spine. Arch Surg. 2006;141:1025–34.PubMedCrossRefGoogle Scholar
  51. 51.
    Kalfas IH. Anterior thoracolumbar stabilization. Neurosurg Clin North Am. 1997;8:487–98.Google Scholar
  52. 52.
    McDonnell MF, Glassman SD, Dimar JR 2nd, et al. Perioperative complications of anterior procedures on the spine. J Bone Joint Surg Am. 1996;78:839–47.PubMedGoogle Scholar
  53. 53.
    Naunheim KS, Barnett MG, Crandall DG, et al. Anterior exposure of the thoracic spine. Ann Thorac Surg. 1994;57:1436–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Abe E, Kobayashi T, Murai H, et al. Total spondylectomy for primary malignant, aggressive benign, and solitary metastatic bone tumors of the thoracolumbar spine. J Spinal Disord. 2001;14:237–46.PubMedCrossRefGoogle Scholar
  55. 55.
    Boriani S, Biagini R, De Iure F, et al. En bloc resections of bone tumors of the thoracolumbar spine. A preliminary report on 29 patients. Spine. 1996;21:1927–31.PubMedCrossRefGoogle Scholar
  56. 56.
    Tomita K, Kawahara N, Baba H, et al. Total en bloc spondylectomy for solitary spinal metastases. Int Orthop. 1994;18:291–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Jackson RJ, Loh SC, Gokaslan ZL. Metastatic renal cell carcinoma of the spine: surgical treatment and results. J Neurosurg. 2001;94 Suppl 1:18–24.PubMedGoogle Scholar
  58. 58.
    Fourney DR, Abi-Said D, Rhines LD, et al. Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization. J Neurosurg. 2001;94 Suppl 2:232–44.PubMedGoogle Scholar
  59. 59.
    Fourney DR, Gokaslan ZL. 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. J Neurosurg Spine. 2005;2:40–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Sciubba DM, Petteys RJ, Dekutoski MB, et al. Diagnosis and management of metastatic spine disease. J Neurosurg Spine. 2010;13:94–108.PubMedCrossRefGoogle Scholar
  61. 61.
    Tokuhashi Y, Matsuzaki H, Oda H, et al. A revised scoring system for preoperative evaluation of metastatic spine tumor prognosis. Spine. 2005;30:2186–91.PubMedCrossRefGoogle Scholar
  62. 62.
    Tomita K, Kawahara N, Kobayashi T, et al. Surgical strategy for spinal metastases. Spine. 2001;26:298–306.PubMedCrossRefGoogle Scholar
  63. 63.
    McLain RF, Weinstein JN. Tumors of the Spine. In: Herkowitz HN, Grarfin SR, Balderston RA, Eismont FJ , Bell GR, Wiesel SW, editors. Rothman-Simeone: the spine. Philadelphia: WB Saunders; 1999. p. 1171–206.Google Scholar
  64. 64.
    Polly DW Jr, Chou D, Sembrano JN, et al. An analysis of decision making and treatment in thoracolumbar metastases. Spine. 2009;34 Suppl 22:S118–27.PubMedCrossRefGoogle Scholar
  65. 65.
    Sciubba DM, Gallia GL, McGirt MJ, et al. Thoracic kyphotic deformity reduction with a distractible titanium cage via an entirely posterior approach. Neurosurgery. 2007;60 4 Suppl 2:223–30.PubMedGoogle Scholar
  66. 66.
    Snell BE, Nasr FF, Wolfla CE. Single-stage thoracolumbar vertebrectomy with circumferential reconstruction and arthrodesis: surgical technique and results in 15 patients. Neurosurgery. 2006;58 4 Suppl 2:ONS-263–8.Google Scholar
  67. 67.
    Sundaresan N, Steinberger AA, Moore F, et al. Indications and results of combined anterior-posterior approaches for spine tumor surgery. J Neurosurg. 1996;85:438–46.PubMedCrossRefGoogle Scholar
  68. 68.
    Bauer HC. Posterior decompression and stabilization for spinal metastases. Analysis of sixty-seven consecutive patients. J Bone Joint Surg Am. 1997;79:514–22.PubMedGoogle Scholar
  69. 69.
    Cappelletto B, Del Fabro P, Meo A. Decompression and surgical stabilization in the palliative treatment of vertebral metastases. Chir Organi Mov. 1998;83:167–76.PubMedGoogle Scholar
  70. 70.
    Chen LH, Chen WJ, Niu CC, Shih CH. Anterior reconstructive spinal surgery with Zielke instrumentation for metastatic malignancies of the spine. Arch Orthop Trauma Surg. 2000;120:27–31.PubMedGoogle Scholar
  71. 71.
    Chen LH, Niu CC, Fu TS, et al. Posterior decompression and stabilization for metastatic spine diseases. Chang Gung Med J. 2004;27:903–10.PubMedGoogle Scholar
  72. 72.
    Chen YJ, Chang GC, Chen HT, et al. Surgical results of metastatic spinal cord compression secondary to non–small cell lung cancer. Spine. 2007;32:E413–8.PubMedCrossRefGoogle Scholar
  73. 73.
    Cooper PR, Errico TJ, Martin R, et al. A systematic approach to spinal reconstruction after anterior decompression for neoplastic disease of the thoracic and lumbar spine. Neurosurgery. 1993;32:1–8.PubMedCrossRefGoogle Scholar
  74. 74.
    Di Martino A, Vincenzi B, Denaro L, et al. “Internal bracing” surgery in the management of solid tumor metastases of the thoracic and lumbar spine. Oncol Rep. 2009;21:431–5.PubMedGoogle Scholar
  75. 75.
    Hertlein H, Mittlmeier T, Piltz S, et al. Spinal stabilization for patients with metastatic lesions of the spine using a titanium spacer. Eur Spine J. 1992;1:131–6.PubMedCrossRefGoogle Scholar
  76. 76.
    Hirabayashi H, Ebara S, Kinoshita T, et al. Clinical outcome and survival after palliative surgery for spinal metastases: palliative surgery in spinal metastases. Cancer. 2003;97:476–84.PubMedCrossRefGoogle Scholar
  77. 77.
    Hofstetter CP, Chou D, Newman CB, et al. Posterior approach for thoracolumbar corpectomies with expandable cage placement and circumferential arthrodesis: a multicenter case series of 67 patients. J Neurosurg Spine. 2011;14:388–97.PubMedCrossRefGoogle Scholar
  78. 78.
    Huang TJ, Hsu RW, Li YY, Cheng CC. Minimal access spinal surgery (MASS) in treating thoracic spine metastasis. Spine. 2006;31:1860–3.PubMedCrossRefGoogle Scholar
  79. 79.
    Jansson KA, Bauer HC. Survival, complications and outcome in 282 patients operated for neurological deficit due to thoracic or lumbar spinal metastases. Eur Spine J. 2006;15:196–202.PubMedCentralPubMedCrossRefGoogle Scholar
  80. 80.
    Jonsson B, Sjostrom L, Olerud C, et al. Outcome after limited posterior surgery for thoracic and lumbar spine metastases. Eur Spine J. 1996;5:36–44.PubMedCrossRefGoogle Scholar
  81. 81.
    Klekamp J, Samii H. Surgical results for spinal metastases. Acta Neurochir. 1998;140:957–67.PubMedCrossRefGoogle Scholar
  82. 82.
    Kocialkowski A, Webb JK. Metastatic spinal tumours: survival after surgery. Eur Spine J. 1992;1:43–8.PubMedCrossRefGoogle Scholar
  83. 83.
    Rompe JD, Eysel P, Hopf C, Heine J. Decompression/stabilization of the metastatic spine. Cotrel-Dubousset-Instrumentation in 50 patients. Acta Orthop Scand. 1993;64:3–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Street J, Fisher C, Sparkes J, et al. Single-stage posterolateral vertebrectomy for the management of metastatic disease of the thoracic and lumbar spine: a prospective study of an evolving surgical technique. J Spinal Disord Tech. 2007;20:509–20.PubMedCrossRefGoogle Scholar
  85. 85.
    Timlin M, Thalgott J, Ameriks J, et al. Management of metastatic tumors to the spine using simple plate fixation. Am Surg. 1995;61:704–8.PubMedGoogle Scholar
  86. 86.
    Villavicencio AT, Oskouian RJ, Roberson C, et al. Thoracolumbar vertebral reconstruction after surgery for metastatic spinal tumors: long-term outcomes. Neurosurg Focus. 2005;19:E8.PubMedCrossRefGoogle Scholar
  87. 87.
    Viswanathan A, Abd-El-Barr MM, Doppenberg E, et al. Initial experience with the use of an expandable titanium cage as a vertebral body replacement in patients with tumors of the spinal column: a report of 95 patients. Eur Spine J. 2012;21:84–92.PubMedCentralPubMedCrossRefGoogle Scholar
  88. 88.
    Walsh GL, Gokaslan ZL, McCutcheon IE, et al. Anterior approaches to the thoracic spine in patients with cancer: indications and results. Ann Thorac Surg. 1997;64:1611–8.PubMedCrossRefGoogle Scholar
  89. 89.
    Wiggins GC, Mirza S, Bellabarba C, et al. Perioperative complications with costotransversectomy and anterior approaches to thoracic and thoracolumbar tumors. Neurosurg Focus. 2001;11:e4.PubMedCrossRefGoogle Scholar
  90. 90.
    Yen D, Kuriachan V, Yach J, Howard A. Long-term outcome of anterior decompression and spinal fixation after placement of the Wellesley Wedge for thoracic and lumbar spinal metastasis. J Neurosurg. 2002;96(1 Suppl):6–9.PubMedGoogle Scholar
  91. 91.
    Danish SF, Burnett MG, Ong JG, et al. Prophylaxis for deep venous thrombosis in craniotomy patients: a decision analysis. Neurosurgery. 2005;56:1286–92.PubMedCrossRefGoogle Scholar
  92. 92.
    Sarna L, Cooley ME, Brown JK, et al. Symptom severity 1 to 4 months after thoracotomy for lung cancer. Am J Crit Care. 2008;17:455–67.PubMedGoogle Scholar
  93. 93.
    Gautschi OP, Seule MA, Cadosch D, et al. Health-related quality of life following spinal cordectomy for syringomyelia. Acta Neurochir. 2011;153:575–9.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • Neil R. Malhotra
    • 1
  • Jennifer Kosty
    • 2
  • Matthew Sanborn
    • 1
  • Jonathan M. Bekisz
    • 3
  • Theodore W. Mooncai
    • 3
  • Thomas M. Neustein
    • 3
  • Jessica Ou
    • 3
  • Anna Zhu
    • 3
  • Ali Bernstein
    • 3
  • Sherman C. Stein
    • 1
  1. 1.Department of NeurosurgeryPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of NeurosurgeryUniversity of CincinnatiCincinnatiUSA
  3. 3.The University of PennsylvaniaPhiladelphiaUSA

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