CLINICAL ARTICLE

J Neurosurg Spine 37:121–129, 2022

Transtubular image-guided surgery for spinal intradural

lesions: techniques, results, and complications in a
consecutive series of 60 patients
John Michael Duff, MD,1 Patrick Omoumi, MD, MSc, PhD,2 Lukas Bobinski, MD, PhD,3
Amani Belouaer, MD,4 Sonia Plaza Wuthrich, PhD,5 Fabio Zanchi, MD,2 and Rodolfo Maduri, MD1
1
Avaton Surgical Group, Genolier Spine Care Center, Clinique de Genolier, Genolier, Switzerland; 2Department of
Radiodiagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland; 3Department of
Orthopedics, University Hospital, Umëa, Sweden; 4Neurosurgical Service, Department of Clinical Neurosciences, Lausanne
University Hospital, Lausanne, Switzerland; and 5Centre Leenaards de la Memoire, Lausanne University Hospital, Lausanne,
Switzerland

OBJECTIVE  The authors previously described the image merge tailored access resection (IMTAR) technique for resec-
tion of spinal intradural lesions (SIDLs). The authors reported their updated experience with the IMTAR technique and
compared surgical results between patients who underwent operations with 2D or 3D fluoroscopic guidance.
METHODS  The authors reviewed 60 patients who underwent SIDL resection with transtubular techniques over a
14-year period. The earlier patients in the series underwent operations with 2D fluoroscopic image guidance. The latter
patients underwent operations with the IMTAR technique based on 3D image guidance. The results of both techniques
were analyzed.
RESULTS  Sixty patients were included: 27 females (45%) and 33 males (55%). The median (range) age was 50.5
(19–92) years. Gross-total resection (GTR) was achieved in 52 patients (86.7%). Subtotal resection was accomplished
in 5 patients (8.3%). Neurological complications occurred in 3 patients (5%), and tumor recurrence occurred in 1 patient
(1.7%). The non-IMTAR and IMTAR cohorts showed similar postoperative Nurick scale scores and rates of neurologi-
cal complications and GTR. The median (interquartile range) bone resection surface area at the index level was 89.5
(51–147) mm2 in the non-IMTAR cohort and 35.5 (11–71) mm2 in the IMTAR cohort, with a statistically significant differ-
ence (p = 0.0112).
CONCLUSIONS  Surgery for SIDLs may be challenging, and meticulous surgical planning is crucial to optimize tumor
access, maximize resection, and minimize risk of complications. Image-guided transtubular resection is an additional
surgical technique for SIDLs and facilitates microsurgical tumor removal of ventrally located lesions with a posterolateral
approach, without requiring potentially destabilizing bone resection.
https://thejns.org/doi/abs/10.3171/2021.10.SPINE211168
KEYWORDS  intradural extramedullary spinal cord neoplasms; neuronavigation; minimally invasive surgical
procedures; minimal access surgical procedures; fluoroscopy; surgical technique

S
pinal intradural lesions (SIDLs) are uncommon
neoplastic lesions with an incidence of 0.3–10 per
100,000 persons.1 The standard treatment for symp-
tomatic SIDLs is resection with a midline translaminar
approach.2,3 This approach enables excellent surgical ac-
cess of SIDLs in the lumbosacral spine below the conus
medullaris. For SIDLs located ventral or ventrolateral to
the spinal cord and above the level of the conus medul-
laris, a translaminar approach provides limited exposure
of the lesion and therefore requires spinal cord manipula-
tion with increased risk of neurological complications.4,5
Minimal access and tubular techniques have been de-
scribed to reduce soft-tissue morbidity in patients who un-
dergo SIDL resection and to improve the angle of access
to the lesions.6–9 Studies that compared open surgical tech-
niques with minimal access/transtubular techniques for
SIDL have shown comparable rates of lesion resection and
complications, with the latter techniques associated with

ABBREVIATIONS  GTR = gross-total resection; IMTAR = image merge tailored access resection; IQR = interquartile range; MIS = minimally invasive surgery; OSAT =
optimal surgical access trajectory; SIDL = spinal intradural lesion; STR = subtotal resection.
SUBMITTED  September 1, 2021.  ACCEPTED  October 26, 2021.
INCLUDE WHEN CITING  Published online January 14, 2022; DOI: 10.3171/2021.10.SPINE211168.

©AANS 2022, except where prohibited by US copyright law J Neurosurg Spine  Volume 37 • July 2022 121

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Duff et al.
decreased intraoperative blood loss and length of hospital
stay.9,10
Since 2004, we have treated patients with SIDL with
transtubular approaches, initially using 2D fluoroscopic
image guidance and subsequently 3D fluoroscopic image
guidance. This has reduced soft-tissue morbidity due to
the approach while allowing standard microsurgical tu-
mor resection. The 2D image-guided technique relies on
laterally imaged vertebral bone anatomy for tumor lo-
calization and tubular placement. The 3D image-guided
technique adds several layers of image guidance precision,
while still allowing standard microsurgical resection and
perhaps enhancing quality of resection. Even if fluoro-
scopic imaging–guided navigation helps to place the tubu-
lar retractor during minimal access surgery,7 fluoroscopic
3D imaging alone does not permit visualization of lesions.
Thus, the surgical trajectory, bone resection, and lesion
exposure are planned on the basis of only bone landmarks
with the inherent limitations associated with this tech-
nique, including poor visualization of certain anatomical
zones such as the cervicothoracic junction and in some
patients with a larger body habitus.
We developed a technique that superimposes or merges
preoperative MR images with intraoperatively obtained
3D fluoroscopically images, so the MR images of the tar-
get lesion and spinal cord can be seen on the workstation
for the 3D fluoroscopic images. This is the basis of the im-
age merge tailored access resection (IMTAR) technique.7
In the present study, we have reported the surgical results
of our patients with SIDL who underwent operations with
non-IMTAR and IMTAR techniques. The aim of this
study was to show that both techniques are safe and reli-
able, as well as to compare the outcomes of the IMTAR
technique such as bone resection area and clinical results
with those of the more readily available 2D fluoroscopic
(non-IMTAR) technique.
Methods
Study Design
We performed a retrospective analysis of anonymized
data of a consecutive series of patients with SIDL who
were surgically treated between 2004 and 2018 at Lau-
sanne University Hospital. A transtubular technique was
used to treat all patients. All patients had the same lead
surgeon (J.M.D.).
Ethics committee approval was obtained in December
2015 from the Vaud Ethics Committee Board. Prespeci-
fied uniform definitions were used to record variables, and
data were entered into a secuTrial platform (InterActive
Systems GmbH) at the time of preoperative consultation,
during the immediate postoperative period, and at the fol-
low-up evaluations.
Patients and Variables
Patients with SIDL were treated with 2D fluoroscopic
image guidance between January 1, 2004, and December
31, 2012. For the remainder of the study period, IMTAR
was used because intraoperative 3D fluoroscopic imaging
became available at our institution.
The study comprised retrospective descriptive and pro-
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spective observational parts. Some of the results of the pro-
spective observational cohort were previously published.7
The study objective was to compare clinical results, sur-
gical complications, and amounts of bone resection and
lesion removal between groups of patients with SIDL who
underwent the two imaging techniques. The key inclusion
criteria were age ≥ 18 years, consent of the patient, and
SIDL that was treated with a transtubular technique (for
both the retrospective and prospective cohorts). The key
exclusion criteria were spine lesion treated with any other
surgical technique, concomitant medical illness that could
have interfered with outcome assessment and follow-up,
and foreseeable difficulties in follow-up (e.g., geographic
distance).
Patient variables included age, sex, Nurick scale score,11
and presence of neurological deficits such as motor or sen-
sory deficit and dysesthesia. These variables were assessed
preoperatively; postoperatively at 3, 6, and 12 months; and
annually thereafter. T1-weighted MRI, T1-weighted MRI
with gadolinium enhancement, and T2-weighted MRI
were performed preoperatively and then at every follow-
up evaluation.
For patients who underwent operations with the IMTAR
technique, preoperative MRI (Medtronic Navigation,
Inc.) was performed with the following parameters: im-
age thickness 1–2 mm; images included half the vertebra
above and below the region of interest; and acquisition of
the sacrum included both sciatic notches. The radiological
variables were lesion position in relation to the dura mater
and spinal cord (extradural, intradural extramedullary, or
intradural intramedullary), and lesion position in the spi-
nal canal in relation to the spinal cord (ventral, dorsal, and
lateral [left or right]). For analytical and descriptive pur-
poses, all tumors were assigned an optimal surgical access
trajectory (OSAT) (Fig. 1). With this classification system,
the horizontal axis was defined as 0° on either side, with
radii every 30°. The vertical axis was assigned a value
of 3. The intervening axes were in numerical sequence,
such that 30° off the midline was 2 (OSAT 2) and 60° off
the midline was 1 (OSAT 1). Tumors located ventral to
the spinal cord and cauda equina were assigned negative
numbers, and tumors located dorsal to the spinal cord and
cauda equina were assigned positive numbers. With this
system, we assigned a number (range −3 to +3) and sign
to each tumor that most closely described the epicenter of
the tumor relative to the neural elements. The principle
was that smaller numbers indicated more difficult surgical
access. Left and right modifiers were assigned to indicate
laterality.
The treatment variables were bone resection (partial or
total hemilaminectomy, mini extracavitary costotransver-
sectomy, facetectomy [defined as none, partial (≤ 70%) or
complete (> 70%)]), planned voluntary nerve root sacri-
fice, surgical time (in minutes), blood loss (in milliliters),
local complications (e.g., CSF leak, wound infection, he-
matoma), neurological complications (e.g., unanticipated
motor or sensory radicular deficit, dysesthesia, myelopa-
thy according to a worsened Nurick scale score), lesion
resection on the first postoperative T1-weighted MRI scan
with gadolinium enhancement, bone resection surface
area (in square millimeters), lesion surface area (in square

FIG. 1. Drawing showing the OSAT classification system. The horizontal
axis is defined as 0° on both sides, with radii every 30°. The vertical axis
is assigned a value of 3. The intervening axes are described numerically
and sequentially at 30° and 60° off the midline. Left and right modifiers
are assigned to indicate laterality.
millimeters), and ratio between the bone resection and le-
sion surface areas.
Surgical Techniques
Patient Positioning and Skin Incision
After intubation, patients are placed prone on a Jackson
table. A Mayfield head holder is used for patients with cer-
vical and upper thoracic tumors. Continuous neurophysio-
logical monitoring, with transcranial motor evoked poten-
tial and somatosensory evoked potential monitoring and
free running electromyography, is used for all patients.
The transtubular technique utilizes a 3-cm paramedian
skin incision centered at a variable distance from the mid-
line depending on patient “thickness” and the desired an-
gle of approach deduced from the preoperative axial MR
images. Subcutaneous tissues are divided using monop-
olar cautery, and the underlying fascia is opened in line
with the skin incision to expose the underlying muscles.
Deep intramuscular injection of local anesthesia with bu-
pivacaine (0.5% carbostesin with 1:200,000 adrenaline;
AstraZeneca) is administered along the intended trans-
muscular trajectory.
Retractor Placement and Image Guidance
2D Fluoroscopic Guidance Technique. After fascial
opening, the first of a series of tubular dilatators is placed
adjacent to the transmuscular corridor, and the target level
is verified with lateral fluoroscopy. The transmuscular
corridor is progressively dilated, and an expandable tubu-
lar retractor (Metrx Quadrant, Medtronic Sofamor Danek)
is placed along the intended trajectory and docked onto
the vertebral surface.
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Duff et al.
3D Fluoroscopic Guidance Technique With IMTAR.
A 10-mm midline incision is made 1 vertebral level be-
low the caudal segment of the tumor, as determined with
manual counting on 2D fluoroscopic images, and the navi-
gation reference frame (NavLock, Medtronic) is attached
to the corresponding spinous process (Fig. 2A).7 3D fluo-
roscopic images are acquired using the O-arm (Medtron-
ic). Then, the 3D images are manually merged with the
preoperative MR images on the Stealth workstation us-
ing Synergy Cranial 2.2 and StealthMerge 1.2 software
(Medtronic) (Fig. 2B).
Specific morphological and anatomical features of
the vertebrae within the field of view are used to ensure
appropriate matching of vertebrae. The accuracy of the
merged superimposed images is verified on the worksta-
tion by manually windowing back and forth between MR
and 3D fluoroscopic images. Windowing is then set at an
intermediate level, where the bone anatomy and tumor
are simultaneously visualized. After registration, track-
able instruments are used to provisionally and visually
verify navigation accuracy through the small midline
incision and the exposed spinous process. With virtual
projection, ideal access to the tumor through the canal is
chosen on the basis of the relative positions of the tumor
and spinal cord or cauda equina. This virtual trajectory
defines the locations of the skin incision and transmus-
cular corridor. The first of a series of tubular dilatators
is placed adjacent to this transmuscular corridor, and the
pointer is then removed. The transmuscular corridor is
progressively dilated, and an expandable tubular retractor
is placed along the intended trajectory and docked onto
the vertebral surface overlying the center of the tumor ac-
cess. The position of the retractor is verified using track-
able instruments, and expandable retractor blades are
opened to span beyond the upper and lower poles of the
tumor.
Bone Removal and Tumor Resection
The operating microscope is used during bone resec-
tion with a drill, small Kerrison punches, and microcu-
rettes. Care is taken regarding the extent of facet resec-
tion to minimize risk of postoperative instability. With
the non-IMTAR technique, extent of bone resection is tai-
lored to the needs of each lesion on the basis of bony ana-
tomical landmarks that are identified preoperatively and
verified with 2D fluoroscopy intraoperatively. With the
IMTAR technique, planned intraoperative neuronaviga-
tion is used to optimize tumor access but avoid excessive
bone resection, with the lesion visible on the workstation
(StealthStation, Medtronic Navigation, Inc.). Tumor expo-
sure is also verified using navigated instruments prior to
dural opening.
Dural opening is performed close to or at the midline,
and the lateral dural margin is retracted with 5-0 Prolene
sutures. The arachnoid is opened with drainage of cere-
brospinal fluid and tacked to the dural margins using mi-
croclips. Standard microsurgical resection of the lesion is
then carried out. For the few selected patients with intra-
medullary tumors, myelotomy is performed at either the
dorsal root entry zone or the point of posterolateral pial
contact with the lesion.
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FIG. 2. A: Intraoperative photograph showing the tubular retractor in place and the reference arch for navigation docked onto the
spinous process. B: Probe’s-eye views, obtained from the navigation suite during planning of the skin incision and the transmus-
cular trajectory, of tumor access based on the virtual projection of the navigation probe (straight purple markers). Images obtained
at the end of manual merging show preoperative MR and intraoperative 3D fluoroscopic data of a right-sided C6–7 meningioma,
with visualization of both the tumor and bone structures. C and D: GTR is shown on sagittal and axial postoperative images of the
same patient described in panel B. Panels A and B are reprinted from Maduri et al. World Neurosurg. 2017;98:594–602.7 © Else-
vier Inc., published with permission.

Dural Closure postoperative CT of the non-IMTAR and IMTAR cohorts

After tumor resection and hemostasis, the dura is
closed from the apices to the center of the dural opening
with two running 5-0 Prolene sutures. A Chitwood Knot
Pusher (Scanlan International) is used to assist with dural
closure. Dural sutures are reinforced with DuraSeal (Con-
fluent Surgical, Inc.).
The tubular retractor is removed, and after epidural and
muscle hemostasis, the wound is closed in layers without
drainage. All patients underwent 24 hours of postopera-
tive bed rest to reduce the risk of postoperative CSF leak.
Radiological Assessment
Two radiologists (F.Z. and P.O.), who were blinded to
the surgical technique, assessed tumor surface area on
preoperative 3D MRI and bone resection surface area on
(Fig. 3). Multiplanar reconstructions were used to com-
pare measurements between methods. The articular sur-
faces of the facet joints were measured on the operated
side at the target level. Differences in articular surfaces on
preoperative and postoperative CT scans were then com-
pared between the non-IMTAR and IMTAR cohorts.
Statistical Analysis
Continuous variables were presented as median (in-
terquartile range [IQR]), and categorical variables were
expressed as number and proportion. Comparisons of
Nurick scale scores, rates of complications, and quality
of lesion resection were analyzed with the chi-square test.
Change in Nurick scale scores between preoperation and
postoperation was analyzed with the paired chi-square

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FIG. 3. A: Preoperative 3D T2-weighted MR imaging sequence show-
ing a left-sided C6 schwannoma. The multiplanar reformatted coronal
oblique plane used to measure the largest surface area of the tumor (S1)
is shown. B and C: The sagittal and transverse planes of the tumor, with
reference (white lines) to panel A, are shown. D: A 10-mm maximum
intensity projection image of a postoperative CT scan of the cervical
spine of the same patient is shown, with the bone resection surface area
(S2 [red circle]) indicated.
test. Changes in bone resection surface area and articular
surface area were analyzed with the Wilcoxon test.
Confidence intervals for differences in mean values
were determined with the noninferiority test for the fol-
lowing variables: surgical time, blood loss, bone resec-
tion surface area, tumor surface area, and preoperative
and postoperative articular surface area at the index level.
The margin of the noninferiority analysis was defined as
a 10% difference in mean values. The ratios of bone re-
section surface area to tumor surface area were compared
between the non-IMTAR and IMTAR cohorts with the
chi-square test. In this study, p < 0.05 was considered sig-
nificant. Statistical analyses were performed using Stata
version 15.0 (StataCorp).
Results
The demographic, clinical, and radiological charac-
teristics of the patient population are outlined in Table 1.
Of 60 patients, there were 27 females (45%) and 33 males
(55%). The median (range) age was 50.5 (19–92) years.
Clinical presentations included myelopathy in 48.4% of
patients (n = 29), radicular deficit in 35% (n = 21), dyses-
thesia in 8.3% (n = 5), and back pain in 8.3% (n = 5).
MRI localized the lesions in the following locations:
cervical in 18.3% of patients (n = 11), thoracic in 43.4% (n
= 26), lumbar in 35% (n = 21), and sacral in 3.3% (n = 2). In
total, 91.7% of patients had intradural-extramedullary tu-
mors (n = 55), 6.7% had intramedullary tumors (n = 4), and
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Duff et al.
TABLE 1. Patient population
Characteristic Value
Age, yrs 50.5 (39.5–62.0; 19–92)
Sex
 Female 27 (45.0)
 Male 33 (55.0)
Clinical presentation
 Myelopathy 29 (48.4)
  Radicular deficit 21 (35.0)
 Dysesthesia 5 (8.3)
  Back pain 5 (8.3)
Spinal level
 Cervical 11 (18.3)
 Thoracic 26 (43.4)
 Lumbar 21 (35)
 Sacral 2 (3.3)
Values are shown as median (IQR; range) or number (%).
1.7% had combined intra- and extramedullary lesions (n =
1). The median (IQR) follow-up was 35 (14–60) months.
Surgical details, histological subtypes, and complica-
tions are detailed in Table 2. The transtubular technique
was used for all patients. Image guidance with 2D fluoros-
copy was used for 27 patients, and the IMTAR technique
was used for 33 cases. The median (IQR) surgical time
was 265 (210–300) minutes for the 2D fluoroscopic cohort
and 295 (236–334) minutes for the IMTAR cohort. The
median (IQR) estimated blood loss was 300 (250–300) ml
for the 2D fluoroscopic cohort and 200 (100–300) ml for
the IMTAR cohort. No statistical differences in surgical
time and blood loss were found between the two tech-
niques.
Extent of bone resection varied depending on lesion
morphology and location relative to the spinal cord. Par-
tial or complete hemilaminectomy was carried out in 54
patients (90%). Extracavitary costotransversectomy was
performed in 6 patients (10%), all with ventrally located
thoracic lesions.
Concerning bone removal at the segmental posterior
articulations, complete facetectomy was carried out in 7
patients (11.6%) (all with lesions in the thoracic spine),
and partial facetectomy was accomplished in 44 patients
(73.4%). Facetectomy was not necessary in 9 patients
(15%). Fusion was not required during follow-up.
Gross-total resection (GTR) was achieved in 52 patients
(86.8%). Planned subtotal resection (STR) was carried
out in 4 patients (6.6%). All these lesions were tumors: 1
myxopapillary ependymoma, 1 thoracic meningioma ad-
herent to the anterior spinal artery, 1 multifocal anaplastic
astrocytoma, and 1 extramedullary and intramedullary
teratoma of which the intramedullary component was
deliberately not resected. The remaining 4 lesions (6.6%)
were arachnoid cysts, for which marsupialization and not
GTR was the surgical goal.
Intentional nerve root sacrifice was performed to fa-
cilitate resection of a nerve sheath tumor in 26 patients
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TABLE 2. Results and complications TABLE 3. Comparison of the non-IMTAR and IMTAR cohorts
Characteristic Value Variable Non-IMTAR Cohort IMTAR Cohort p Value
Image guidance Surgical time, mins 265 (210–300) 295 (236–334) 0.1064
  2D (non-IMTAR) 27 (45.0) Blood loss, ml 300 (250–300) 200 (100–300) 0.1609
  3D (IMTAR) 33 (55.0) Nurick scale, grade
Follow-up, mos 35 (14–60)  Preop 1 (0–3) 3 (0–3) 0.4354
Nerve root sacrifice 26 (43.3)  Postop 0 (0–2) 0 (0–1) 0.3923
Bone resection approach
Values are shown as median (IQR) unless indicated otherwise.
  Partial/complete hemilaminectomy 54 (90)
  Mini extracavitary costotransversectomy 6 (10)
Facetectomy
 Complete 7 (11.6) In terms of general medical complications, only 1 pa-
tient (1.7%) presented with transient delirium related to
 Partial 44 (73.4)
medications. Neurological complications occurred in 3
 None 9 (15) patients (5%). One patient with a C6–7 meningioma had
Lesion removal worsened right triceps weakness that improved at follow-
 GTR 52 (86.8) up. Postoperative Horner’s syndrome after resection of an
 STR 4 (6.6) extraforaminal C8 root schwannoma occurred in 1 patient,
 NA* 4 (6.6) and 1 patient presented with dysesthesias in the distribu-
tion of the right L3 nerve root that were controlled with
Histology
gabapentin at follow-up.
 Schwannoma 22 (36.6) Recurrence of an S1 sacral synovial cyst occurred after
 Meningioma 19 (31.7) GTR in only 1 patient (1.7%), but without clinical manifes-
 Other† 19 (31.7) tations. Comparison of the 2D fluoroscopic group with the
Local complications 5 (8.3) IMTAR group showed no significant differences in terms
  CSF leak 1 (1.7) of the rates of GTR and neurological complications (p >
0.05). Furthermore, when we compared lesions with posi-
  Wound infection 3 (5.0)
tive OSAT values (dorsal lesions) and those with negative
  Subcutaneous hematoma 1 (1.7) OSAT values (ventral lesions) between the 2D fluoroscopic
General medical complications‡ 1 (1.7) and IMTAR groups, no differences were found in terms of
Overall neurological complications 3 (5.0) the rates of complications (p = 0.717) and GTR (p = 0.983).
Postop dysesthesia 1 (1.7) Patients in the non-IMTAR and IMTAR groups had simi-
Lesion recurrence 1 (1.7) lar amounts of blood loss, surgical times, and Nurick scale
scores preoperatively and at follow-up (Table 3).
NA = not applicable. The median (IQR) bone resection surface area at the
Values are shown as number (%) or median (IQR). index level was 89.5 (51–147) mm2 in the non-IMTAR co-
* Three lesions were arachnoid cysts, and GTR was not attempted.
hort and 35.5 (11–71) mm2 in the IMTAR cohort, and this
† Included neurofibroma (n = 4), myxopapillary ependymoma (n = 6),
hemangioblastoma (n = 1), teratoma (n = 1), anaplastic astrocytoma (n = 2),
difference was statistically significant (p = 0.0112) (Table
cavernoma (n = 1), and arachnoid cyst (n = 4). 4). No differences were found between groups in terms of
‡ Included pulmonary embolism, cardiac infarction, and delirium. tumor dimensions and extent of facet resection. At follow-
up, no patient presented with mechanical pain suggestive
of instability.
(43.3%). Among patients who underwent voluntary nerve
root sacrifice, an expected new or worsened sensory deficit Discussion
presented in 4 patients (6.7%) and persisted in 2 patients Minimally invasive surgery (MIS) is defined as a pro-
(3.3%) at last follow-up. Twenty-two of 29 myelopathic pa- cedure that “by virtue of the extent and means of surgical
tients (75.9%) improved postoperatively, but the status of 7 technique results in less collateral tissue damage.”12 Thus,
of 29 patients (24.1%) remained unchanged at last follow- the bedrock of MIS is minimal disruption of soft and osse-
up. Histologically, the majority of SIDLs were schwanno- ous tissue while not compromising extent and/or quality of
mas (22 patients [36.6%]) and meningiomas (19 [31.7%]). decompressive or resective surgery. Since the first develop-
Local complications occurred in 5 patients (8.3%). One ment of MIS techniques for spine surgery, instrumentation
patient (1.7%) with CSF leak required surgical revision of and procedures have improved.13 Since the introduction of
the dural closure. Three patients presented with superficial the operating microscope during midline approaches for
wound infections that were treated with wound care and subperiosteal muscle dissection and hemilaminectomy,
oral antibiotics, and 1 patient presented with a subcutane- muscle-sparing MIS techniques for the spine have used
ous hematoma that resolved spontaneously. In 1 patient, the tubular and expandable retractors to allow serial muscle
wrong level at the cervicothoracic junction was exposed, dilation and a less traumatic approach compared with the
which required extension of the surgical exposure for tu- mini open midline approach.14
mor resection and a subsequently longer operative time. We believe that tubular techniques with and without 3D
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TABLE 4. Comparison of radiologic measurements between the non-IMTAR and IMTAR cohorts
Variable Non-IMTAR Cohort IMTAR Cohort p Value
Bone resection surface area, mm 2
89.5 (51–147) 35.5 (11–71) 0.0112
Tumor surface area, mm2 226.1 (150.7–357.2) 250.8 (233.5–535.4) 0.4127
Articular surface area at index level, mm2
 Preop 96 (81–112) 88 (83–93) 0.55
 Postop 81.5 (42.5–147.0) 66 (37–120) 0.575
Values are shown as median (IQR) unless indicated otherwise. Boldface type indicates statistical significance.

fluoroscopy are viable alternatives to traditional laminec-
tomy for SIDL. Laminectomy has limitations for certain
ventrally located lesions at the level of the spinal cord.
Studies have reported a link between laminectomy and
increased risk of intraoperative neurological complica-
tions. One study reported a 41.6% overall rate of compli-
cations, of which 25% were neurological complications,
and a 1.5% rate of mortality.4 When we compared patients
with ventrally and dorsally located lesions in our series,
we found no differences in the rates of complications and
tumor removal between the patients who underwent 2D
fluoroscopic guidance and those who received 3D guid-
ance. This finding suggests that the use of tubular tech-
niques, and specifically enhanced flexibility regarding the
angle of approach trajectory, may reduce the complication
rate without compromising tumor removal. Our series
showed a significant reduction in bone removal with the
3D IMTAR technique compared with that achieved with
2D fluoroscopic image guidance, without compromised
extent of tumor resection and without increased rates of
neurological complications or CSF fistulae. Regarding
tumor location as a risk factor (i.e., OSAT classification),
we were unable to show a difference between ventral and
dorsal lesions in terms of the GTR and complication rates,
thus supporting the added value of MIS techniques for the
resection of ventrally located intradural spinal tumors.
Tubular techniques add flexibility to the approach tra-
jectory, perhaps allowing for an easier and possibly safer
microsurgical resection. We used the OSAT classification
system to help us define the ideal approach trajectory to
the spinal lesions on the basis of their precise locations
relative to the spinal cord (a higher OSAT classification
number indicates better surgical accessibility). The preop-
erative plan was verified intraoperatively with 3D imaging
and neuronavigation and direct visualization of the tumor
lesion based on the merged MR images.
Our results are in line with those reported by previ-
ous authors, with a GTR rate (86.7%) between 61.5% and
100%. The rate of neurological complications in the pres-
ent series was 5%, and the rate of CSF leak was 1.7% (0%–
7% in previous series). We found no reports of integrated
3D navigation methods for SIDL (other than those report-
ed by our group) among previously reported studies on the
use of paramedian access, tubular retractors, and MIS to
achieve lesion resection of spinal lesions (Table 5).8,10,15–21
Reduced approach-related morbidity in terms of bone
removal is an additional advantage. The senior surgeon
had significant experience with transtubular tumor resec-
tion without image guidance, but it was possible to refine
and reduce bone resection even further with image guid-
ance. The use of such techniques is also helpful for ju-
nior spine surgeons because use of navigation-guided tube
placement and bone resection avoids unnecessary bone
removal. Studies in the literature provide evidence of cor-
relations between amount of bone resection and risk of
subsequent deformity and instability after spinal intradu-
ral resection.22 Use of MIS techniques for intradural tumor
removal permits the surgeon to tailor exposure while lim-
iting unnecessary bone removal and thus diminishing the
risk of postoperative instability.
The use of MIS techniques for spinal intradural lesions
has technical challenges and limitations. The learning

TABLE 5. Findings of the literature review of minimally invasive intradural tumor series
Total No. Paramedian Tubular Retractors Intraop Image GTR Neurological CSF Leak
Authors & Year of Cases Access for Muscular Dilation Guidance (%) Complications (%) (%)
Mannion et al., 201121 13 Yes Yes No 92.3 0 0
Haji et al., 201120 22 Yes Yes No 77.2 5 5
Nzokou et al., 20138 13 Yes Yes No 90 0 0
Wong et al., 201510 27 Yes Yes No  92.5 0  3.7
Afathi et al., 201518 18 Yes Yes No 100 0 0
Formo et al., 201817 83 Yes Variable No 87 4.9 2.4
Thavara et al., 201916 13 Yes Yes No 61.5 0 7.6
Soriano Sánchez et al., 202015 13 Yes Yes No 84.6 0 0
Present study 60 Yes Yes Yes 86.7 5.0 1.67

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Duff et al.
curve for tumor resection with MIS is shallow,23 and the
surgeon needs to master the use of 3D imaging–based nav-
igation and microsurgery with tubular retractors in order
to improve their surgical results. In our series, the opera-
tive times for the conventional 2D fluoroscopic technique
and the 3D navigated technique for tumor resection with
MIS were similar, thus showing that the additional steps of
the IMTAR technique did not prolong surgery.
Although theoretically MIS techniques may be used to
treat patients with any subtype of spinal intradural tumor,
there are some limitations.14 Better access to lesions that
extend over 3 or more vertebrae and require extensive sur-
gical exposure may be obtained with an open surgical ap-
proach. Rarely, excessive bone removal may require spine
fixation. The availability of image guidance and specific
MRI sequences is a technical limitation, particularly for
the IMTAR technique. Furthermore, use of the IMTAR
technique may be more useful for resection of tumors at
the level of the spinal cord, where open translaminar ap-
proaches provide limited exposure of ventral and ventro-
lateral tumors.
In our series, no complications were related to midline
placement of the reference frame, and the impact of post-
operative pain was minimal owing to limited tissue dissec-
tion. Nevertheless, the patient should receive preoperative
counseling regarding the additional aesthetic compromise
related to an additional incision.
The present study had some limitations. The retrospec-
tive nature of the series, with a small number of patients
who underwent operations by the same surgeon, had an
inherent selection bias. It was also difficult to draw final
conclusions regarding potential differences between tech-
niques. Furthermore, spinal alignment parameters were
not radiologically measured. Even though no patients in
our series presented with mechanical back pain or under-
went further surgery for progressive postoperative defor-
mity, the difference between the IMTAR and non-IMTAR
techniques in terms of postoperative deformity remains
unknown.
Conclusions
MIS techniques are viable options for resection of SIDLs.
The potential incremental gain that may be achieved with
the use of these techniques is certainly less in the region
of the cauda equina. However, as suggested in a previ-
ously published study,4 we believe that the use of tubular
techniques and image guidance may provide an advantage
for the treatment of ventrally located SIDLs at the level
of the spinal cord by reducing unnecessary bone removal,
optimizing tumor resection, and minimizing spinal cord
manipulation. Reduced bone removal, specifically mini-
mization of facet joint resection, may decrease the risk of
iatrogenic instability after SIDL resection. Not only does
the flexibility of these techniques allow for microsurgical
resection that is at least equivalent to standard translami-
nar approaches, but it may enhance and facilitate resection
by allowing a better angle for tumor access. The advan-
tages of MIS techniques may become better defined with
more widespread availability of the technology and fur-
ther experience by multiple centers.
128 J Neurosurg Spine  Volume 37 • July 2022
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Acknowledgments
This study received funding from the Department of Clinical
Neurosciences, Lausanne University Hospital, Lausanne,
Switzerland.
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Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
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Duff et al.
Author Contributions
Conception and design: Maduri, Bobinski. Acquisition of data:
Maduri, Omoumi, Belouaer, Zanchi. Analysis and interpretation
of data: Maduri, Omoumi, Belouaer, Plaza Wuthrich. Zanchi.
Drafting the article: Maduri, Duff, Omoumi, Bobinski, Plaza
Wuthrich, Zanchi. Critically revising the article: Maduri, Duff,
Bobinski. Reviewed submitted version of manuscript: Maduri.
Approved the final version of the manuscript on behalf of all
authors: Maduri. Administrative/technical/material support:
Maduri, Belouaer, Plaza Wuthrich. Study supervision: Maduri,
Duff.
Supplemental Information
Previous Presentations
The abstract of the paper was presented at the European
Association of Neurosurgical Societies Congress, Hamburg,
Germany, October 4, 2021.
Correspondence
Rodolfo Maduri: Avaton Surgical Group, Genolier Spine Care
Center, Genolier, Switzerland. rodolfo.maduri@gmail.com.
J Neurosurg Spine  Volume 37 • July 2022 129