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Chapter Summary
• Context: The treatment of spinal tumors has evolved from large open resections to multimodal strategies aimed at achieving neural decompression, mechanical stability, and tumor control with reduced surgical aggression. This shift is particularly relevant in oncologic patients who frequently present comorbidities, systemic frailty, and the need for prompt resumption of radiotherapy or systemic therapy. The chapter integrates various minimally invasive techniques: endoscopic surgery, vertebroplasty and kyphoplasty, percutaneous tumor ablation, laser interstitial thermal therapy (LITT), stereotactic body radiation therapy (SBRT), separation surgery, and percutaneous instrumentation. These modalities are presented as complementary tools targeting distinct problems—neural compression, instability, pain, and local control. The primary challenge lies in selecting and sequencing interventions appropriately, avoiding both excessively aggressive procedures and insufficient treatments for existing neurological, oncologic, or mechanical compromise.
• Chapter Objective: To present the main minimally invasive techniques and their integration with adjuvant therapies in spinal tumor treatment. The reader will understand principles, indications, and limitations, correlate neural compression, instability, and oncologic control with therapeutic selection, and recognize how endoscopy, vertebral augmentation, ablation, SBRT, separation surgery, and percutaneous stabilization can be combined into individualized strategies.
• Reduced Invasiveness in Oncologic StrategyMinimally invasive spine surgery (MISS) techniques aim to reduce muscle damage, blood loss, postoperative pain, and hospital stay. In oncologic patients, this reduced morbidity facilitates early mobilization and rapid resumption of adjuvant systemic therapies and radiation. Decision-making remains governed by neurological, mechanical, and oncologic treatment objectives.
• Endoscopy: Selective ApplicationUniportal and biportal modalities are discussed. In spine oncology, both permit biopsy, targeted decompression, and resection of selected epidural lesions with minimal tissue disruption. Intradural tumor application remains restricted and highly operator-dependent, with its prime utility being limited decompression enabling rapid recovery.
• Vertebral Augmentation and Percutaneous AblationVertebroplasty and kyphoplasty reinforce vertebral bodies weakened by pathological fractures, providing mechanical stabilization and prompt pain relief. Percutaneous ablation adds local tumor control and analgesia. The chapter reviews radiofrequency, microwave, cryoablation, and laser interstitial thermal therapy (LITT), as well as combination ablation-cementoplasty procedures.
• Stereotactic Radiotherapy and Separation SurgeryStereotactic body radiation therapy (SBRT) delivers ablative radiation doses to defined tumor volumes while sparing the adjacent spinal cord. Separation surgery redefines the classic paradigm of radical resection: instead of complete epidural tumor removal, it aims to decompress neural elements (creating a 2-3 mm safe margin) so that SBRT can effectively treat the residual tumor.
• Percutaneous Instrumentation and StabilityPercutaneous pedicle screw stabilization is indicated when neoplastic destruction produces mechanical instability or pain. The Spinal Instability Neoplastic Score (SINS) standardizes clinical and radiographic assessment of spinal stability. Percutaneous instrumentation is readily combined with separation surgery, vertebroplasty, or radiation.
• Clinical Application: Treatment selection begins with identifying the dominant problem: fracture pain without neural compression suggests vertebral augmentation; mechanical instability indicates stabilization using SINS criteria; and symptomatic epidural cord compression places neural decompression at the center. Separation surgery allows targeted decompression followed by SBRT for local oncologic control, avoiding massive open resection. Percutaneous pedicle screws provide rigid stabilization with minimal blood loss and low infection risk, enabling prompt postoperative radiotherapy.
