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The traditional approach for resection of intradural spinal tumors is an open laminectomy. This approach provides a wide, bilateral exposure to the spinal column. However, in order to achieve this exposure, the bilateral musculature must be stripped away from the bony anatomy and the posterior ligamentous complex disrupted. Minimally invasive spine surgery (MISS) has garnered increasing popularity over the past two decades and the use of tubular retractors to access the spinal column has been applied to all levels of the spine for multiple pathologies and surgical procedures. The potential benefits of MISS approaches are less postoperative pain, less blood loss, shorter hospital stays, faster recovery and return to work, and fewer complications. In this chapter, we will describe our method for the resection of intradural spinal tumors utilizing an MISS technique. We discuss the indications and preoperative considerations when considering an MISS approach. Our technique utilizing a non-expandable tubular retractor is then described. Finally, we examine the existing body of literature of intradural extramedullary and intramedullary spinal tumors. We aim to provide readers with a comprehensive overview of how to approach patients with intradural spinal tumors from an MISS perspective and safely and effectively perform resection through a tubular retractor.

Study Design: Technical note, retrospective case series. Objective: Lumbar stenosis can be effectively treated using tubular unilateral laminotomy for bilateral decompression (ULBD). For multilevel stenosis, a multilevel ULBD through separate, alternating crossover approaches has been described as the “slalom technique.” To increase efficacy, we introduced this approach with 2 microscopes simultaneously. Methods: We collected data on 13 patients, with multilevel lumbar stenosis, operated at our institution between 2015 and 2016 by the aforementioned technique. We assessed surgical time (ST), estimated blood loss (EBL), complications, and revision surgeries. Furthermore, we provide a stepwise instruction for performing the tandem microscopic slalom technique in a safe and efficient manner. Results: The mean age of the patients was 68 ± 8 years. The ST per level was 68 ± 19 minutes with an EBL per level of 39 ± 30 mL. We had no intraoperative complications and none of our patients required a revision surgery during a mean follow-up of 12 months. Conclusions: We have shown that this technique is feasible and can be performed safely for multisegmental lumbar spinal stenosis with minimal tissue trauma and low EBL. Furthermore, randomized controlled studies with a larger sample size may be necessary to drive any final conclusions.

Background Superficial siderosis of the central nervous system is a rare neurologic disorder characterized by the superficial deposition of hemosiderin in the subpial layer resulting in iron-related progressive neurodegeneration. Case Description In this report, we present a case of superficial siderosis of the central nervous system secondary to an intradural thoracic disk herniation causing a cerebrospinal fluid (CSF) leak. Conclusions The patient was successfully treated with T6-T8 transpedicular partial corpectomy, as well as diskectomy with decompression followed by watertight closure of the CSF leak. Intraoperative watertight closure of the CSF leak was achieved.

BACKGROUND In patients who have previously undergone maximum radiation for metastatic brain tumors, a progressive enhancing inflammatory reaction (PEIR) that represents either tumor recurrence or radiation necrosis, or a combination of both, can occur. Magnetic resonance-guided laser-induced thermal therapy (LITT) offers a minimally invasive treatment option for this problem. OBJECTIVE To report our single-center experience using LITT to treat PEIRs after radiosurgery for brain metastases. METHODS Patients with progressive, enhancing reactions at the site of prior radiosurgery for metastatic brain tumors and who had a Karnofsky performance status of ≥70 were eligible for LITT. The primary endpoint was local control. Secondary end points included dexamethasone use and procedure-related complications. RESULTS Between 2010 and 2017, 59 patients who underwent 74 LITT procedures for 74 PEIRs met inclusion criteria. The mean pre-LITT PEIR size measured 3.4 ± 0.4 cm3. At a median follow-up of 44.6 wk post-LITT, the local control rate was 83.1%. Most patients were weaned off steroids post-LITT. Patients experiencing a post-LITT complication were more likely to remain on steroids indefinitely. The rate of new permanent neurological deficit was 3.4%. CONCLUSION LITT is an effective treatment for local control of PEIRs after radiosurgery for metastatic brain disease. When possible, we recommend offering LITT once PEIRs are identified and prior to the initiation of high-dose steroids for symptom relief.

This video demonstrates the step-by-step surgical technique for the minimally invasive laminotomy for contralateral "over-the-top" foraminal decompression. This technique allows for excellent decompression with clearance of the contralateral recess and foramen. In the video, we present the case of a 51-yr-old female patient with a past medical history of left L5-S1 microdiscectomy who presented in clinic with residual/recurrent foraminal disc herniation at L5-S1 compressing the left L5 nerve root. The patient had left lower extremity pain in the left hip and thigh that radiated down the front and side of the leg, as well as tingling and numbness in the left foot. The patient was treated via a L5-S1 microdiscectomy using a portable intraoperative computed tomography scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with 3-dimensional (3D) computer navigation. Patient consent was obtained prior to performing the procedure. The main advantage of this technique is the direct "over-the-top" trajectory to the foraminal pathology that minimizes the need of facet joint resection. The use of 3D navigation facilitates surgical planning and further minimizes facet joint compromise. Particularly, the inferior facet contralateral to the approach side as well as its outer capsular surroundings can be preserved. Recent biomechanical studies have shown that "over-the-top" decompression produces significantly less instability than a traditional open midline laminectomy.

Symptomatic lumbar spondylolisthesis is commonly accompanied by spinal stenosis in multiple segments. These pathologies are routinely treated by multilevel decompression and instrumented fusion. However, it was hypothesized that a minimally invasive surgery (MIS) fusion in the unstable segment combined with a unilateral laminotomy for bilateral decompression (ULBD) in the adjacent stenotic segment is a biomechanically feasible alternative to a two-level fusion and superior to open laminectomy adjacent to a fused segment. This concept has demonstrated success in a recently published biomechanical cadaver study performed by our group. The present article offers a detailed step by step technical description for an MIS-TLIF (transforaminal lumbar interbody fusion) with adjacent ULBD.

Minimally invasive spine surgery (MISS) is a combination of specialized techniques, instruments, and technology for performing operations with less disruption of the adjacent tissues that surround the spine than traditional, open approaches. Three surgical objectives have driven the evolution of MISS: minimize tissue disruption, achieve bilateral decompression via a unilateral approach, and achieve indirect neural decompression. MISS began with the treatment of herniated lumbar intervertebral discs and has evolved tremendously since to be applicable to the treatment of a variety of spinal pathologies involving the entirety of the spinal column, including foraminotomies, fusion procedures, tumor resections, and fixation of traumatic fractures. The key elements of MISS include a small access approach to limit exposure-related tissue damage, magnification and illumination with the use of a microscope or endoscope, supplemental localization such as computer-assisted navigation, and surgical instruments that facilitate minimal access to the relevant spinal anatomy, all contributing to the goal of leaving the smallest possible operative footprint while achieving good clinical outcomes. The rapid advancement in technology has allowed the field to evolve significantly, such that traditional procedures that previously required larger exposures with increased morbidity are being effectively and efficiently performed in a minimally invasive fashion. In this chapter, the authors present a review of the history and evolution of MISS.

Background Traumatic burst fractures of the lumbar spine can result in significant neurologic injury and mechanical instability. The ideal surgical approach for the treatment of unstable lumbar spine burst fractures remains debatable. Case Description A 37-year-old man presented with severe neurologic injury including loss of motor function below the level of the iliopsoas muscles bilaterally, saddle anesthesia, and absent rectal tone, after a fall from 18.28 m (60 ft). Computed tomography showed an L4 vertebral body comminuted burst fracture with complete posterior translation of L4 over L5. The patient was taken to the operating room for an L4 corpectomy and L2-S1 posterior fusion. The L4 vertebral body was visualized posterior to the posterior elements of L5 and resected in a piecemeal fashion. Because the thecal sac had been completely transected, a visible path down the L3-L4 and L4-L5 disk spaces was apparent, allowing direct posterior discectomies at these levels and completion of the L4 segment resection. The use of a direct posterior approach resulted in minimal blood loss, correction of sagittal alignment, and satisfactory outcomes comparable with the standard posterior transpedicular approach. Construct stability and solid bony fusion have been maintained for 4 years postoperatively. Conclusions The use of a direct midline posterior corpectomy approach may be considered for patients with lumbar burst fractures, high-grade neurologic injury, and transection of the thecal sac.

An fMRI pitch memory task was administered to left and right anterior temporal lobectomy (ATL) patients. The goal was to verify the neuroanatomical correlates of non-verbal memory, and to determine if pitch memory tasks can identify cognitive risk prior to ATL. The data showed that the bilateral posterior superior temporal lobes implement pitch memory in both ATL patients and NCs (normal controls), indicating that the task can be accomplished with either anterior temporal lobe resected. NCs activate the posterior temporal lobes more strongly than ATL patients during highly accurate performance. In contrast, both ATL groups activate the anterior cingulate in association with accuracy. While our data clarifies the functional neuroanatomy of pitch memory, it also indicates that such tasks do not serve well to lateralize and functionally map potentially “at risk” non-verbal memory skills prior to ATL.