Endoscope-assisted far-lateral transcondylar approach for craniocervical junction chordomas: a retrospective case series and cadaveric dissection

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  • 1 Department of Neurosurgery, Lariboisière Hospital, Assistance Publique—Hôpitaux de Paris;
  • 2 Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris;
  • 3 University of Paris; and
  • 4 Proton Therapy Center, Institut Curie, Orsay, France
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OBJECTIVE

Craniocervical junction (CCJ) chordomas are a neurosurgical challenge because of their deep localization, lateral extension, bone destruction, and tight relationship with the vertebral artery and lower cranial nerves. In this study, the authors present their surgical experience with the endoscope-assisted far-lateral transcondylar approach (EA-FLTA) for the treatment of CCJ chordomas, highlighting the advantages of this corridor and the integration of the endoscope to reach the anterior aspect and contralateral side of the CCJ and the possibility of performing occipitocervical fusion (OCF) during the same stage of surgery.

METHODS

Nine consecutive cases of CCJ chordomas treated with the EA-FLTA between 2013 and 2020 were retrospectively reviewed. Preoperative characteristics, surgical technique, postoperative results, and clinical outcome were analyzed. A cadaveric dissection was also performed to clarify the anatomical landmarks.

RESULTS

The male/female ratio was 1.25, and the median age was 36 years (range 14–53 years). In 6 patients (66.7%), the lesion showed a bilateral extension, and 7 patients (77.8%) had an intradural extension. The vertebral artery was encased in 5 patients. Gross-total resection was achieved in 5 patients (55.6%), near-total resection in 3 (33.3%), and subtotal resection 1 (11.1%). In 5 cases, the OCF was performed in the same stage after tumor removal. Neither approach-related complications nor complications related to tumor resection occurred. During follow-up (median 18 months, range 5–48 months), 1 patient, who had already undergone treatment and radiotherapy at another institution and had an aggressive tumor (Ki-67 index of 20%), showed tumor recurrence at 12 months.

CONCLUSIONS

The EA-FLTA provides a safe and effective corridor to resect extensive and complex CCJ chordomas, allowing the surgeon to reach the anterior, lateral, and posterior portions of the tumor, and to treat CCJ instability in a single stage.

ABBREVIATIONS BTO = balloon test occlusion; CCJ = craniocervical junction; EA-FLTA = endoscope-assisted far-lateral transcondylar approach; EEA = endoscopic endonasal approach; GTR = gross-total resection; HC = hypoglossal canal; JF = jugular foramen; LCN = lower cranial nerve; NTR = near-total resection; OC = occipital condyle; OCF = occipitocervical fusion; PA = petrous apex; PBRT = proton-beam radiation therapy; PMMA = polymethylmethacrylate; STR = subtotal resection; VA = vertebral artery.

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Contributor Notes

Correspondence Sébastien Froelich: Lariboisière Hospital, University of Paris Diderot, Paris, France. sebastien.froelich@aphp.fr.

INCLUDE WHEN CITING Published online April 2, 2021; DOI: 10.3171/2020.9.JNS202611.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Vujovic S, Henderson S, Presneau N, . Brachyury, a crucial regulator of notochordal development, is a novel biomarker for chordomas. J Pathol. 2006;209(2):157165.

    • Search Google Scholar
    • Export Citation
  • 2

    Stacchiotti S, Sommer J. Building a global consensus approach to chordoma: a position paper from the medical and patient community. Lancet Oncol. 2015;16(2):e71e83.

    • Search Google Scholar
    • Export Citation
  • 3

    Sebro R, DeLaney T, Hornicek F, . Differences in sex distribution, anatomic location and MR imaging appearance of pediatric compared to adult chordomas. BMC Med Imaging. 2016;16(1):53.

    • Search Google Scholar
    • Export Citation
  • 4

    Zuckerman SL, Bilsky MH, Laufer I. Chordomas of the skull base, mobile spine, and sacrum: an epidemiologic investigation of presentation, treatment, and survival. World Neurosurg. 2018;113:e618e627.

    • Search Google Scholar
    • Export Citation
  • 5

    Crockard HA, Steel T, Plowman N, . A multidisciplinary team approach to skull base chordomas. J Neurosurg. 2001;95(2):175183.

  • 6

    al-Mefty O, Borba LAB. Skull base chordomas: a management challenge. J Neurosurg. 1997;86(2):182189.

  • 7

    Yasuda M, Bresson D, Chibbaro S, . Chordomas of the skull base and cervical spine: clinical outcomes associated with a multimodal surgical resection combined with proton-beam radiation in 40 patients. Neurosurg Rev. 2012;35(2):171183.

    • Search Google Scholar
    • Export Citation
  • 8

    Weber AL, Liebsch NJ, Sanchez R, Sweriduk STJ Jr. Chordomas of the skull base. Radiologic and clinical evaluation. Neuroimaging Clin N Am. 1994;4(3):515527.

    • Search Google Scholar
    • Export Citation
  • 9

    Kehr P. Book review. Pathology and Surgery Around the Vertebral Artery. B. George, M. Bruneau, R.F. Spetzler (Eds).ArgoSpine News J. 2012;24(3-4):196.

    • Search Google Scholar
    • Export Citation
  • 10

    George B, Lot G. Anterolateral and posterolateral approaches to the foramen magnum: technical description and experience from 97 cases. Skull Base Surg. 1995;5(1):919.

    • Search Google Scholar
    • Export Citation
  • 11

    Sen C, Shrivastava R, Anwar S, Triana A. Lateral transcondylar approach for tumors at the anterior aspect of the craniovertebral junction. Neurosurgery. 2010;66(3)(suppl):104112.

    • Search Google Scholar
    • Export Citation
  • 12

    Choi D, Melcher R, Harms J, Crockard A. Outcome of 132 operations in 97 patients with chordomas of the craniocervical junction and upper cervical spine. Neurosurgery. 2010;66(1):5965.

    • Search Google Scholar
    • Export Citation
  • 13

    Shkarubo AN, Andreev DN, Konovalov NA, . Surgical treatment of skull base tumors, extending to craniovertebral junction. World Neurosurg. 2017;99:4758.

    • Search Google Scholar
    • Export Citation
  • 14

    Hyun SJ, Kim JW, Kim KJ, . Long-term results following surgical resection of chordomas in the craniocervical junction and the upper cervical spine: review of 12 consecutive cases. Oper Neurosurg (Hagerstown). 2018;14(2):112120.

    • Search Google Scholar
    • Export Citation
  • 15

    Zoli M, Rossi N, Friso F, . Limits of endoscopic endonasal approach for cranio-vertebral junction tumors. J Neurosurg Sci. 2018;62(3):356368.

    • Search Google Scholar
    • Export Citation
  • 16

    George B, Carpentier A. Chordomas of the craniocervical junction. Oper Tech Neurosurg. 2002;5(2):129136.

  • 17

    Hanakita S, Labidi M, Watanabe K, Froelich S. A staged strategy for craniocervical junction chordoma with combination of endoscopic endonasal approach and far lateral approach with endoscopic assistance: case report. J Neurol Surg B Skull Base. 2018;79(3)(suppl 4):S371S377.

    • Search Google Scholar
    • Export Citation
  • 18

    Wang L, Wu Z, Tian K, . Clinical features and surgical outcomes of patients with skull base chordoma: a retrospective analysis of 238 patients. J Neurosurg. 2017;127(6):12571267.

    • Search Google Scholar
    • Export Citation
  • 19

    Shin H, Barrenechea IJ, Lesser J, . Occipitocervical fusion after resection of craniovertebral junction tumors. J Neurosurg Spine. 2006;4(2):137144.

    • Search Google Scholar
    • Export Citation
  • 20

    Tardivo V, Labidi M, Passeri T, . From the occipital condyle to the sphenoid sinus, extradural extension of the far lateral transcondylar approach with endoscopic assistance. World Neurosurg. 2020;134:e771e782.

    • Search Google Scholar
    • Export Citation
  • 21

    Labidi M, Watanabe K, Hanakita S, . The chopsticks technique for endoscopic endonasal surgery-improving surgical efficiency and reducing the surgical footprint. World Neurosurg. 2018;117:208220.

    • Search Google Scholar
    • Export Citation
  • 22

    Colli B, Al-Mefty O. Chordomas of the craniocervical junction: follow-up review and prognostic factors. J Neurosurg. 2001;95(6):933943.

    • Search Google Scholar
    • Export Citation
  • 23

    Verburg JM, Seco J. Dosimetric accuracy of proton therapy for chordoma patients with titanium implants. Med Phys. 2013;40(7):071727.

  • 24

    Wang EW, Zanation AM, Gardner PA, . ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol. 2019;9(S3):S145S365.

  • 25

    Singh H, Harrop J, Schiffmacher P, . Ventral surgical approaches to craniovertebral junction chordomas. Neurosurgery. 2010;66(3)(suppl):96103.

    • Search Google Scholar
    • Export Citation
  • 26

    Chibbaro S, Cornelius JF, Froelich S, . Endoscopic endonasal approach in the management of skull base chordomas—clinical experience on a large series, technique, outcome, and pitfalls. Neurosurg Rev. 2014;37(2):217225.

    • Search Google Scholar
    • Export Citation
  • 27

    Visocchi M, Signorelli F, Liao C, . Transoral versus transnasal approach for craniovertebral junction pathologies: never say never. World Neurosurg. 2018;110:592603.

    • Search Google Scholar
    • Export Citation
  • 28

    Youssef AS, Sloan AE. Extended transoral approaches: surgical technique and analysis. Neurosurgery. 2010;66(3)(suppl):126134.

  • 29

    Dlouhy BJ, Dahdaleh NS, Menezes AH. Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update. Neurosurg Focus. 2015;38(4):E8.

    • Search Google Scholar
    • Export Citation
  • 30

    Choi D, Crockard HA. Evolution of transoral surgery: three decades of change in patients, pathologies, and indications. Neurosurgery. 2013;73(2):296304.

    • Search Google Scholar
    • Export Citation
  • 31

    Shriver MF, Kshettry VR, Sindwani R, . Transoral and transnasal odontoidectomy complications: a systematic review and meta-analysis. Clin Neurol Neurosurg. 2016;148:121129.

    • Search Google Scholar
    • Export Citation
  • 32

    Kassam AB, Snyderman C, Gardner P, . The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery. 2005;57(1)(suppl):E213.

    • Search Google Scholar
    • Export Citation
  • 33

    Alzhrani G, Gozal YM, Eli I, . Extreme lateral transodontoid approach to the ventral craniocervical junction: cadaveric dissection and case illustrations. J Neurosurg. 2018;131(3):920930.

    • Search Google Scholar
    • Export Citation
  • 34

    Sen CN, Sekhar LN. Surgical management of anteriorly placed lesions at the craniocervical junction—an alternative approach. Acta Neurochir (Wien). 1991;108(1-2):7077.

    • Search Google Scholar
    • Export Citation
  • 35

    Di Carlo DT, Voormolen EH, Passeri T, . Hybrid antero-lateral transcondylar approach to the clivus: a laboratory investigation and case illustration. Acta Neurochir (Wien). 2020;162(6):12591268.

    • Search Google Scholar
    • Export Citation
  • 36

    Heros RC. Lateral suboccipital approach for vertebral and vertebrobasilar artery lesions. J Neurosurg. 1986;64(4):559562.

  • 37

    Spetzler RF, Graham TW. The far lateral approach to the inferior clivus and the upper cervical region. Technical note. BNI Q. 1990;6(4):3538.

    • Search Google Scholar
    • Export Citation
  • 38

    al-Mefty O, Borba LA, Aoki N, . The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction. J Neurosurg. 1996;84(1):16.

    • Search Google Scholar
    • Export Citation
  • 39

    Kawashima M, Tanriover N, Rhoton AL Jr, . Comparison of the far lateral and extreme lateral variants of the atlanto-occipital transarticular approach to anterior extradural lesions of the craniovertebral junction. Neurosurgery. 2003;53(3):662675.

    • Search Google Scholar
    • Export Citation
  • 40

    Lot G, George B. The extent of drilling in lateral approaches to the cranio-cervical junction area from a series of 125 cases. Acta Neurochir (Wien). 1999;141(2):111118.

    • Search Google Scholar
    • Export Citation
  • 41

    Sorteberg A, Bakke SJ, Boysen M, Sorteberg W. Angiographic balloon test occlusion and therapeutic sacrifice of major arteries to the brain. Neurosurgery. 2008;63(4):651661.

    • Search Google Scholar
    • Export Citation
  • 42

    Zoarski GH, Seth R. Safety of unilateral endovascular occlusion of the cervical segment of the vertebral artery without antecedent balloon test occlusion. AJNR Am J Neuroradiol. 2014;35(5):856861.

    • Search Google Scholar
    • Export Citation
  • 43

    Freeman JL, DeMonte F, Al-Holou W, . Impact of early access to multidisciplinary care on treatment outcomes in patients with skull base chordoma. Acta Neurochir (Wien). 2018;160(4):731740.

    • Search Google Scholar
    • Export Citation
  • 44

    Kooshkabadi A, Choi PA, Koutourousiou M, . Atlanto-occipital instability following endoscopic endonasal approach for lower clival lesions: experience with 212 cases. Neurosurgery. 2015;77(6):888897.

    • Search Google Scholar
    • Export Citation
  • 45

    Bejjani GK, Sekhar LN, Riedel CJ. Occipitocervical fusion following the extreme lateral transcondylar approach. Surg Neurol. 2000;54(2):109116.

    • Search Google Scholar
    • Export Citation

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