Novel approach using ultrasonic bone curettage and transoral robotic surgery for en bloc resection of cervical spine chordoma: case report

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Chordomas are rare, locally aggressive neoplasms that develop from remnants of the notochord. The typical approach to chordomas of the clivus and axial cervical spine often limits successful en bloc resection. In this case report, authors describe the first-documented transoral approach using both transoral robotic surgery (TORS) for exposure and the Sonopet bone scalpel under navigational guidance to achieve en bloc resection of a cervical chordoma. This 27-year-old man had no significant past medical history (Charlson Comorbidity Index 0). During a trauma workup following a motor vehicle collision, a CT of the patient’s cervical spine demonstrated an incidental 2.2-cm lesion situated along the posterior aspect of the C2 vertebral body. Postoperative imaging showed successful en bloc resection with adequate placement of hardware, and the pathology report demonstrated negative resection margins. The patient tolerated the procedure well, and because of the successful en bloc resection, radiation has been deferred. At 7 months postoperatively, the patient returned to work in New York City. Contrasted MRI at 15 months postoperatively showed the patient to be disease free. This approach offers a promising way forward in the treatment of these complex tumors.

ABBREVIATIONS TORS = transoral robotic surgery.

Article Information

Correspondence Neil R. Malhotra: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. neil.malhotra@uphs.upenn.edu.

INCLUDE WHEN CITING Published online March 1, 2019; DOI: 10.3171/2018.11.SPINE181162.

Disclosures Dr. O’Malley receives royalties from the University of Pennsylvania through Olympus for the FKWO retractor.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative imaging. A: Axial CT demonstrating a lytic lesion in the body of C2 with encroachment into the spinal canal. B: Axial postcontrast T1-weighted MR image demonstrating a heterogeneously enhancing lesion in the posterior aspect of the C2 vertebral body. C: Sagittal T2-weighted MR image showing chordoma on the posterior aspect of the C2 vertebral body without dural invasion. D: Guided sheathed biopsy with needle in the tumor.

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    Intraoperative imaging. A: Post–stage 1 CT showing tumor and osteotomy. B: Stage 2, posterior view of chordoma at C2 with en bloc osteotomy cuts. C: Stage 2, anterior view of upper cervical spine and C2 mass via TORS exposure, before discectomy and dens cut. D: Posterior osteotomy in C2 after en bloc removal of the chordoma, now with screw placement at the lateral masses of C1 and C3 and a pars screw at C2. Because of instability, the fusion was extended to include occipital plating, as well as C4 and C5 screws.

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    The use of TORS for adequate anterior exposure to allow osteotomy cuts via the Sonopet, leading to en bloc resection of a C2 chordoma (upper right) with stabilization via anterior plating (lower right). Copyright Neil R. Malhotra. Published with permission.

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    Postoperative imaging. Sagittal (A) and coronal (B) radiographs demonstrating anterior plate and screw fixation at C1–2 and C2–3 with posterior fusion extending from the occiput to C5. Sagittal (C) and axial (D) MR images obtained at the inferior aspect of C2, showing maintained alignment of the cervical spine with preservation of the spinal canal.

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