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. 2014 Dec;8(6):820-6.
doi: 10.4184/asj.2014.8.6.820. Epub 2014 Dec 17.

Operative technique for en bloc resection of upper cervical chordomas: extended transoral transmandibular approach and multilevel reconstruction

Luis Alberto Ortega-Porcayo  1 , Eibar Ernesto Cabrera-Aldana  1 , Nicasio Arriada-Mendicoa  1 , Juan Luis Gómez-Amador  1 , Martín Granados-García  2 , Juan Barges-Coll  1
Affiliations

Operative technique for en bloc resection of upper cervical chordomas: extended transoral transmandibular approach and multilevel reconstruction

Luis Alberto Ortega-Porcayo et al. Asian Spine J. 2014 Dec.

Abstract

Anterior exposure for cervical chordomas remains challenging because of the anatomical complexities and the restoration of the dimensional balance of the atlanto-axial region. In this report, we describe and analyze the transmandibular transoral approach and multilevel spinal reconstruction for upper cervical chordomas. We report two cases of cervical chordomas (C2 and C2-C4) that were treated by marginal en bloc resection with a transmandibular approach and anterior-posterior multilevel spinal reconstruction/fixation. Both patients showed clinical improvement. Postoperative imaging was negative for any residual tumor and revealed adequate reconstruction and stabilization. Marginal resection requires more extensive exposure to allow the surgeon access to the entire pathology, as an inadequate tumor margin is the main factor that negatively affects the prognosis. Anterior and posterior reconstruction provides a rigid reconstruction that protects the medulla and decreases axial pain by properly stabilizing the cervical spine.

Keywords: Chordoma; Neurosurgical instrumentation; Spinal neoplasms; Transmandibular approach.

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Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1
Preoperative images of the first case. Computed tomography (A, axial; B, coronal; and C, sagittal) and magnetic resonance imaging (D, axial; E, coronal; and F, sagittal).
Fig. 2
Fig. 2
Second case. (A) Preoperative sagittal magnetic resonance imaging (MRI). (B) Postoperative sagittal MRI reveals no residual tumor. (C) Intraoperative photograph, showing the anterior cervical plate placed from C1-C4. (D) Microscopic photograph, demonstrating classical tumor lobules separated by bands of fibrous tissue (Masson's trichrome stain, ×50). (E) Lateral plain radiograph of the two-column reconstruction.
Fig. 3
Fig. 3
Artist's illustration of the posterior stage (occipitocervical fixation) of the surgery from the first case.
Fig. 4
Fig. 4
Artist's illustration of the anterior stage of the surgery from the first case. Extended oral transmandibular-transpharyngeal approach. Notice the extension of the approach with the addition of a glossotomy and mandibular osteotomy. The illustration shows the titanium cage before the anterior plate fixation.
Fig. 5
Fig. 5
Intraoperative images. (A) Notice the wide view allowed by the approach favoring marginal resection. (B) En bloc specimen. (C) Anterior reconstruction with a titanium cage filled with bone matrix and fixated with a plate.
Fig. 6
Fig. 6
Postoperative images of the first case. Magnetic resonance imaging (A, axial; B, coronal; and C, sagittal) reveals no evidence of residual tumor and (D) the postoperative three-dimensional sagittal computed tomography reconstruction.
See this image and copyright information in PMC

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