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OBJECT: In this paper, the authors' goal was to demonstrate the clinical and technical nuances of a minimally invasive lateral extracavitary approach (MI-LECA) for thoracic corpectomy and anterior column reconstruction. METHODS: A cadaveric feasibility study and the subsequent application of this approach in 3 clinical cases are reported. Six procedures were completed in 3 human cadavers. Minimally invasive, extrapleural thoracic corpectomies were performed with the aid of a 24-mm tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT scanning, using 3D volumetric averaging software, was used to evaluate the degree of bone removal and decompression. Three clinical cases, including a T-11 burst fracture, a T-7 plasmacytoma, and a T4-5 vertebral body (VB) tuberculosis lesion, were treated using the approach. RESULTS: At 6 cadaveric levels, the mean circumferential volumetric decompression was 48% ± 16%, and the mean resection of the VB was 72% ± 13%. The mean change in anterior and posterior vertebral height with expansion of the corpectomy cage was 47 and 61 mm, respectively. There were no violations of the pleura or dura. Pedicle screw reliability was 95.8% (23 of 24 screws) with a single lateral breach. All 3 patients in the clinical cohort had excellent clinical outcomes. There was a single pleural tear requiring chest tube drainage. Operative images and a video clip are provided to illustrate the approach. CONCLUSIONS: A minimally invasive lateral extracavitary thoracic corpectomy has the ability to provided excellent spinal cord decompression and VB resection. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to improve upon established traditional open corridors for posterolateral thoracic corpectomy.

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Over the past decade, the development and refinement of minimally invasive spine surgery techniques has lead to procedures with the potential to minimize iatrogenic and post-operative sequelae that may occur during the surgical treatment of various pathologies. In a similar manner, parallel advances in other current treatment technologies have led to the development of other minimally invasive treatments of spinal malignancies. These advances include percutaneous techniques for vertebral reconstruction, including vertebroplasty and kyphoplasty, the development of safe and effective spinal radiosurgery, and minimal-access spinal surgical procedures that allow surgeons to safely decompress and reconstruct the anterior spinal column. The advent of these new techniques has given modern practitioners treatment options in situations where they previously were limited by the potentially significant morbidities of the available techniques. Here, the authors discuss the application of current minimally invasive technologies in the treatment of malignancies of the thoracic spine, focusing on vertebral kyphoplasty, spinal radiosurgery, and minimally invasive spinal decompression techniques. The author's describe how these emerging treatment options are significantly expanding the options open to clinicians in the treatment of thoracic spinal column malignancies. Specific illustrative case examples are provided. The development of these techniques has the potential to improve clinical outcomes, limit surgical morbidity, and also improve the safety and efficiency of treatment pathways.

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BACKGROUND: We describe a new posterior dynamic stabilizing system that can be used to augment the mechanics of the degenerating lumbar segment. The mechanism of this system differs from other previously described surgical techniques that have been designed to augment lumbar biomechanics. The implant and technique we describe is an extension-limiting one, and it is designed to support and cushion the facet complex. Furthermore, it is inserted through an entirely percutaneous technique. The purpose of this technical note is to demonstrate a novel posterior surgical approach for the treatment of lumbar degenerative. METHODS: This report describes a novel, percutaneously placed, posterior dynamic stabilization system as an alternative option to treat lumbar degenerative disk disease with and without lumbar spinal stenosis. The system does not require a midline soft-tissue dissection, nor subperiosteal dissection, and is a truly minimally invasive means for posterior augmentation of the functional facet complex. This system can be implanted as a stand-alone procedure or in conjunction with decompression procedures. RESULTS: One-year clinical results in nine individual patients, all treated for degenerative disease of the lower lumbar spine, are presented. CONCLUSIONS: This novel technique allows for percutaneous posterior dynamic stabilization of the lumbar facet complex. The use of this procedure may allow a less invasive alternative to traditional approaches to the lumbar spine as well as an alternative to other newly developed posterior dynamic stabilization systems.

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BACKGROUND: Perineural cysts of the sacrum, or Tarlov cysts, are cerebrospinal fluid (CSF)-filled sacs that commonly occur at the intersection of the dorsal root ganglion and posterior nerve root in the lumbosacral spine. Although often asymptomatic, these cysts have the potential to produce significant symptoms, including pain, weakness, and/or bowel or bladder incontinence. We present a case in which the sacral roof is removed and reconstructed via plated laminoplasty and describe how this technique could be of potential use in maximizing outcomes. METHODS: We describe technical aspects of a sacral laminoplasty in conjunction with cyst fenestration for a symptomatic sacral perineural cyst in a 50-year-old female with severe sacral pain, lumbosacral radiculopathy, and progressive incontinence. This patient had magnetic resonance imaging (MRI) and computed tomography (CT)-myelographic evidence of a non-filling, 1.7 × 1.4 cm perineural cyst that was causing significant compression of the cauda equina and sacral nerve roots. This surgical technique was also employed in a total of 18 patients for symptomatic tarlov cysts with their radiographic and clinical results followed in a prospective fashion. RESULTS: Intraoperative images, drawings, and video are presented to demonstrate both the technical aspects of this technique and the regional anatomy. Postoperative MRI scan demonstrated complete removal of the Tarlov cyst. The patient's symptoms improved dramatically and she regained normal bladder function. There was no evidence of radiographic recurrence at 12 months. At an average 16 month followup interval 10/18 patients had significant relief with mild or no residual complaints, 3/18 reported relief but had persistent coccydynia around the surgical area, 2/18 had primary relief but developed new low back pain and/or lumbar radiculopathy, 2/18 remained at their preoperative level of symptoms, and 1/18 had relief of their preoperative leg pain but developed new pain and neurological deficits. CONCLUSIONS: Sacral laminoplasty and microscopic cystic fenestration is a feasible approach in the operative treatment of this difficult, and often controversial, spinal pathology. This technique may be used further and studied in an attempt to minimize potential surgical morbidity, including CSF leaks, cyst recurrence, and sacral insufficiency fractures.

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Ossification of the posterior longitudinal ligament (OPLL) is an important cause of cervical myelopathy that results from bony ossification of the cervical or thoracic posterior longitudinal ligament (PLL). It has been estimated that nearly 25% of patients with cervical myelopathy will have features of OPLL. Patients commonly present in their mid-40s or 50s with clinical evidence of myelopathy. On MR and CT imaging, this can be seen as areas of ossification that commonly coalesce behind the cervical vertebral bodies, leading to direct ventral compression of the cord. While MR imaging will commonly demonstrate associated changes in the soft tissue, CT scanning will better define areas of ossification. This can also provide the clinician with evidence of possible dural ossification. The surgical management of OPLL remains a challenge to spine surgeons. Surgical alternatives include anterior, posterior, or circumferential decompression and/or stabilization. Anterior cervical stabilization options include cervical corpectomy or multilevel anterior cervical corpectomy and fusion, while posterior stabilization approaches include instrumented or noninstrumented fusion or laminoplasty. Each of these approaches has distinct advantages and disadvantages. While anterior approaches may provide more direct decompression and best improve myelopathy scores, there is soft-tissue morbidity associated with the anterior approach. Posterior approaches, including laminectomy and fusion and laminoplasty, may be well tolerated in older patients. However, there often is associated axial neck pain and less improvement in myelopathy scores. In this review, the authors discuss the epidemiology, imaging findings, and clinical presentation of OPLL. The authors additionally discuss the merits of the different surgical techniques in the management of this challenging disease.

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