BACKGROUND: Angiomatoid fibrous histiocytoma (AFH) is an exceptionally rare soft tissue neoplasm. This tumor primarily presents as a benign soft tissue lesion in children with an average age of 14 years. The standard treatment regimen is wide local excision with interval follow-up. However, newer reports have demonstrated malignant potential with the possibility of intracranial metastasis. OBSERVATIONS: A 45-year-old male with no soft tissue primary tumor presented with a primary intracranial lesion and thoracic spine metastasis refractory to chemotherapy and radiation treatment. LESSONS: This report illustrates the potential for a highly malignant nature of metastatic AFH. In addition, the authors demonstrate an incidence of AFH in a middle-aged male without a primary soft tissue or skin lesion. This report highlights the importance of prompt treatment and excision for AFH, as there is still little understanding of successful options for systemic therapy.

The transforaminal (TF) and interlaminar (IL) approaches compose the two endoscopic approaches to lumbar discectomy. There is a growing tendency to utilize the TF route for higher lumbar disc herniations and the IL approach related to anatomical factors for the caudal lumbar levels. The L5-S1 level produces a particular challenge due to anatomical barriers, including the height of the iliac crest and the orientation of the facet when confronted with a lateral or far-lateral disc herniation. Traditional approaches can lead to significant joint destabilization in the effort to resect the disc fragment Here we present an operative video with technical nuances of the TF approach utilized to perform both a far-lateral and paracentral discectomy at L5-S1 to treat a 52-year-old male with two distinct and noncontiguous herniations with severe acute right-sided L5 and S1 radiculopathy. This would have otherwise required either two different endoscopic approaches or a more extensive open approach for successful discectomy

Background: The endoscopic approach to the spine has a steep learning curve, primarily due to challenges in learning how to access Kambin’s triangle, leading to significant radiation exposure. Real-time live instrument tracking using two-dimensional fluoroscopic navigation has been shown to significantly reduce the time and radiation exposure needed to perform a trans-Kambin approach; however, the impact on the learning curve for those in training has not been studied. Methods: Physicians in training (PITs) in a single program were evaluated while accessing Kambin’s triangle using a gel sawbone model. The PITs were randomized in terms of spinal level, the technology used first, and the approach side. Time to access Kambin’s triangle and radiation were recorded for each cohort. A linear regression model was used to assess associations between procedure time and radiation exposure and endoscopic experience and PGY level. Results: Seven PITs were studied with a range of prior experience, consisting of three PITs with high exposure (HE) (≥30 cases) and four with low exposure (LE) (0–20 cases, averaging 7.5). Unassisted by instrument tracking, the SE group was 63% faster and was exposed to 63% less radiation. Further, there was a moderate correlation with experience and time (R = −0.52) and radiation (R = −0.60). Using instrument tracking allowed all the PITs to be 40% faster, taking 6.6 min (range 2.9–12.4) without instrument tracking and 4.0 min (1.9–6.3) with it. Radiation also decreased by 91% (2.52 vs. 0.23 mGy with instrument tracking). Conclusions: Experience significantly enhanced the accessibility of Kambin’s triangle, reducing time and radiation exposure by about two-thirds. Regardless of experience, instrument tracking reduced radiation exposure by 90%. Additionally, familiarizing PITs with instrument location can eliminate 70% of the learning curve for those inexperienced with accessing Kambin’s triangle.

The transforaminal (TF) and interlaminar (IL) approaches compose the two endoscopic approaches to lumbar discectomy. There is a growing tendency to utilize the TF route for higher lumbar disc herniations and the IL approach related to anatomical factors for the caudal lumbar levels. The L5-S1 level produces a particular challenge due to anatomical barriers, including the height of the iliac crest and the orientation of the facet when confronted with a lateral or far-lateral disc herniation. Traditional approaches can lead to significant joint destabilization in the effort to resect the disc fragment Here we present an operative video with technical nuances of the TF approach utilized to perform both a far-lateral and paracentral discectomy at L5-S1 to treat a 52-year-old male with two distinct and noncontiguous herniations with severe acute right-sided L5 and S1 radiculopathy. This would have otherwise required either two different endoscopic approaches or a more extensive open approach for successful discectomy