Minimally Invasive Far-Lateral Hybrid Exoscopic-Endoscopic Lateral Rolling Technique for T1-2 Anterior Intradural Extramedullary Meningioma.

Anterior intradural extramedullary meningiomas are intimidating, especially in the thoracic spine due to the spinal cord impeding conventional surgical corridor, restricted space, and precarious cord vascularity. This is possibly the first report in the literature of a minimally invasive surgery: far-lateral hybrid exoscopic and angled endoscopic approach for an anterior thoracic spine meningioma. A 60-year-old woman presented with an anterior T1-2 meningioma with a flattened cord draping over the tumor more toward the right, leaving a potential corridor on the left lateral aspect (Video 1). Under a three-dimensional exoscope, a minimally invasive retractor was placed through the left paramedian incision centered on the lamina-transverse process junction; lateral fenestration and T1-2 facetectomy were carried out with a high-speed drill and rongeurs, meticulously preserving C7-T1 articulations. Following coagulation of the anterolateral dura over the tumor, a lateral longitudinal durotomy with a T-shaped anterolateral extension was performed around the tumor. Following devascularization, disconnection, and extra-arachnoidal dissection, a unique lateral rolling technique was employed, wherein the tumor was bimanually rolled onto the bony gutter created earlier without disturbing the spinal cord. This was followed by coagulation and excision of the dural tail. A 45° endoscope was then inserted to look for any residual tumor or dural tail. As the durotomy was lateral with excision of the dural tail, a multilayered soft tissue closure without dead space was sufficient to prevent cerebrospinal fluid leak. Fixation was not needed as only a single thoracic spine facet was disrupted. The patient recovered fully with radiology confirming total excision. This minimally invasive lateral rolling technique is safe and effective for anterior meningioma with the ergonomics of exoscope & the angled optics of endoscope complementing each other.