Minimally invasive spinal approaches in oncologic spinal surgery: a comprehensive narrative review

Introduction

Spinal tumors, including both metastatic and primary lesions, represent a significant source of morbidity in oncology patients. The spine is the most common site of skeletal metastasis, occurring in up to 70% of patients with systemic cancer, particularly from breast, prostate, lung, and renal primaries (1-3). These lesions can result in mechanical instability, intractable pain, spinal cord compression, and neurologic deficits—necessitating prompt, multidisciplinary intervention to preserve function and quality of life (4,5). Similarly, benign primary spinal tumors such as schwannomas, meningiomas, and neurofibromas can lead to progressive myelopathy or radiculopathy, often requiring surgical resection for definitive management (6).

Historically, the surgical treatment of spinal tumors relied heavily on open techniques involving extensive exposures, wide muscle dissection, and prolonged recovery periods (7). While effective in achieving decompression and stabilization, these approaches are associated with high perioperative morbidity, particularly in cancer patients who are often immunocompromised, nutritionally deficient, and at increased risk of infection and wound complications (8). The need to minimize surgical trauma while maintaining oncologic efficacy has driven a paradigm shift over the past two decades toward minimally invasive spine surgery (MISS) (9).

Minimally invasive spinal approaches offer several theoretical and demonstrated advantages, including reduced blood loss, lower rates of infection and wound dehiscence, decreased postoperative pain, shorter hospitalization, and faster return to adjuvant oncologic therapies (10-12). These techniques span a spectrum of interventions, from percutaneous instrumentation and cement augmentation to tubular decompression, endoscopic surgery, radiofrequency ablation (RFA), and robot-assisted procedures. Importantly, these methods allow surgical goals such as neural decompression and spinal stabilization to be achieved with minimal disruption to surrounding tissues (13-15).

Recent studies have expanded the evidence base supporting MISS in oncologic settings. For instance, percutaneous pedicle screw fixation (PPSF) has been shown to effectively stabilize pathologic fractures with low complication rates (16), and separation surgery performed through tubular retractors allows for targeted decompression of metastatic epidural disease while facilitating high-dose postoperative radiotherapy (17,18). Endoscopic spine surgery and robotic navigation have further pushed the boundaries of precision and minimal invasiveness, even enabling targeted ablation and decompression in select cases of spinal metastasis (19,20). This review provides an updated narrative overview of MISS for metastatic spinal tumors, highlighting percutaneous fixation, mini-open and tubular separation techniques, and emerging technologies such as robotics and endoscopy. Table 1 outlines the principal minimally invasive approaches, including their key indications, advantages, and limitations. We present this article in accordance with the Narrative Review reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-65/rc).

Methods

A systematic literature search was conducted using PubMed (MEDLINE), with the final search performed on October 31, 2025, to identify studies evaluating minimally invasive surgical techniques for spinal tumors. No additional electronic databases were systematically searched. Search terms included “minimally invasive spine surgery”, “metastatic spine tumor”, “spinal tumor”, “spinal metastasis”, “spinal neoplasm”, “endoscopy”, “tubular”, “mini-open”, “percutaneous pedicle screw”, “robotics”, “navigation”, and “spinal instability neoplastic score”, used alone and in combination.

Studies published between January 2010 and June 2025 were eligible. Inclusion criteria were: (I) publication in a PubMed-indexed journal; (II) English language; (III) full-text availability; (IV) focus on minimally invasive surgical techniques for spinal tumors; and (V) clinical study design. Exclusion criteria included non-English publications, abstract-only articles, preclinical or cadaveric studies, and studies with irrelevant data.

Three authors (J.J.P., V.G., and S.K.) independently screened titles and abstracts, followed by full-text review of eligible studies. Study selection was performed by consensus, with disagreements resolved through discussion and senior author input when necessary. Further details on the search methodology can be found organized in Table 2.

Percutaneous screw placement and cement augmentation for pathologic fractures

Spinal metastases frequently lead to pathological fractures and structural instability (17). To evaluate tumor-induced instability in the spine, the Spine Oncology Study Group developed the Spinal Instability Neoplastic Score (SINS) (21). Stabilizing the affected spinal segment mechanically can help minimize abnormal movement and provide relief from pain associated with motion.

PPSF has become a cornerstone of minimally invasive management for spinal metastases and pathological fractures (22). Traditionally, spinal stabilization has been performed using open surgical approaches involving fixation at least two levels above and below the index level (23). PPSF involves placing pedicle screws through small stab incisions under fluoroscopic or navigational guidance, thereby preserving musculature and reducing surgical trauma. Clinical evidence from the last 15 years shows that PPSF can effectively stabilize the spine, alleviate mechanical pain, and minimize perioperative complications in metastatic spinal disease (11,24). For example, a retrospective series of 74 patients with metastatic spinal fractures demonstrated significant pain relief [mean Visual Analog Scale (VAS) pain score improved from 6.3 to 3.4 postoperatively] with a low hardware failure rate of 4% (25).

Comparative studies and meta-analyses support the advantages of PPSF over open instrumentation. A 2022 systematic review and meta-analysis (8 studies, 448 patients) found PPSF was associated with significantly fewer complications and infections than open posterior fusion, as well as markedly less blood loss (∼586 mL reduction) and shorter hospital stays (∼3.8 days shorter) (26). Notably, postoperative pain improvements were similar between PPSF and open surgery, indicating that minimally invasive stabilization achieves equivalent palliation with less morbidity. PPSF also enables faster stabilization for patients requiring urgent radiation but are hindered by intolerable mechanical pain that prevents them from lying flat for treatment (27). Notably, when MISS techniques are employed, radiation can often be initiated within a week of surgery, particularly when using conformal delivery methods such as volumetric arc therapy (28,29).

Vertebral augmentation encompasses techniques that involve percutaneous injection of polymethyl methacrylate (PMMA) bone cement into a collapsed or weakened vertebral body, stabilizing microfractures and reducing pain by reinforcing the structure (30). Augmentation when combined with other therapies can be part of a comprehensive minimally invasive approach. An add-on to the aforementioned PPSF is cement augmented pedicle screw fixation. Bone quality is a key factor contributing to hardware failure in cancer patients. Due to tumor involvement, prior chemotherapy, and other comorbidities, bone is often diffusely weakened, limiting optimal pedicle screw fixation (31). A common failure mode in this context is screw pullout from poor screw purchase. Fenestrated screws with fluoroscopy-guided PMMA injection have improved pullout strength, partially mitigating this issue (31-34).

This enhanced fixation has enabled the use of shorter constructs, with early studies showing comparable hardware failure rates to traditional longer constructs in select patients (11,35). However, failure patterns differ—cement-augmented constructs more frequently fail at the screw-tulip interface or rod. Screw-tulip fractures can be challenging to revise and may require construct extension, sometimes with additional cement augmentation (27).

Vertebral augmentation is generally safe in oncology patients. Cement leakage is the most common event but is usually asymptomatic. Rarely, extravasated cement can cause neural compression or pulmonary embolism (36). Overall complication rates in cancer patients remain low, and the benefit-risk ratio is very favorable for pain relief (37).

Decompression and/or separation surgery via minimally invasive approaches

“Separation surgery” is a surgical strategy for metastatic epidural spinal cord compression where the goal is to decompress the spinal cord and establish a margin (typically >3 mm) between the dura and tumor, without attempting gross total resection of the tumor (38). This creates a safe space for high-dose postoperative stereotactic body radiotherapy (SBRT) to sterilize the remaining tumor (39). Traditionally, separation surgery was performed via open laminectomy and debulking. In the last decade, however, hybrid mini-open and minimally invasive tubular approaches have been developed for separation surgery, using muscle-splitting dilators and working channels to achieve decompression with less tissue disruption (40).

The “mini-open” approach in spine oncology represents a hybrid surgical technique that bridges fully percutaneous and traditional open procedures. It involves a smaller, targeted incision with limited muscle dissection, often combined with percutaneous instrumentation (41,42). These techniques aim to preserve soft tissue integrity while still allowing adequate exposure for complex oncologic procedures, such as tumor resection or anterior column reconstruction (43).

One common application is the mini-open lateral or anterior approach for thoracolumbar metastases. For example, a mini-open transpedicular corpectomy can resect the invaded vertebral body and place an anterior cage through a smaller exposure than a conventional open corpectomy (44). In the cervical and thoracic spine, mini-open retropleural or retroperitoneal approaches allow tumor access without the extensive disruption of a full thoracotomy (45).

Minimally invasive tubular separation surgery involves percutaneous screw placement for stabilization (if needed), followed by insertion of a tubular retractor through a small incision targeted to the affected level. Through the tube, surgeons perform laminectomy, facetectomy, transpedicular decompression, and epidural tumor resection sufficient to decompress the cord and separate it from the tumor ventrally (40). A key step is removal of the posterior longitudinal ligament and any tumor just dorsal to it, creating a plane between tumor and dura (40).

The main benefits of mini-open and tubular surgery include reduced muscle damage, blood loss, and postoperative pain. These approaches provide adequate access for complex pathology with significantly less morbidity than traditional open techniques. Wound complication and infection rates are generally lower (41,46). Recent studies and technical series have demonstrated that minimally invasive surgery (MIS) separation surgery yields outcomes comparable to open surgery in terms of neurologic improvement and tumor control, with the added benefits of less blood loss and quicker recovery (47-49). For example, Laufer et al. reported on 186 patients who underwent separation surgery followed by SBRT; although that cohort largely used open techniques, it established the paradigm of durable local control (~90% at median 10-month follow-up) when surgery is combined with modern radiotherapy (50). Building on this, newer reports describe MIS techniques: De la Garza Ramos et al. presented a case of tubular separation surgery for a metastatic thoracic tumor causing cord compression, highlighting significant recovery and the feasibility of MIS decompression before radiation (14) (Figure 1). A separate retrospective comparison between mini-open and tubular approaches for decompression in 34 spine metastasis patients found both to be safe and effective; notably, the tubular group had significantly less postoperative drainage and, in hypo-vascular tumors, less intraoperative blood loss (51). This suggests tubular approaches are especially advantageous for metastases that are not highly vascular, whereas very vascular tumors might still benefit from a slightly larger (mini-open) exposure for better bleeding control.

Figure 1 Preoperative gadolinium-enhanced magnetic resonance imaging in the sagittal (A) and axial (B) planes reveals epidural tumor involvement at the T5 vertebral level. The lesion extends laterally on the right, involving the posterior elements, transverse process, and adjacent rib. There is both anterior and posterior compression of the spinal canal, with predominant right-sided involvement. Postoperative computed tomography scans (C,D) demonstrate successful decompression of both the anterior and posterior aspects of the spinal canal, along with spinal instrumentation spanning T3 to T7 and circumferential decompression at the T5 level. (E) The transpedicular approach allows for a decompression of the anterior area of the thecal sac. The thecal sac is hence decompressed posteriorly, ipsilaterally, and anteriorly. This image is published with the patient/participant’s consent.

Minimally invasive separation surgery successfully enables ablative radiotherapy, achieving outcomes in pain relief, ambulation, and neurological improvement comparable to open surgery, provided decompression is adequate (48,52). Limitations include a smaller visual field, which can hinder tumor control in very large or circumferential lesions. Proficiency with intraoperative navigation is essential to safely perform these procedures (27). Other limitations are a steep learning curve and challenges with multi-level disease [tubular approaches are ideal for 1–2 levels; extensive disease may require multiple incisions or a mini-open approach (53)]. Additionally, if gross total tumor resection is indicated—such as in high-grade spinal cord compression with radioresistant tumors—some surgeons may prefer an open approach to maximize decompression (54). For most metastatic cases, however, maximal safe decompression via MIS suffices, as adjuvant SBRT manages residual tumor. In summary, minimally invasive separation surgery exemplifies the evolution of oncologic spine surgery toward less invasive yet effective palliative interventions that balance tumor control with patient quality of life (55).

Minimally invasive tubular techniques have also been applied to primary benign spinal tumors such as schwannomas, neurofibromas, paragangliomas, and meningiomas (Figure 2) (56). These benign spinal nerve sheath tumors (BNSTs) often affect younger, healthier patients, where minimizing muscle damage and preserving spinal stability are important for long-term outcomes (57). A small paramedian incision is made, and a tubular retractor (expandable or fixed diameter) is docked on the lamina at the tumor level. A hemilaminectomy or laminotomy is performed through the tube, often aided by an operating microscope. The dura is opened in a keyhole fashion sufficient to expose the intradural tumor. Using microsurgical techniques, larger tumors are internally debulked, then dissected free from neural structures (58,59).

Figure 2 Preoperative gadolinium-enhanced magnetic resonance imaging in the sagittal (A) and axial (B) planes reveals intradural extramedullary tumor at the L4–5 vertebral level. (C) Highlighting of the neoplasm on a preoperative magnetic resonance imaging using Brainlab elements software^®. (D) Confirmation of the approach trajectory after placement of the tubular retractor using 3-dimensional navigation and the intraoperative view through the microscope after placement of the tubular retractor. The size, shape, and location of the neoplasm (blue shape) is visible during the soft tissue dissection via augmented reality projection. (E) Exposure and resection of the neoplasm. After the incision of the dura, the neoplasm is found at the location of the augmented reality projection. This image is published with the patient/participant’s consent.

Numerous case series have shown that tubular resection of benign intradural-extramedullary tumors is not only feasible but yields outcomes comparable to traditional open laminectomy, with added benefits of reduced blood loss, shorter hospital stay, and faster recovery (47,59). A 2024 case series of 49 patients (51 tumors) demonstrated the effectiveness of the tubular approach for schwannomas and neurofibromas: 93.7% achieved gross total resection (59), none required conversion to open surgery, and there were no major complications. Wong et al. [2015] found significantly lower blood loss and complications in MIS vs. open resection of various spinal tumors (nerve sheath tumors and meningiomas) (47). In Wong et al.’s series of 45 patients, no MIS patient needed a blood transfusion, whereas 11% of open surgery patients did. Hospital stays were shorter in MIS (by a few days), and fewer MIS patients needed spinal fusion or instrumentation (47).

Robotic spine surgery

Robotics has rapidly transformed the landscape of spine surgery over the past 15 years, initially emerging in the context of degenerative and deformity cases, and more recently gaining traction in oncologic spine care. Modern robotic systems are designed to improve surgical precision, minimize intraoperative radiation exposure, and reduce soft tissue disruption (60-62). In the setting of spine tumors, robotics has primarily been used for pedicle screw placement and biopsy, but its applications are steadily expanding to include minimally invasive tumor ablation and cement augmentation (63-65).

A striking example of this evolution is the recent use of robotic guidance in RFA for spinal metastases (66). In a 2024 case series by Ricciardo and colleagues, the ExcelsiusGPS robot was used to guide the percutaneous placement of ablation probes across multiple vertebral levels, followed by targeted cement injection for stabilization. This hybrid approach—essentially combining tumor destruction with structural reinforcement—yielded substantial pain relief (a median VAS reduction from 6 to 2) and improved function [a 24% improvement in Oswestry Disability Index (ODI)] without any complications. Patients were discharged the next day and resumed systemic therapy without delay. This case series highlights the potential of robotics not just to support conventional instrumentation but to enable entirely new minimally invasive oncologic strategies (66).

In the domain of pedicle screw placement, robotic systems have demonstrated at least equivalent and often superior accuracy compared to traditional freehand or fluoroscopic techniques (67-69) (Figure 3). Meta-analyses, including a 2022 review of seven randomized controlled trials encompassing over 2,400 screws, have shown that certain robotic platforms—such as TiRobot (TINAVI Medical Technologies Co., Ltd., Beijing, China)—significantly outperform others in placement accuracy, especially in cases with complex or distorted anatomy. An additional benefit is the marked reduction in radiation exposure for the surgical team, as robotic systems rely more on intraoperative imaging for registration and verification rather than continuous fluoroscopy (70). While early robotic cases were associated with slightly longer operative times due to setup, this gap has narrowed with experience, and the improved accuracy has translated into lower rates of screw malposition and reoperation (71,72)—an especially critical consideration in oncologic patients where spinal anatomy may be disrupted by tumor involvement or previous surgeries.

Figure 3 Preoperative computed tomography scans in the midsagittal (A) as well as left (B) and right (C) parasagittal cuts show a T9 pathologic fracture in a patient with multiple myeloma. Postoperative lateral (D) and anteroposterior (E) X-ray images demonstrate spinal instrumentation spanning T7 to T11 with cement augmentation. This image is published with the patient/participant’s consent.

Despite its many strengths, robotics is not without limitations. System failures—such as registration errors or mechanical drift—can result in screw misplacement if not promptly identified (73). A culture of intraoperative verification using three-dimensional (3D) imaging is therefore essential. When implemented correctly, however, robotics can significantly enhance safety by preventing high-risk breaches near neural structures. Multiple meta-analyses, including a 2019 review by Sielatycki et al., have confirmed lower breach rates with robot-assisted techniques and complication profiles at least equivalent, if not superior, to freehand methods (68,74,75).

In sum, robotics represents an enabling technology in spine oncology—augmenting, rather than replacing, existing surgical approaches. It enhances the precision and efficiency of minimally invasive techniques while expanding the treatment landscape to include sophisticated interventions like image-guided tumor ablation. As evidence grows and robotic systems continue to evolve, their role in the multimodal management of spinal tumors is poised to expand, offering safer and more effective care for patients with complex oncologic spinal disease.

Endoscopic spine surgery

Endoscopic spine surgery represents an emerging frontier in the minimally invasive management of spinal tumors, particularly for patients with metastatic disease requiring neural decompression or biopsies (76). Utilizing high-definition cameras and small portals, endoscopic techniques further reduce tissue disruption compared to traditional microscopic or tubular MIS approaches (77). Endoscopic spine surgery can be performed via interlaminar or transforaminal approaches. Surgeons insert a full endoscope or use two portals—one for visualization and one for instruments—under continuous saline irrigation, which enhances visualization and reduces bleeding (78).

Overall, many studies show that endoscopic spine surgery is associated with less blood loss, decreased hospitalization and length of stay, and quicker recovery times (79,80). Although these advantages increase the popularity of MIS approaches in degenerative cases, they are even more important in frail oncology patients (76). These patients often have poorer nutritional status, are immunocompromised, and are prone to higher complication risks. These complications and overall delayed recovery times can affect the prognosis of oncology patients, as they may delay systemic treatments such as chemotherapy and radiotherapy.

While endoscopy has long been used for degenerative conditions, recent multicenter studies have demonstrated the feasibility and safety of extending this approach to oncologic indications. Ideal candidates include those with focal epidural compression from metastatic lesions, particularly patients who are poor surgical candidates or who require a rapid return to systemic therapy (15,76).

Several authors have demonstrated the utility of endoscopic approaches for awake biopsy of epidural metastatic spinal lesions, which reduces the anesthesia burden for poor surgical candidates (81,82). Telfeian et al. published a case of awake transforaminal endoscopic biopsy and partial resection of a recurrent thoracic Ewing sarcoma lesion (83). Compared to conventional computed tomography (CT)-guided biopsies, endoscopic biopsies may lower the risk of tumor cell seeding along the biopsy tract and also decrease radiation exposure (76,84,85). Multiple studies have reported symptomatic local tumor recurrence rates ranging from 2.94% to 8% (15,86,87).

A 2023 international multicenter cohort study by Suvithayasiri et al. evaluated 29 patients across eight countries who underwent uniportal or biportal endoscopic decompression for thoracic and lumbar spinal metastases (15). Patients experienced rapid and sustained improvements in pain and neurologic function, with 62% of those with preoperative deficits improving by at least one American Spinal Injury Association (ASIA) grade (15). The average hospital stay was 4.4 days, and complications were minimal—none life-threatening—supporting endoscopy as a valid alternative to conventional MISS techniques (15).

For ventral epidural thoracic tumors that typically require facetectomy, transpedicular approach, or costotransversectomy, the transforaminal endoscopic approach can serve as an alternative surgical technique that significantly decreases morbidity in these particularly frail patients. This method allows surgeons to avoid extensive bony resection and consequent fusion for these anatomically challenging tumors (83,88).

Another recent systematic review by Patel et al. examined outcomes of endoscopic techniques in spinal oncology based on 24 studies encompassing 147 patients. For all cases reporting neurological outcomes, postoperative pain scores, and functional parameters, improvements were observed. The total complication rate was 6.8% (10/147). These complications included temporary motor worsening, transient urinary incontinence, progressive spinal deformity, transient radiculopathy, pseudomeningocele, transient voiding difficulty, postoperative hematoma requiring drainage, neurological worsening requiring revision surgery, local tumor recurrence requiring vertebroplasty, and transient numbness (76).

Besides its benefits, the use of endoscopy in the treatment of spinal tumors presents notable limitations. These include the risk of significant or uncontrollable bleeding, which can impair visualization of the operative field, and the potential for neurological injury, especially in cases involving severe spinal compression (27,89,90). Many surgical tools, such as ultrasonic aspirators that are beneficial for resection of firm tumors, cannot be used during endoscopic procedures (76). The steep learning curve and limited visualization are additional disadvantages of endoscopic approaches for metastatic spinal lesions (76,83,91). As a result, endoscopy is currently employed primarily for palliative decompression rather than curative tumor resection, with local tumor control still relying on adjunctive treatments such as radiation therapy. As more spine surgeons adopt endoscopic techniques for degenerative cases, their application in oncology is expected to expand.

Limitations

This narrative review did not follow systematic-review methodology and therefore may be vulnerable to selection and publication biases. We did not perform formal quality or level-of-evidence assessments or quantitative synthesis, and some cited reports were small case series or observational studies with heterogeneous methods, limited follow-up, and uncontrolled confounders that constrain causal inference.

Conclusions

In recent years, considerable innovations in technology, techniques, and tools have revolutionized the minimally invasive treatment of spinal tumors. These advances offer significant benefits, including decreased blood loss, shorter hospital stays, faster recovery, and earlier initiation of adjuvant therapies. These advantages are particularly impactful for oncology patients, who often present with complex medical conditions and limited physiological reserves. The future of surgical treatment for spinal tumors is expected to become less invasive with advancements in navigation, robotics, augmented reality, artificial intelligence, and surgical tools such as endoscopy. Further studies should investigate the safety and efficacy of these techniques in larger patient populations.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal for the series “Advances in Minimally Invasive Spine Surgery”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-65/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-65/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-65/coif). The series “Advances in Minimally Invasive Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. M.S.F. serves as an unpaid editorial board member of AME Surgical Journal from February 2025 to January 2027 and the unpaid Guest Editor of the series. M.S.F. received consulting fees from 4Web, VB Spine and Stryker and received Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from 4Web. M.S.F. also joined the NASS-Payor Policy Committee, Lumbar Spine Research Society-Education Committee and served as the Associate Editor of Montefiore Einstein Journal of Musculoskeletal Medicine and Surgery. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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