Intraspinal tumors refer to primary tumors and metastatic tumors growing in the spinal cord itself and in the tissue structures adjacent to the spinal cord (such as nerve roots, dura mater, adipose tissue in the spinal canal, blood vessels, etc.). Clinically, according to the location of tumors in relation to the spinal cord and dura mater, intradural tumors are generally classified into three categories: intramedullary, extramedullary intradural and epidural. Extramedullary intradural tumors are the most common, followed by extradural tumors, and the least common are intradural tumors in the spinal cord. Intramedullary tumors account for 9% to 18%, extramedullary intradural tumors account for about 55%, epidural tumors account for about 25%, and dumbbell-shaped intradural tumors account for about 8.5%. Intradural tumors can be divided into neurofibroma, nerve sheath tumor, spinal meningioma, glioma, hemangioma and ventricular meningioma according to their histological origin, among which fibroma and sheath tumor account for 40%~55%, spinal meningioma accounts for about 25%~30%, and glioma, hemangioma and ventricular meningioma accounts for about 10%, which can be seen in various parts of the cervical, thoracic, lumbar and sacral areas. The effective treatment for intraspinal tumors is surgical resection. The goal of surgery is to completely remove the tumor, improve neurological function, stop the deterioration of neurological function, and improve motor and sensory function. Early diagnosis, early surgical resection, timely release of spinal cord compression, and minimizing secondary spinal cord injury during surgery are the keys to improving the cure rate. The choice of approach is a key issue in the treatment of complex intraspinal tumors. With the application of MRI imaging technology, the development of spinal and spinal cord microsurgery techniques and the renewal of instruments and equipment brought about by technological development, the surgical approach to intraspinal tumors has gradually changed, not only in terms of innovation of the traditional surgical approach, but also in terms of the emergence of minimally invasive spinal and spinal cord surgery. International minimally invasive spinal surgery was developed jointly by neurosurgery and orthopedics. Currently, in many developed countries and regions such as Europe, the United States, Japan, Korea, and Taiwan, neurosurgeons adopt the concept of minimally invasive surgery, strategies for protection of the nerve and spinal cord during surgery, and microscopic techniques to play a leading role in the development of minimally invasive spinal surgery due to the high-risk characteristics of cervical spondylosis, craniocervical junction disease, and spinal cord disease. This article provides the following review of current traditional spinal cord surgery approaches and the characteristics of minimally invasive spinal cord surgery. Minimally invasive techniques are the direction of surgical development in the 21st century. International minimally invasive spinal surgery was developed jointly by neurosurgery and orthopedics. Currently, in many developed countries and regions such as Europe, the United States, Japan, Korea, Taiwan, etc., due to the high-risk characteristics of cervical spondylosis, craniocervical junction disease and spinal cord disease, neurosurgeons have adopted the concept of minimally invasive surgery, strategies for protection of the nerve and spinal cord during surgery, and microscopic techniques have played a leading role in the development of minimally invasive spinal surgery, and many minimally invasive surgical instruments have come from the design of neurosurgeons. For example, the world’s first artificial disc and its successful application in cervical spine was designed by Dr. Vincent Bryan, a neurosurgeon in Seattle, USA, in 1990 and named Bryan Cervical Artificial Disc, which has been used until now. In the field of spinal cord surgery, in addition to endoscopic resection of herniated discs and endovascular interventions to treat endovascular malformations in the spinal canal, minimally invasive techniques include percutaneous puncture vertebral scleroplasty and kyphoplasty, myeloscopy and spondyloscopy, stereotactic spine surgery (including navigation techniques) and stereotactic radiosurgery. I. Posterior total laminectomy approach Posterior total laminectomy tumor removal is the traditional and most classic surgical approach and the basis of various surgical approaches. The operation is performed under general anesthesia in prone position. During the operation, C-arm X-ray machine fluoroscopy is used to determine the lesion site, center on the tumor, bite away the related spinous process, lamina and intervertebral ligament, fully reveal the spinal canal and decompression, thoroughly stop bleeding, keep the operation field clear, handle the dural sac according to the relationship between the tumor and dura, carefully dissect and separate, and strive for complete and thorough removal of the tumor. If the tumor is located in the epidural area, the tumor should be separated from the dural adhesions and removed. If the tumor is located in the subdural area, the dural sac should be incised longitudinally in the center of the plane where it is located and tracted with silk thread to investigate the position of the tumor, separate the tumor from the dural adhesions, and separate the nerve fibers passing through the tumor. If the tumor is large and difficult to remove, it can be excised in pieces. If the tumor envelope is intact, the tumor should be resected completely. The tumor in the lumbar spinal canal often adheres to the cauda equina nerve and nerve root, and sometimes the cauda equina nerve and nerve root are completely surrounded by the tumor, so it is difficult to separate them out. After resection of the intradural tumor, the dura should be thoroughly hemostatic and carefully sutured to protect the spinal cord or cauda equina. This procedure has the advantages of clear intraoperative exposure, easy operation and short operation time, and is especially suitable for multisegmental intravertebral tumors. Posterior hemilaminectomy approach Posterior hemilaminectomy tumor removal is developed on the basis of total laminectomy. Since 60% to 70% of the subdural tumors in the spinal canal are located laterally or posteriorly, when the hemilaminectomy, sphenoid root, and inner 1/3 of the articular eminence are removed, 4/5 of the transverse diameter of the posterior dura can be revealed, and after the dura is cut, the tumors located in the posterior and posterior lateral part of the spinal cord can be completely exposed to the field of view. During surgery, only half of the vertebral plate of the corresponding segment of the tumor is occluded, and it is not required to occlude all the vertebral plate and spinous process. This approach has the advantages of less trauma, less impact on the spinal cord and nerves, less impact on the stability of the spine, and faster postoperative recovery of the patient. Third, the posterior laminectomy has a great impact on the stability of the spine after total laminectomy, for example, “goose neck deformity” in the long term after cervical spine surgery, which aggravates spinal cord dysfunction. The posterior approach is a posterior median approach centered on the lesion site, where the muscles are separated along the midline to reach the supraspinous ligament, the paravertebral muscles are stripped bilaterally, the supraspinous and interspinous ligaments and the bilateral vertebral plates are separated to reveal the small articular processes, and the supraspinous and interspinous ligaments are protected, a narrow groove is ground in the bilateral arch isthmus and removed along with the supraspinous, interspinous and yellow ligaments to form a vertebral plate spine complex, and after the tumor is removed. After removal of the tumor, the vertebral plate and spinous process complex is fixed in situ after drilling on the osteotomy surface. The advantage of this approach is that it not only maintains the integrity of the spinal canal and the stability of the spine, but also effectively prevents postoperative scar adhesions from compressing the spinal cord. Anterolateral spinal approach This approach is suitable for tumors growing ventral to the cervical spinal cord, and the results are more satisfactory. For tumors in the cervical 1~3 spinal canal, a longitudinal incision is made along the anterior edge of the sternocleidomastoid muscle, which becomes posterior at the mastoid root and reveals the ventral and lateral aspects of the cervical spinal cord from the lateral side to better reveal the intervertebral foramen, the tumor in the spinal canal and the vertebral artery. The advantages are: entering the spinal canal from the lateral side without stretching the spinal cord; avoiding damage to the vertebral artery; looking directly at the interface between the tumor and the spinal cord to avoid damage to the spinal cord; less bone destruction and removal of small joints without causing cervical instability. V. Combined anterior and posterior spinal approach Depending on the location and size of tumor, most of them choose one approach, but if necessary, two approaches can be chosen for combined surgery. For example: ① posterior median + posterior lateral cervical approach; ② anterior lateral + posterior median cervical approach; ③ anterior lateral + posterior lateral cervical approach; ④ anterior-posterior combined approach. Minimally invasive spinal cord surgery and characteristics Minimally invasive surgery is the “concept”, is the “means”, is the “purpose”, that is, the concept of minimally invasive through minimally invasive means or technology to achieve treatment Minimally invasive surgery is a surgical technique with the aim of achieving good results and quick recovery for patients. Minimally invasive spine surgery technology means avoiding large incisions under certain medical risks, using tiny incisions or puncture channels, using special instruments and devices to reach the lesion from the normal anatomy under the supervision of imaging instruments or guided by navigation technology, and using various miniature manual or electric instruments and devices to complete the entire procedure under visual conditions, in order to achieve smaller incisions, less tissue trauma, less bleeding, and fewer operations than traditional or standard spine surgery. The aim is to achieve smaller incisions, less tissue trauma, less bleeding, greater precision, more positive results, and faster functional recovery than traditional or standard spine surgery. Usually in traditional surgery, a large incision is required to reveal the diseased tissue, and in order to complete this step, most of the muscles in the back of the neck must be stripped of their connection to the spine, resulting in a longer recovery time for the patient. The main reasons for this are: (1) Surgical separation of these muscles produces pain during surgery, which must be reduced by pain medication, and the patient must suffer the side effects of this medication. (2) The separation of the paraspinal muscles from their normal anatomical attachment points will result in scarring of these muscles during healing, and scarring of different layers of muscles into another layer will result in the loss of their individual functions. In addition, it has been found that this form of muscle stripping can sometimes lead to loss of innervation and atrophy of the muscle groups, resulting in a permanent weakening of the back muscles. This result leads directly to fatigue pain and limited motor function in the patient’s back. Therefore, the need to develop this minimally invasive surgical technique arose as a result of these traditional surgeries reaching muscle injuries. Minimally invasive spine surgery techniques are derived from traditional spine surgery, but they are not a complete replacement for traditional spine surgery techniques. The general principles of traditional spine surgery management and operating techniques are still applied to the practice of minimally invasive spine surgery techniques. To carry out minimally invasive techniques, it is important to first correctly understand the intent of minimally invasive techniques. Small incision operations are not the same as minimally invasive techniques. Simply narrowing the incision, inadequate exposure, increasing the strength of the pull hook, difficult to operate with ease, difficult to perfect hemostasis, increased tissue damage, rough and forced placement of fixation does not mean minimally invasive operation, and contrary to the intent of minimally invasive techniques, blindly pursuing tiny incisions is not minimally invasive techniques. Although with the configuration of high precision instruments, tiny incisions can achieve minimal damage, but the blind pursuit of tiny makes the anatomy unclear, the operation too rough, the steps are not in place, easy to accidentally injure important organs, the blind pursuit of tiny artificially causes the operation too difficult, prolongs the operation time, and even turns into traditional surgery in the middle of the operation, but becomes invasive or mega-invasive surgery, which fails to achieve the purpose of minimally invasive and destabilizes the internal environment is not minimally invasive technology trauma It is a kind of malignant stimulation to human body. Trauma can cause systemic reactions, and strong trauma reactions can lead to serious complications and even endanger life. In order to achieve the purpose of minimally invasive, excessive damage to normal tissues, prolonging the operation time, disrupting the stability of the internal environment of the body, causing other serious complications, and failing to achieve effective treatment. This kind of surgical operation is by no means minimally invasive. It is not minimally invasive because it is operated by hand and experience without the monitoring of imaging instruments. Due to the lack of equipment or fear of X-ray radiation damage, the surgeon’s blind and random operation is based on his clinical experience and sense of touch, and although the operation is completed and the tissue damage is minimal, the accuracy of the operation lacks objective testing and loses the meaning of minimally invasive techniques. Minimally invasive spine surgery techniques must be carried out to break the shackles of traditional concepts, familiar with the local and overall anatomy, master the performance and use of modern high-precision instruments, inherit the experience of traditional surgery operations, establish a highly responsible professional ethics, perform a rigorous, scientific and meticulous research style, and possess a hard-working and self-dedicated work ethic. Spinal microsurgery techniques. The use of the operating microscope or high magnification, magnification of the surgical field of view for surgical operations, through the smallest possible skin incision to perform “keyhole surgery”, so that spine surgery with minimal medical source of injury to implement the most effective treatment. The use of the surgical microscope allows the operator to clearly see small structures that are not visible to the naked eye, such as the arachnoid membrane and tumor, nerve roots and tumor, the boundary between tumor and cervical spinal cord, and especially the small vessels that supply or drain the blood flow to the tumor. With the help of surgical microscope, different spinal cord surgical approaches can be realized for microsurgical operation, which has the advantages of precision, clear anatomical levels, high resolution and small accidental injuries. However, it is characterized by a small surgical field of view, long operating time, and requires precise positioning of the surgical approach and skilled microsurgery techniques. Endoscopic applications in minimally invasive spinal cord surgery Endoscopic-assisted spinal surgery techniques include: (1) thoracoscopic technology-assisted anterior thoracic surgery; (2) laparoscopic-assisted anterior lumbar surgery; (3) posterior discoscopic lumbar disc removal; (4) discoscopic minimally invasive anterior cervical surgery. Endoscopically assisted spine surgery technology allows surgical operations to be performed under direct vision, which has the advantages of not affecting the stability of the spine and fast postoperative recovery, in line with the development trend of minimally invasive spine surgery. Compared with open surgery, endoscopic-assisted spine surgery significantly reduces the stripping and stretching of tissues and organs, and the microscopic endoscope has a magnifying effect, making the operative field look clearer, the surgical operation more delicate, and the surgical trauma smaller, significantly reducing the amount of surgical bleeding and significantly shortening the patient’s hospital stay, thus reducing the burden on the patient’s family and society. VIII. Application of intraoperative electrophysiological monitoring technology Intraoperative neuromonitoring refers to the use of neuroelectrophysiological technology to monitor the electromyography and evoked potentials of nerve pathways that may cause injury during surgery, in order to improve the rate of nerve preservation and improve the quality of life of patients after surgery. Intraoperative neuromonitoring provides surgeons with accurate and reliable information, which is very important to ensure patient safety during surgery and reduce the occurrence of neurological impairment and improve the prognosis of surgery. In recent years, this technique has become more and more mature and widely used, and has become routine internationally. As an important adjunct, monitoring of spinal cord function is essential in the treatment process. Both the electrodes buried in the epidural cavity and those used to record the terminal muscle potentials of the limb reflect the integration function of the conduction bundles on the neuromuscular junction. This is closely related to the functional recovery of the spinal cord after surgery. This test is fast, reliable, practical and free of complications. It constantly reminds the operator of the relationship to the normal spinal cord during the surgical approach; it allows for more precise localization and reduces postoperative complications. There are three main spinal cord monitoring techniques used in spinal cord and spinal nerve surgery: (1) somatosensory evoked potential (SEP) monitoring to determine the function of the spinal sensory pathway; (2) motor evoked potential (MEP) to determine the function of the motor pathway. (3) electromyographic monitoring (EMG) of the muscles innervated by the spinal nerve, which is used to monitor the pulling injury of the spinal nerve. As an important adjunct, monitoring of spinal cord function is essential during surgery. Neurophysiological monitoring reminds the surgeon of the relationship to the normal spinal cord during the surgical approach, allowing for more precise positioning and reducing postoperative complications. It is closely related to the functional recovery of the spinal cord after surgery. A decrease in MEP amplitude is a red flag, and operators should pay close attention to spinal cord protection, monitor changes in evoked potentials, reduce invasive operations on the spinal cord, and expand the scope of tumor resection. Postoperative neurological function is the gold standard for evaluating spinal cord and nerve root monitoring. Intraoperative monitoring of evoked potentials can give important early warning signals, and in theory it always precedes all information provided by clinical examination. Studies have shown that 1.6% of patients suffer neurological damage during surgery, and 72% of these cases can be predicted during monitoring. In the United States, spinal cord monitoring records have legal effect. Nine, navigation system-assisted spine surgery technology computer-assisted spine surgery navigation system is a combination of three-dimensional spine positioning system computer medical image processing and three-dimensional visualization to assist doctors to complete the increasingly complex spine surgery and complex internal fixation operations, which has the advantages of less trauma, high precision, less radiation, etc., is a new and emerging technology in spine surgery. Computer-aided spine surgery navigation systems provide a broader range of preoperative surgical data, providing a multidimensional view for the surgeon to select an optimal entry point and access pathway; they can also be used for anatomical ectoplasm, trauma, deformity, and malignancy, which are not usually easily treated; and they can greatly reduce the risk of perforation of the spinal arch nail and reduce intraoperative radiation exposure. The main applications are: (1) placement of pedicle screws; (2) C1-C2 posterior transarticular Magerl screws; (3) placement of dentate screws; (4) anterior cervical decompression; and (5) scoliosis correction. Three-dimensional visualization information and simulated surgery can develop the best surgical plan for the patient; provide real-time dynamic feedback on intraoperative conditions and precise surgical operation, making the built-in toward more precise and perfect; reduce the exposure of surgery, making the surgery more precise, safe and minimally invasive. X. Prospect Surgery is the main mode of surgical treatment, and surgeons should strive to achieve the best treatment effect with the least tissue damage. Minimally invasive surgery for intravertebral tumors exposes and removes the tumor while reducing the exposure of the spinal cord, decreasing the risk of spinal cord injury, and also minimizing the damage to the bony structures of the spine and maintaining the stability of the spine after surgery. Therefore, minimally invasive spine surgery techniques should be less invasive, less painful, faster recovery, more effective, less complications, and less costly for patients. At the same time, minimally invasive spine surgery techniques require doctors to break the shackles of traditional concepts, constantly learn new theories, master new techniques, and have the spirit of innovation and self-dedication. Minimally invasive spine surgery technology should be carried out in accordance with the medical ethics of “medical ethics and benevolence”, to gain the approval of society, to reduce the negative effects to a minimum level, to bring about a good medical market, and to achieve fruitful economic and social benefits. With the further development of modern biological science, network information science, nano-materials science and computer intelligence science, the ideal of minimally invasive and non-invasive spinal surgery will certainly be realized. Minimally invasive spine surgery techniques will gradually replace many conventional surgeries.