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Background Robotic-assisted techniques have been implemented in the surgical treatment of tumors in the pelvis, abdomen, and thorax. In pelvic tumors, robotic-assisted techniques evade the need for sizable surgical exposure, but make stimulation of the nerves of the sacral plexus very difficult. Objective To describe how laparoscopic robotic-assisted surgery can couple with tools such as the nerve stimulator to aid in the resection of presacral masses emanating from the neural elements and potentially improve neurological outcome by preventing inadvertent injury to involved nerves. Methods A patient with a large presacral ganglioneuroma underwent resection using the DaVinci system (Intuitive Surgical, Sunnyvale, California) for robotic assistance. A nerve stimulator was coupled to the bipolar cautery instrument of the DaVinci robot to define the presence of functional nerves in the surroundings of the tumor. Results By coupling a nerve stimulator to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical), it was possible to identify important neural structures in close proximity to the tumor. After identifying functional nerves, the surgeon was able to preserve them and preserve neurological function avoiding motor dysfunction. Conclusion The use of a nerve stimulator coupled to the bipolar cautery instrument of the DaVinci robot (Intuitive Surgical) during laparoscopic, robotic-assisted surgery for resection of presacral masses is safe and feasible. In addition to the preoperative evaluation, intraoperative monitoring and stimulation of nerves in close proximity to the tumor and also exiting through neural foramina involved by the tumor allowed the surgeon to understand the anatomy and preserve neurological function while obtaining optimal surgical resection.

Background Surgical treatment of severe cervicothoracic kyphotic deformity may require the use of 3-column osteotomies such as the pedicle subtraction osteotomy and vertebral column resection (VCR), or VCR with anterior longitudinal ligament resection. Such procedures are extensive and are associated with high intra- and perioperative morbidity, in part, due to the need for risky reduction maneuvers. Objective To describe a novel technique utilizing a laterally placed articulating hinge to facilitate kyphotic deformity correction of the cervicothoracic spine. Methods A patient with severe chin-on-chest deformity of the cervicothoracic spine presented for evaluation and a 2-stage VCR with anterior longitudinal ligament resection was planned. To reduce the risk of intraoperative neurological injury and for increased control during reduction maneuvers, lateral instrumentation was placed through the chest wall resection above and below the level of VCR, which was adjoined with an articulating hinge rod apparatus. Results Satisfactory reduction of the kyphosis was achieved utilizing the hinge rod apparatus for controlled deformity correction. The patient remained neurologically intact following this procedure with improvement in their spinal alignment. Conclusion We present a novel technique utilizing a lateral hinge rod apparatus for efficient, controlled correction of severe kyphotic deformity.

BACKGROUND AND IMPORTANCE Occurrence of spinal epithelioid sarcomas is rare, with few cases reported in the literature. Although wide local resection is the recommended treatment, this technique is challenging in the spine. CLINICAL PRESENTATION The case of a 17-year-old male with a recurrent epithelioid sarcoma with intradural extension in the cervical spine is presented. Because of nerve root involvement, the patient presented with right upper extremity weakness. The patient underwent a posterior C1-C4 spondylectomy to achieve an en bloc resection, followed by reconstruction from the occiput to T4. The right vertebral artery and C1-C4 nerve roots were sacrificed because of tumor involvement. After 3 years of follow-up the patient is disease-free but has persistent right deltoid weakness. CONCLUSION Cervical spondylectomy via a single-staged posterior approach is a challenging yet feasible procedure for the treatment of epithelioid sarcomas. To the best of the authors' knowledge, this is the first report of complete resection of an epithelioid sarcoma with intradural extension in the cervical spine. Although neurovascular structures may warrant sacrifice, this procedure may provide improved long-term prognosis.

Giant cell tumors (GCTs) are rare primary bone neoplasms. The best long-term prognosis is achieved via complete tumor excision, but this feat is challenging in the spine due to proximity of blood vessels and nervous tissue. When occurring in the sacrum, GCTs have been removed in an en bloc fashion via combined anterior/posterior approaches, oftentimes with nerve root sacrifice. The purpose of this article is to present a case of a single-staged, posterior-only approach for en bloc resection of a sacral GCT without nerve root sacrifice.A 45-year-old female presented with intractable lower back and leg pain, saddle anesthesia, and lower extremity weakness. She underwent imaging studies, which revealed a lesion involving the S1 and S2 vertebral bodies. Computed tomography guided biopsy revealed the lesion to be a GCT. The patient underwent a posterior-only approach without nerve root sacrifice to achieve an en bloc resection, followed by lumbopelvic reconstruction.Sacrectomy via a single-staged posterior approach with nerve root preservation is a challenging yet feasible procedure for the treatment of giant cell tumors in carefully selected patients.

Background Occipitocervical instability with vertical migration of the odontoid is a rare but potentially debilitating anomaly of the craniocervical junction. Anterior decompression by means of a transoral or transcervical approach followed by posterior instrumentation commonly is used to treat this pathology. Objective To develop an innovative operative technique to correct reducible occipitocervical instability using a purely posterior approach. Clinical presentation Two patients presented to our institution with occipitocervical instability. One patient developed vertical migration of the odontoid secondary to a retropharyngeal abscess after radiation treatment. The second patient developed occipitocervical instability as a result of pathological destruction of C2 from a breast metastasis. Both patients were myelopathic with severe neck pain. Technique Both patients were brought to the operating room for intraoperative reduction and fixation using a purely posterior approach. This new technique obviated the need for an anterior decompression procedure or preoperative halo reduction. Postoperatively, both patients had excellent restoration of spinal alignment as well as improvement in both pain and myelopathy. Conclusion We achieved intraoperative reduction of occipitocervical instability through a purely posterior approach. This technique adds a tool to the armamentarium of techniques used for the treatment of occipitocervical instability.

OBJECTIVE: The first in vitro biomechanical investigation comparing the immediate and postcyclical rigidities of thoracic translaminar versus pedicle screws in posterior constructs crossing the cervicothoracic junction (CTj). METHODS: Ten human cadaveric spines underwent C4-C6 lateral mass screw and T1-T2 translaminar (n = 5) versus pedicle (n = 5) screw fixation. Spines were then potted in polymethylmethacrylate bone cement and placed on a materials testing machine. Rotation about the axis of bending was measured using passive retroreflective markers and infrared motion capture cameras. The motion of C6 relative to T2 in flexion-extension and lateral bending was assessed uninstrumented, immediately after instrumentation, and after 40,000 cycles of 4 N•m flexion-extension and lateral bending moments at 1 Hz. The effect of instrumentation and cyclical loading on rotational motion across the CTJ was analyzed for significance. RESULTS: Compared with preinstrumented spines, pedicle and translaminar screw constructs significantly (P < 0.001) decreased motion during flexion-extension and lateral bending. After cyclical loading, rotational motion at the CTJ was significantly increased (P < 0.05) during flexion-extension and lateral bending in both groups. With flexion-extension, the mean rotational motion across the CTJ was similar in the translaminar and pedicle constructs immediately after fixation, but slightly greater (P = 0.03) after cyclical loading in the translaminar versus the pedicle screw constructs (0.39 degrees versus 0.26 degrees). Nevertheless, after cyclical loading, the mean angular motion across the CTJ remained less than one half of a degree in both groups. With lateral bending, the mean rotational motion was similar in both translaminar and pedicle screw constructs. CONCLUSION: Both upper thoracic translaminar and pedicle screws allow for rigid fixation at the CTJ. Although translaminar screw constructs demonstrated one eighth of a degree more motion at the CTJ after cycling, this minimal difference is likely less than would influence the biological fusion process. Upper thoracic translaminar screws are a biomechanically effective option to rigidly stabilize the CTJ.

OBJECTIVE Spinal cord compression secondary to a subluxation of one vertebral body over another can be achieved with reduction of the translational deformity. Intraoperative reduction of C1-C2 subluxations can be technically challenging when one uses traditional techniques (e.g., wiring and transarticular screw fixation). The popularization of C1 lateral mass and C2 pedicle screws has allowed surgeons to achieve a more complex realignment at this region of the spine. Control of both C1 and C2 with independent fixation can be used to obtain reduction. In certain instances, placement of C2 pedicle screws is not possible. The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2 and can be used for intraoperative reduction. CLINICAL PRESENTATION A 15-year-old boy with juvenile rheumatoid arthritis presented with spinal cord compression secondary to a C1-C2 subluxation. The C2 pedicle anatomy precluded safe placement of C2 pedicle screws. An alternative method of fixation with the use of C2 translaminar screws and reduction was performed to obtain proper alignment and decompress the spinal cord. TECHNIQUE C1 lateral mass screws and C2 translaminar screws are inserted in the usual fashion. Two contoured rods, two rod holders, and two distractors, combined with C1 lateral mass screws and C2 translaminar screws, were used to achieve reduction. Concomitant distraction between the C2 translaminar screw head and the rod holder resulted in ventral translation of C2 on C1, decompressing the spinal cord. The reduction was maintained by tightening the C2 locking nut onto the rod. CONCLUSION The use of C2 translaminar screws (if the C2 lamina is present and suitable) is an alternative method of fixation in C2. C1 lateral mass and C2 translaminar screw fixation provide a powerful means of reducing C1-C2 subluxations and maintaining alignment, achieving indirect decompression of the spinal cord.

OBJECTIVE Total sacrectomies are performed for extensive en bloc tumor resections. Exposure traditionally combines a posterior approach with a laparotomy to facilitate vascular control. We present a case of a total en bloc sacrectomy performed entirely through the posterior approach, thereby avoiding the need for a laparotomy. CLINICAL PRESENTATION A 57-year-old man presented with sacral pain and loss of bowel and bladder function. A large sacral mass was identified and submitted to biopsy. Results were consistent with an osteoblastoma, although osteosarcoma could not be excluded on pathological examination. The patient was taken to the operating room for a total sacrectomy and en bloc resection of the mass. TECHNIQUE Lateral iliac osteotomies were performed, followed by an L5-S1 discectomy and resection of the annulus, thus mobilizing the sacrum. Gradual distraction of the interspace coupled with upward traction of the sacrum provided an anterior exposure through which the internal iliac vessels were controlled, dissected, and divided. A combined transperineal approach completed the posterior dissection and the tumor was delivered en bloc. Lumbopelvic reconstruction was performed simultaneously. CONCLUSION With the use of interspace distraction and sacral elevation to facilitate vascular control, a total sacrectomy was performed without the need for the anterior exposure of a laparotomy.

OBJECTIVE: Surgical correction of thoracic kyphotic deformity is often associated with significant surgical and neurological morbidity and unsatisfactory reduction of kyphosis, especially in patients who cannot tolerate anterior thoracic procedures because of associated comorbidity. We describe a technique in which kyphotic deformity of the thoracic and thoracolumbar spine is corrected, decompressed, and stabilized with a circumferential fixation construct from a lone posterior approach. METHODS: We reviewed the radiographic and clinical outcomes of seven patients undergoing vertebrectomy via a bilateral modified costotransversectomy approach followed by posterior placement of a distractible cage, reduction of the deformity via cage distraction, and supplemental dorsal instrumentation. All patients possessed thoracic/thoracolumbar kyphosis; however, a transthoracic approach was thought to be high risk because of medical comorbidity. RESULTS: Seven patients underwent this procedure for thoracolumbar kyphosis resulting from a spinal tumor, osteomyelitis, and fracture. Vertebrectomies were performed at T2‐T3, T4‐T5, T5‐T6, T12‐L1, and L1. The mean preoperative kyphosis was 28.6 degrees, the mean postoperative kyphosis at the time of the final follow-up examination was 12.1 degrees, and the mean change in kyphosis was 53%. The mean long-term follow-up period was approximately 16 months. At the time of the final follow-up examination for all patients, there was no decline in neurological function, and pain management consisted of minimal use of oral narcotics. CONCLUSION: This technique allows for circumferential decompression of the spinal cord via a posterior approach in patients with thoracic kyphotic deformities who cannot tolerate anterior thoracic approaches. In addition, in situ distraction of the expandable cage allows correction of sagittal imbalance and restores height without the potential loss of spinal height associated with osteotomies.

BACKGROUND AND IMPORTANCE Primary tumors of the spine are considered for en bloc resection to improve local control and even obtain cure. Anatomic restrictions often prohibit extensive resections with negative margins that are safe and feasible. We report the first case involving a patient with a large chordoma of the thoracic spine who underwent a successful 5-level spondylectomy with bilateral chest wall resection for en bloc resection without neurologic compromise. CLINICAL PRESENTATION A 26-year-old woman with a chest mass was found to have a T1-5 chordoma via a percutaneous biopsy. En bloc resection of the mass was thought to be the best option for long-term local control and possible cure. She presented without neurologic or pulmonary dysfunction. The patient underwent a 3-stage procedure. The first stage involved a posterior C2-T8 exposure, allowing release of posterior elements from C7 to T6 and instrumented stabilization from C2 to T8. T1-5 ribs were cut bilaterally, and 2 wire saws were placed ventral to the thecal sac at the C7-T1 and T5-6 disc levels. The second stage involved a right-sided thoracotomy, and the T5-6 wire saw was used to complete the lower osteotomy. The third stage involved completion of the C7-T1 osteotomy with the wire saw, delivery of the tumor specimen en bloc, ventral reconstruction of the spine with a titanium mesh cage, and bilateral thoracoplasty. CONCLUSION This is the first case report of a 5-level spondylectomy for en bloc resection of an extensive thoracic chordoma via a bilateral thoractomy without neurologic compromise.