Introduction Intradural extramedullary (IDEM) metastatic disease is infrequently encountered by spine surgeons and consequently poorly understood. Discovery often corresponds with the onset of neurologic symptoms and no consensus exists regarding the importance of complete resection or anticipated postoperative outcome. We aim to elucidate treatment methodologies that exist in the literature. Case presentation We present a unique case of a 57-year-old male with a known history of esophageal adenocarcinoma, including brain and visceral metastases, who presented with cauda equina syndrome. An IDEM metastatic esophageal adenocarcinoma lesion was identified on advanced imaging and biopsy. This was treated operatively without return of neurologic function. Discussion We reviewed and summarized the existing literature. Trends are highlighted to further guide surgeons treating this unusual metastatic phenomenon. Conclusion Intradural metastasis is a harbinger of advanced disease with a poor prognosis regardless of the etiology of the primary lesion. There are a number of proposed mechanisms for metastatic spread with little available literature for surgeon guidance. Most authors are advocates of a palliative, decompressive approach.

Outcomes in posterior cervical spine surgery are highly dependent on proper operative head and neck positioning. As with any spinal procedure, posterior cervical surgery can be associated with significant morbidity; known complications directly related to positioning include postoperative vision loss, neurological injury, and poor surgical outcome. Unsurprisingly, a variety of techniques have been developed that aim to mitigate these complications while improving overall outcomes. The aim of this article is to present a standardized technique for application of the Mayfield skull clamp focusing on a team-based approach for patient positioning to minimize complications. The existing literature is also reviewed for complications associated with head positioning devices. Our method of clamp application and patient positioning minimizes complications (0.36% over a 14-y period), optimizes surgical exposure with anatomic position of the bony elements, and maximizes intraoperative spinal stability. This protocol is ideal for all the posterior cervical procedures.

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