Objective: Minimally invasive surgery (MIS) has attracted increasing interest for the excision of intradural extramedullary (IDEM) spinal cord tumors. While open surgery is associated with excellent rates of gross total resection (GTR), minimal neurological deficits, and favorable quality of life outcomes, MIS provides potential benefits including reduced morbidity, less postoperative pain, decreased tissue damage, reduced blood loss, and accelerated recovery. This study aimed to evaluate the efficacy of MIS compared to open techniques for IDEM tumor excision by analysing clinical outcomes and procedural advantages. Methods: This retrospective study included 80 patients who underwent surgery for IDEM tumors by a single surgeon between 2012 and 2019. Outcomes between MIS and open surgery were compared. Assessed parameters included intraoperative blood loss, operative duration, tumor location, postoperative visual analogue scale (VAS) scores, length of hospital stay, and time to return to work. The primary outcomes were GTR rates and complications; secondary outcomes comprised symptom relief and tumor recurrence. All patients were followed for at least 3 years. Statistical analysis was performed to evaluate differences between groups. Results: Of the 80 patients, 38 underwent MIS and 42 underwent open surgery. MIS was associated with significantly reduced blood loss (65 mL vs. 240 mL, p<0.01) and shorter hospital stays (4.4 days vs. 6.8 days, p<0.01). Although operative times were initially longer for MIS (160 minutes vs. 130 minutes), this was attributed to the learning curve. GTR rates were similar between the groups (94.6% MIS vs. 96.4% open, p=0.46). There were no significant differences in rates of cerebrospinal fluid leak, infection, or neurological complications (p=0.32). Postoperative VAS scores showed significant improvement at 1 and 3 months in the MIS group, but differences were no longer evident at 1 year. No patient in either group required revision surgery within 3 years (p=0.33). Conclusion MIS for IDEM tumor excision offers distinct advantages over open surgery, including reduced morbidity and faster recovery, while achieving comparable long-term outcomes. With the implementation of advanced MIS techniques, results equal or surpass those of traditional open approaches.

Sacral tumors are rare and can be benign or malignant. Their management is multifactorial and is based on the pathology, extent, and local and distant spread. Managing sacral tumors is challenging due to their proximity to visceral and neural structures. Surgical wide excision has been the standard of care for aggressive benign and malignant tumors. Our purpose was to evaluate the outcomes of a multimodal approach to managing primary sacral tumors in Sakra World Hospital, a tertiary spine care center in Bengaluru, India and perform a literature review to determine a workflow pathway. Our study was a retrospective review of patient records and included 15 patients with primary sacral tumors. Eleven surgically treated patients were evaluated clinically and radiologically and underwent biopsy before surgical excision by an all-posterior approach. A multidisciplinary approach that included intraoperative neural monitoring, plastic reconstruction, adjuvant chemotherapy, and radiotherapy was implemented whenever necessary. Sacral root preservation was attempted whenever feasible. Functional outcomes (based on the Visual Analog Scale [VAS] and Biagini scoring system) were analyzed along with disease control, with a minimum of 2 years of follow-up. The mean follow-up was 29±9.8 months. The mean VAS score significantly improved from 7.8±2.6 to 3.7±3.8 (p =0.026). Bowel function showed statistically significant improvement, from a mean score of 0.81±0.47 to 0.63±0.52 (p =0.026) at 2 years of follow-up. The mean pretreatment motor and bladder function scores were 0.53±0.31 and 0.74±0.44, respectively, improving to 0.48±0.33 and 0.68±0.56 at follow-up but without statistical significance. There was no significant loss of function, which is expected in radical sacral resections. In conclusion, primary sacral tumors require a multidisciplinary approach and management for optimal outcomes. A stand-alone posterior approach can be employed to treat most sacral lesions. En-bloc wide resection is the optimal treatment for primary malignant and aggressive benign tumors. Preservation of at least one functional S2 nerve root is imperative to preserve bowel and bladder function.