Intradural Extramedullary Tumor in the Lumbar Spine



The management of intradural extramedullary tumors in the lumbar spine has evolved considerably from the technique described by Love in 1966 (Love JG. J Neurosurg 25(1):116–21, 1966). That evolution has marched in parallel with the developments in magnetic resonance imaging (MRI), intraoperative localization (the introduction of intraoperative fluoroscopy and image guidance), intraoperative neurophysiological monitoring, and minimally invasive techniques. Although the microsurgical techniques involved in the resection of these lesions remain essentially unchanged from Love’s technique, there has been a seismic shift in accessing the lesion within the spinal canal. The advancements in imaging and localization have allowed for precise monosegmental localization and exposure that result in less disruption of the native spine and thereby less postoperative discomfort for the patient. The minimally invasive paramedian approach builds upon the concept introduced by Yaşargil and Eggert in the 1980s and 1990s (Chiou SM, Eggert HR, Laborde G, Seeger W. Acta Neurochir (Wien) 100:127–33, 1989; Yasargil MG, Tranmer BI, Adamson TE, Roth P. Adv Tech Stand Neurosurg 18:113–32, 1991). The paramedian approach is a paradigm shift in conceptualizing the spine, whereby the midline elements, specifically the spinous processes, are not considered an obstacle to the central spinal canal. Paramedian approaches with minimal access ports allow for the necessary access to the entire central spinal canal for safe and complete resection of the lesion. The introduction and the synthesis of MRI, fluoroscopy, and paramedian minimally invasive approaches have transformed the resection of intradural extramedullary lesions. This chapter details the evolution of the paramedian minimally invasive approach, describes the surgical technique, and presents a case illustration.


Extramedullary Intradural Laminectomy Lumbar Meningioma Minimally invasive Schwannoma Spine Surgical technique Tumors 



The author thanks the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.


The author is a consultant for Medtronic, plc, and DePuy-Synthes.

Financial Support


Supplementary material

Video 26.1

Intraoperative footage demonstrating the resection of an L2–L3 intradural extramedullary meningioma. Used with permission from Barrow Neurological Institute, Phoenix, Arizona (MP4 191208 kb)


  1. 1.
    Love JG. Laminectomy for the removal of spinal cord tumors. J Neurosurg. 1966;25(1):116–21. Scholar
  2. 2.
    Chiou SM, Eggert HR, Laborde G, Seeger W. Microsurgical unilateral approaches for spinal tumour surgery: eight years’ experience in 256 primary operated patients. Acta Neurochir. 1989;100(3–4):127–33.CrossRefGoogle Scholar
  3. 3.
    Yasargil MG, Tranmer BI, Adamson TE, Roth P. Unilateral partial hemi-laminectomy for the removal of extra- and intramedullary tumours and AVMs. Adv Tech Stand Neurosurg. 1991;18:113–32.CrossRefGoogle Scholar
  4. 4.
    Ahmed R, Menezes AH, Awe OO, Mahaney KB, Torner JC, Weinstein SL. Long-term incidence and risk factors for development of spinal deformity following resection of pediatric intramedullary spinal cord tumors. J Neurosurg Pediatr. 2014;13(6):613–21. Scholar
  5. 5.
    Kelley BJ, Johnson MH, Vortmeyer AO, Smith BG, Abbed KM. Two-level thoracic pedicle subtraction osteotomy for progressive post-laminectomy kyphotic deformity following resection of an unusual thoracolumbar intradural extramedullary tumor. J Neurosurg Pediatr. 2012;10(4):334–9. Scholar
  6. 6.
    McGirt MJ, Chaichana KL, Atiba A, Bydon A, Witham TF, Yao KC, et al. Incidence of spinal deformity after resection of intramedullary spinal cord tumors in children who underwent laminectomy compared with laminoplasty. J Neurosurg Pediatr. 2008;1(1):57–62. Scholar
  7. 7.
    de Jonge T, Slullitel H, Dubousset J, Miladi L, Wicart P, Illes T. Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours. Eur Spine J. 2005;14(8):765–71. Scholar
  8. 8.
    Otsuka NY, Hey L, Hall JE. Postlaminectomy and postirradiation kyphosis in children and adolescents. Clin Orthop Relat Res. 1998;354:189–94.CrossRefGoogle Scholar
  9. 9.
    Albert TJ, Vacarro A. Postlaminectomy kyphosis. Spine (Phila Pa 1976). 1998;23(24):2738–45.CrossRefGoogle Scholar
  10. 10.
    Eggert HR, Scheremet R, Seeger W, Gaitzsch J. Unilateral microsurgical approaches to extramedullary spinal tumours: operative technique and results. Acta Neurochir. 1983;67(3–4):245–53.CrossRefGoogle Scholar
  11. 11.
    Foley KT, Smith MM. Microendoscopic discectomy. Tech Neurosurg. 1997;3(4):301–7.Google Scholar
  12. 12.
    Schwender JD, Holly LT, Rouben DP, Foley KT. Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech. 2005;18(Suppl):S1–6.CrossRefGoogle Scholar
  13. 13.
    Tredway TL, Santiago P, Hrubes MR, Song JK, Christie SD, Fessler RG. Minimally invasive resection of intradural-extramedullary spinal neoplasms. Neurosurgery. 2006;58(1 Suppl):ONS52–8. discussion ONS-8.PubMedGoogle Scholar
  14. 14.
    Zhu YJ, Ying GY, Chen AQ, Wang LL, Yu DF, Zhu LL, et al. Minimally invasive removal of lumbar intradural extramedullary lesions using the interlaminar approach. Neurosurg Focus. 2015;39(2):E10. Scholar
  15. 15.
    Turel MK, D’Souza WP, Rajshekhar V. Hemilaminectomy approach for intradural extramedullary spinal tumors: an analysis of 164 patients. Neurosurg Focus. 2015;39(2):E9. Scholar
  16. 16.
    Nzokou A, Weil AG, Shedid D. Minimally invasive removal of thoracic and lumbar spinal tumors using a nonexpandable tubular retractor. J Neurosurg Spine. 2013;19(6):708–15. Scholar
  17. 17.
    Panjabi MM, Goel V, Oxland T, Takata K, Duranceau J, Krag M, et al. Human lumbar vertebrae: quantitative three-dimensional anatomy. Spine (Phila Pa 1976). 1992;17(3):299–306.CrossRefGoogle Scholar
  18. 18.
    De Verdelhan O, Haegelen C, Carsin-Nicol B, Riffaud L, Amlashi SF, Brassier G, et al. MR imaging features of spinal schwannomas and meningiomas. J Neuroradiol. 2005;32(1):42–9.CrossRefGoogle Scholar
  19. 19.
    Kucia EJ, Maughan PH, Kakarla UK, Bambakidis NC, Spetzler RF. Surgical technique and outcomes in the treatment of spinal cord ependymomas: part II: myxopapillary ependymoma. Neurosurgery. 2011;68(1 Suppl Operative):90–4.; discussion 4. Scholar
  20. 20.
    Iunes EA, Stavale JN, de Cassia Caldas Pessoa R, Ansai R, Onishi FJ, de Paiva Neto MA, et al. Multifocal intradural extramedullary ependymoma: case report. J Neurosurg Spine. 2011;14(1):65–70. Scholar
  21. 21.
    Turel MK, Rajshekhar V. Magnetic resonance imaging localization with cod liver oil capsules for the minimally invasive approach to small intradural extramedullary tumors of the thoracolumbar spine. J Neurosurg Spine. 2014;21(6):882–5. Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryBarrow Neurological Institute, St. Joseph’s Hospital and Medical CenterPhoenixUSA

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