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Yu AC, Ko M, Han AY, St John M, Chhetri DK. Speech and Swallowing Outcomes of Surgically Managed Cervical Chordoma: A Case Series. Laryngoscope 2024; 134:3706-3712. [PMID: 38544468 DOI: 10.1002/lary.31418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 03/08/2024] [Accepted: 03/18/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVES Cervical chordoma is a rare, low-grade primary bone tumor occurring in the axial skeleton. Due to challenges in surgical exposure caused by anatomic location, patients may experience dysfunction in speech and swallowing. The objective of this study was to characterize speech and swallowing outcomes for patients undergoing surgical resection of cervical chordoma. Moreover, we detail in-depth two cases with similar initial presentations to compare prognostic factors and management strategies. METHODS Eleven patients with histologically confirmed cervical chordoma treated between 1993 and 2020 were included in this retrospective case series. Outcomes measured included overall survival, disease-free survival, need for enteral feeds, as well as results of modified barium swallow study (MBSS) and fiberoptic laryngoscopy. RESULTS The mean age at diagnosis was 55.9 years. The patient population was 81.8% male. Mean survival after diagnosis was 96 months. Four (36.4%) patients required post-operative MBSS and demonstrated aspiration. All four of these patients presented with tumors in the superior cervical spine and received surgeries utilizing anterior approaches. Of the four, 2 required enteral feeds long-term. Four (36.4%) patients endorsed dysphonia. One patient developed post-operative right vocal fold paresis. The remaining three patients experienced stable dysphonia pre- and post-operatively. Additionally, three (27%) patients required tracheostomy placement, two of which remained in place long-term. CONCLUSIONS Dysphagia is a common side effect of cervical chordoma resection. It is associated with the use of an anterior approach during resection and with tumors located in the superior cervical spine. Patients with postoperative dysphagia should receive early multidisciplinary swallow rehabilitation. LEVEL OF EVIDENCE 4 Laryngoscope, 134:3706-3712, 2024.
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Affiliation(s)
- Alice C Yu
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles (UCLA), Los Angeles, California, U.S.A
| | - Myungjun Ko
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles (UCLA), Los Angeles, California, U.S.A
| | - Albert Y Han
- Department of Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, U.S.A
| | - Maie St John
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles (UCLA), Los Angeles, California, U.S.A
- University of California Los Angeles, Los Angeles (UCLA) Head and Neck Cancer Program, Los Angeles, California, U.S.A
| | - Dinesh K Chhetri
- Department of Head and Neck Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles (UCLA), Los Angeles, California, U.S.A
- University of California Los Angeles, Los Angeles (UCLA) Head and Neck Cancer Program, Los Angeles, California, U.S.A
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Hu P, Du S, Wei F, Zhai S, Zhou H, Liu X, Liu Z. Reconstruction after resection of C2 vertebral tumors: A comparative study of 3D-printed vertebral body versus titanium mesh. Front Oncol 2022; 12:1065303. [PMID: 36601475 PMCID: PMC9806260 DOI: 10.3389/fonc.2022.1065303] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022] Open
Abstract
Background Surgical resection of C2 vertebral tumors is challenging owing to the complex anatomy of C2 vertebrae and the challenges to surgical exposure. Various surgical approaches are available, but some are associated with excessively high risks of complications. An additional challenge is reconstruction of the upper cervical spine following surgery. In the last decade, additive-manufacturing personalized artificial vertebral bodies (AVBs) have been introduced for the repair of large, irregular bony defects; however, their use and efficacy in upper cervical surgery have not been well addressed. Therefore, in this study, we compared instrumented fixation status between patients who underwent conventional titanium mesh reconstruction and those who underwent the same resection but with personalized AVBs. Methods We performed a retrospective comparative study and recruited a single-institution cohort of patients with C2 vertebral tumors. Clinical data and imaging findings were reviewed. Through data processing and comparative analysis, we described and discussed the feasibility and safety of surgical resection and the outcomes of hardware implants. The primary outcome of this study was instrumented fixation status. Results The 31 recruited patients were divided into two groups. There were 13 patients in group A who underwent conventional titanium mesh reconstruction and 18 group B patients who underwent personalized AVBs. All patients underwent staged posterior and anterior surgical procedures. In the cohort, 9.7% achieved total en bloc resection of the tumor, while gross total resection was achieved in the remaining 90.3%. The perioperative complication and mortality rates were 45.2% and 6.5%, respectively. The occurrence of perioperative complications was related to the choice of anterior approach (p < 0.05). Group A had a higher complication rate than group B (p < 0.05). Four patients (4/13, 30.8%) developed hardware problems during the follow-up period; however, this rate was marginally higher than that of group B (1/18, 5.6%). Conclusions Total resection of C2 vertebral tumors was associated with a high risk of perioperative complications. The staged posterior and retropharyngeal approaches are better surgical strategies for C2 tumors. Personalized AVBs can provide a reliable reconstruction outcome, yet minor pitfalls remain that call for further modification.
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Affiliation(s)
- Panpan Hu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Suiyong Du
- Department of Spine Surgery, 521 Hospital of Norinco Group, Xi’an, China
| | - Feng Wei
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China,*Correspondence: Feng Wei,
| | - Shuheng Zhai
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Hua Zhou
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
| | - Zhongjun Liu
- Department of Orthopedics and Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, Beijing, China
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He S, Ye C, Zhong N, Yang M, Yang X, Xiao J. Customized anterior craniocervical reconstruction via a modified high-cervical retropharyngeal approach following resection of a spinal tumor involving C1-2/C1-3. J Neurosurg Spine 2020; 32:432-440. [PMID: 31756709 DOI: 10.3171/2019.8.spine19874] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 08/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The surgical treatment of an upper cervical spinal tumor (UCST) at C1-2/C1-3 is challenging due to anterior exposure and reconstruction. Limited information has been published concerning the effective approach and reconstruction for an anterior procedure after C1-2/C1-3 UCST resection. The authors attempted to introduce a novel, customized, anterior craniocervical reconstruction between the occipital condyles and inferior vertebrae through a modified high-cervical retropharyngeal approach (mHCRA) in addressing C1-2/C1-3 spinal tumors. METHODS Seven consecutive patients underwent 2-stage UCST resection with circumferential reconstruction. Posterior decompression and occiput-cervical instrumentation was conducted at the stage 1 operation, and anterior craniocervical reconstruction using a 3D-printed implant was performed between the occipital condyles and inferior vertebrae via an mHCRA. The clinical characteristics, perioperative complications, and radiological outcomes were reviewed, and the rationale for anterior craniocervical reconstruction was also clarified. RESULTS The mean age of the 7 patients in the study was 47.6 ± 19.0 years (range 12-72 years) when referred to the authors' center. Six patients (85.7%) had recurrent tumor status, and the interval from primary to recurrence status was 53.0 ± 33.7 months (range 24-105 months). Four patients (57.1%) were diagnosed with a spinal tumor involving C1-3, and 3 patients (42.9%) with a C1-2 tumor. For the anterior procedure, the mean surgical duration and average blood loss were 4.1 ± 0.9 hours (range 3.0-6.0 hours) and 558.3 ± 400.5 ml (range 100-1300 ml), respectively. No severe perioperative complications occurred, except 1 patient with transient dysphagia. The mean pre- and postoperative visual analog scale scores were 8.0 ± 0.8 (range 7-9) and 2.4 ± 0.5 (range 2.0-3.0; p < 0.001), respectively, and the mean improvement rate of cervical spinal cord function was 54.7% ± 13.8% (range 42.9%-83.3%) based on the modified Japanese Orthopaedic Association scale score (p < 0.001). Circumferential instrumentation was in good position and no evidence of disease was found at the mean follow-up of 14.8 months (range 7.3-24.2 months). CONCLUSIONS The mHCRA provides optimal access to the surgical field at the C0-3 level. Customized anterior craniocervical fixation between the occipital condyles and inferior vertebrae can be feasible and effective in managing anterior reconstruction after UCST resection.
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Extended Maxillotomy for Nasopharynx Access in Infantile Immature Teratoma. J Craniofac Surg 2019; 31:77-78. [PMID: 31449225 DOI: 10.1097/scs.0000000000005875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infantile immature teratoma located in the nasopharynx is a rare congenital tumor that is not easily removed. Three surgeries and chemotherapy for recurrence of the tumor have been performed since a male infant with a nasopharyngeal mass was born at a gestational age of 35 weeks. Extended maxillotomy combining Le Fort I osteotomy with midline palatal split was performed at 2 years and 6 months of age. Residual tumor left in the intracranial region had not increased as of 4 years of age. Careful follow-up is needed until the patient reaches adulthood.
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Howell EP, Williamson T, Karikari I, Abd-El-Barr M, Erickson M, Goodwin ML, Reynolds J, Sciubba DM, Goodwin CR. Total en bloc resection of primary and metastatic spine tumors. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:226. [PMID: 31297391 PMCID: PMC6595209 DOI: 10.21037/atm.2019.01.25] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Primary and metastatic tumors of the spine represent a significant cause of patient morbidity, and present a management challenge to treating providers. From a neurosurgical standpoint, resection surgery may be warranted in cases of spinal instability, progressive disease, neurological compromise, or intractable symptoms. Removal of a tumor "en bloc" offers a more aggressive modality over more conservative resection techniques. En bloc resection entails the removal of the entirety of a tumor without violation of its capsule, and may offer improved rates of local control and overall survival in appropriately selected patients. Conversely, this technique carries a higher complication rate, and requires a unique set of technical skills as compared to more traditional resection. Here, we describe the technical aspects of en bloc resection, as well as specific indications and considerations when employing this operative technique.
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Affiliation(s)
| | - Theresa Williamson
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Isaac Karikari
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | - Melissa Erickson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew L Goodwin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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6
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Zhou H, Yang X, Jiang L, Wei F, Liu X, Liu Z. Radiofrequency ablation in gross total excision of cervical chordoma: ideas and technique. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:3113-3117. [PMID: 29915886 DOI: 10.1007/s00586-018-5628-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/03/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE To use radiofrequency ablation (RFA) in the resection of C4 cervical chordoma with a giant paravertebral tumor mass to achieve tumor-free exposed margins and perform a gross total excision. METHODS A gross total excision using combined posterior and anterior approaches was performed. In the posterior stage, the C4 posterior arch was removed and the C4/C5 nerve roots and vertebral artery were released from the tumor. In the anterior stage, the giant soft mass of tumor from C3 to C6 was treated with RFA to make it shrink and solidify visually to achieve tumor-free exposed margins before resecting the tumor. Finally, a gross total excision was performed followed by the implantation of titanium plate and mesh filled with allograft bone. RESULTS A gross total excision was performed with tumor-free exposed margins and radiotherapy. The patient survived more than 5 years without recurrence. CONCLUSIONS RFA can help achieve tumor-free exposed margins. A gross total excision combined with RFA can improve the local relapse-free survival of patients with cervical chordoma. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Hua Zhou
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Xiaoxiong Yang
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.,Department of Surgery, Beijing North Hospital of Ordnance Industry, Beijing, 100081, China
| | - Liang Jiang
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Feng Wei
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China
| | - Xiaoguang Liu
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.
| | - Zhongjun Liu
- Key Laboratory of Spinal Diseases, Department of Orthopaedics, Peking University Third Hospital, No. 49 Huayuanbei Road, Beijing, 100191, Haidian District, China.
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Ji W, Tong J, Huang Z, Zheng M, Wu X, Chen J, Zhu Q. Stabilization of the Craniovertebral Junction with Clivus Plate Constructs: Biomechanical Comparison with Conventional Technique. World Neurosurg 2016; 94:42-49. [DOI: 10.1016/j.wneu.2016.06.104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 01/22/2023]
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Ji W, Liu X, Huang W, Huang Z, Chen J, Zhu Q, Wu Z. Clival Screw Placement in Patient with atlas assimilation: A CT-based feasibility study. Sci Rep 2016; 6:31648. [PMID: 27539005 PMCID: PMC4990935 DOI: 10.1038/srep31648] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 07/18/2016] [Indexed: 11/11/2022] Open
Abstract
Clival screw and plate fixation technique is an alternative or supplement to the occipitocervical instrumentation. However, no report has clarified the applied anatomy of clivus in patients with atlas assimilation (C1A), especially for clival screw fixation. Therefore, we measured the parameters of clival lengths, widths, putative screw lengths, clival-cervical angel and foramen magnum diameters on CT images in a cohort of 81 C1A patients and patients without C1A. The clivus showed a rectangular shape in 96.3% (78/81) of C1A patients, and a normal-like triangle shape in 3.7% (3/81) of C1A patients. The intracranial clival length decreased 13% (37 mm) in C1A patients, the extracranial clival length 14.8% (24.1 mm), the clival-cervical angle 6.2% (122.3°) and the superior screw length 11.3% (14.1 mm), the sagittal diameter of foramen magnum 16% (28.0 mm), respectively. There was no significant difference in the widest or narrowest clival width, or the middle screw length, or the transverse diameter of foramen magnum between groups. The inferior clivus was feasible for an average 9.7-mm-length screw placement in C1A patients, while not in patients without C1A. The present study characterizes clivus of C1A patients with an unnormal-like rectangular shape, and confirmes a screw placement at the inferior clivus.
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Affiliation(s)
- Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiang Liu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wenhan Huang
- Hospital of Orthopaedics, Guangzhou General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liuhua Road, Guangzhou, China
| | - Zucheng Huang
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianting Chen
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qingan Zhu
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zenghui Wu
- Hospital of Orthopaedics, Guangzhou General Hospital of Guangzhou Military Command (Liuhuaqiao Hospital), 111 Liuhua Road, Guangzhou, China
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Navigated Pin-Point Approach to Osteoid Osteoma Adjacent to the Facet Joint of Spine. Asian Spine J 2016; 10:158-63. [PMID: 26949472 PMCID: PMC4764529 DOI: 10.4184/asj.2016.10.1.158] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/09/2015] [Accepted: 04/11/2015] [Indexed: 11/24/2022] Open
Abstract
Osteoid osteoma (OO) is a benign osteoblastic tumor. Its curative treatment is complete removal of the nidus, where intraoperative localization of the nidus governs clinical results. However, treatment can be difficult since the lesion is often invisible over the bony surface. Accordingly, establishment of an ideal less invasive surgical strategy for spinal OO remains yet unsettled. We illustrate the efficacy of a computed tomography (CT)-based navigation system in excising OO located adjacent to the facet joint of spine. In our 2 cases, complete and pin-point removal of the nidus located close to the facet joint was successfully achieved, without excessive removal of the bone potentially leading to spinal instability and possible damage of nearby neurovascular structures. We advocate a less invasive approach to spinal OO, particularly in an environment with an available CT-based navigation system.
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10
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Ji W, Tong J, Huang Z, Zheng M, Wu X, Chen J, Zhu Q. A clivus plate fixation for reconstruction of ventral defect of the craniovertebral junction: a novel fixation device for craniovertebral instability. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:1658-65. [PMID: 26002353 DOI: 10.1007/s00586-015-4025-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 05/12/2015] [Accepted: 05/13/2015] [Indexed: 01/22/2023]
Affiliation(s)
- Wei Ji
- Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China
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11
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En bloc resection of primary malignant bone tumors of the cervical spine. Acta Neurochir (Wien) 2014; 156:2159-64. [PMID: 24789709 DOI: 10.1007/s00701-014-2075-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/19/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Due to the poor response of primary malignant bone tumors to adjuvant therapies, surgical resection performed in an en bloc fashion with free margins remains the best option for long-term recurrence-free survival of patients harboring such lesions. METHODS In this article the authors provide a stepwise review of the technical details involved in the performance of en bloc resections of tumoral lesions in the cervical spine. CONCLUSIONS Due to the anatomical peculiarities of the cervical spine related to the presence of functional nerve roots as well as the vertebral arteries, en bloc resections in this region remains a challenging surgical procedure.
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Mattei TA, Ramos E, Rehman AA, Shaw A, Patel SR, Mendel E. Sustained long-term complete regression of a giant cell tumor of the spine after treatment with denosumab. Spine J 2014; 14:e15-21. [PMID: 24534393 DOI: 10.1016/j.spinee.2014.02.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/05/2014] [Accepted: 02/05/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Although giant cell tumors (GCTs) are histologically benign, they may become locally aggressive bone tumors. As these lesions tend to respond poorly to radio- and chemotherapy, currently the standard surgical paradigm for the treatment of spinal GCTs involves en bloc surgical resection. Denosumab is a newly developed monoclonal antibody designed to inhibit the receptor activator of nuclear factor kappa-B ligand (RANKL) which has already been demonstrated to induce marked radiographic responses on GCTs of the appendicular skeleton. Nevertheless, the role of denosumab in the treatment algorithm of GCTs of the spine has not yet been defined. PURPOSE To describe the first case of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab. STUDY DESIGN Case report and literature review. METHODS The authors describe the case of 22-year-old female patient, harboring a GCT involving the C2 vertebral body and odontoid process, who was treated in monotherapy with denosumab, resulting in complete long-term clinical and radiographic tumor remission. RESULTS There were no major side effects associated with the long-term pharmacological treatment with denosumab. From the clinical standpoint, the patient demonstrated complete remission of the disease while under treatment. The 16-month radiographic follow-up demonstrated complete disappearance of the osteolytic process and intense new cortical bone formation with restoration of the bone integrity of the C2 vertebral body. CONCLUSIONS This is the first report of sustained long-term complete clinical and radiographic regression of a GCT of the spine after treatment with the new RANKL antibody denosumab. Although future long-term follow-up studies are still necessary to establish important key points regarding the best therapeutic protocol with such a new drug (such as the optimal time frame to keep the patient under treatment), denosumab promises to bring major changes to the current therapeutic paradigm for GCTs of the spine, which, up to now, has strongly relied on en bloc surgical resection.
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Affiliation(s)
- Tobias A Mattei
- Department of Neurosurgery - InvisionHealth Brain & Spine Center, Buffalo - NY, USA.
| | - Edwin Ramos
- Department of Neurological Surgery, The Wexner Medical Center at The Ohio State University and The James Cancer Center, Columbus, OH, USA
| | - Azeem A Rehman
- The University of Illinois College of Medicine, Peoria, IL, USA
| | - Andrew Shaw
- Department of Neurological Surgery, The Wexner Medical Center at The Ohio State University and The James Cancer Center, Columbus, OH, USA
| | - Shreyasumar R Patel
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Ehud Mendel
- Department of Neurosurgery - InvisionHealth Brain & Spine Center, Buffalo - NY, USA; Department of Neurological Surgery, The Wexner Medical Center at The Ohio State University and The James Cancer Center, Columbus, OH, USA
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Recurrent upper cervical chordomas after radiotherapy: surgical outcomes and surgical approach selection based on complications. Spine (Phila Pa 1976) 2013; 38:E1141-8. [PMID: 23698574 DOI: 10.1097/brs.0b013e31829c2bb0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review of a case series. OBJECTIVE To present and analyze our surgical results of recurrent chordomas in the upper cervical spine after radiotherapy and compare 2 surgical strategies. SUMMARY OF BACKGROUND DATA Surgical treatment of recurrent chordomas in the upper cervical spine after radiotherapy is clinically rare but extremely challenging. No reports are found in the literatures focusing on the surgical results and strategies of such recurrent chordomas. METHODS Clinical data of 8 patients with recurrent chordomas in the upper cervical spine after radiotherapy were retrospectively reviewed. RESULTS Preoperative symptoms were relieved after our surgical procedures in 7 of the 8 patients. Total tumor removal was achieved in 6 of the 8 patients. Surgical complications mainly including cerebrospinal fluid leak and incision disunion were observed in 6 of the 8, and all the 3 patients after transoral operation had those complicated surgical complications, whereas the other 3 of the 5 patients after anterior retropharyngeal operation had relatively slighter complications. The disease free survival rates 1 year and 2 years after the surgery in this series were 50% and 12.5%, respectively, comparing with the general survival rates 1 year and 2 years after the surgery 87.5% and 37.5%. CONCLUSION Revised surgery is effective for improving quality of life of patients with recurrent upper cervical chordomas after radiotherapy before further tumor recurrence. However, the prognosis of those patients is usually poor and surgical complications mainly including incision disunion and cerebrospinal fluid leak are common. To reduce the risk of surgical complications, anterior retropharyngeal approach may be superior to the transoral approach. LEVEL OF EVIDENCE N/A.
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Yang X, Wu Z, Xiao J, Teng H, Feng D, Huang W, Chen H, Wang X, Yuan W, Jia L. Sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach: surgical technique and results in 11 patients. Neurosurgery 2012; 69:ons184-93; discussion ons193-4. [PMID: 21499150 DOI: 10.1227/neu.0b013e31821bc7f9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Surgical treatment of C2 tumors remains challenging. Because of the deep location and unique anatomical complexity, anterior exposure in this region is considered difficult and dangerous, and few reports concerning anterior tumor resection and reconstruction exist. OBJECTIVE To describe a technique of sequentially staged resection and 2-column reconstruction for C2 tumors through a combined anterior retropharyngeal-posterior approach. METHODS Eleven patients with C2 tumors underwent sequentially staged tumor resection and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were involved. Tumor resections and anterior reconstructions with conventional constructs were accomplished by an anterior retropharyngeal approach, and occipitocervical fusions through posterior access were performed in the same anesthesia. RESULTS No operative mortality occurred in this series. All patients experienced pain relief and neurological improvement after surgery. Except for 1 incidence of screw pullout, which was corrected by revision surgery, solid fusion was achieved in all patients. A follow-up period of 12 to 37 months was available for this study. Two patients with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two patients with metastasis died of multiple remote metastases. No evidence of local recurrence was found in the other patients. CONCLUSION The anterior retropharyngeal approach is a favorable route to treat tumor lesions of the C2 vertebral body that allows tumor resection and placement of anterior constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column reconstruction could safely be accomplished simultaneously through the combined anterior retropharyngeal-posterior approach.
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Affiliation(s)
- Xinghai Yang
- Department of Orthopedics, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
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15
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Ahsan F, Inglis T, Allison R, Inglis GS. Cervical chordoma managed with multidisciplinary surgical approach. ANZ J Surg 2010; 81:331-5. [PMID: 21518181 DOI: 10.1111/j.1445-2197.2010.05575.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND This paper describes the interdisciplinary management of a 62-year-old man who presented with a cervical chordoma of C2/3. This is a rare neoplasm of the axial skeleton which is usually treated surgically. This is technically challenging due to the surrounding anatomy and requirement for wide exposure. A number of surgical approaches have been described to access the clivus and upper cervical spine. METHODS This case involved both the Orthopaedic and Otolaryngology Head and Neck Surgery departments. Trotter's surgical technique was used to gain access for excision of the cervical chordoma and there was collaboration with an Orthopaedic Biotechnology Company in which a bio-model of the spine was created and a corpectomy cage specific to the patient developed. RESULTS This approach allowed excellent visualisation of the tumour and the unique cage and plate achieved immediate stability and long term fusion. CONCLUSION An interdisciplinary approach should be used in the management of upper cervical chordomas to facilitate tumour resection and reduce the potential for recurrence.
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Affiliation(s)
- Farhan Ahsan
- Department of Otolaryngology, Head & Neck Surgery, Christchurch Hospital, New Zealand
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Zhou H, Chen CB, Lan J, Liu C, Liu XG, Jiang L, Wei F, Ma QJ, Dang GT, Liu ZJ. Differential proteomic profiling of chordomas and analysis of prognostic factors. J Surg Oncol 2010; 102:720-7. [DOI: 10.1002/jso.21674] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
STUDY DESIGN A report of 4 cases of spinal osteotomy performed under the guidance of a computer-assisted navigation system and a technical note about the use of the navigation system for spinal osteotomy. OBJECTIVE To document the surgical technique and usefulness of computer-assisted surgery for spinal osteotomy. SUMMARY OF BACKGROUND DATA A computer-assisted navigation system provides accurate 3-dimensional (3D) real-time surgical information during the operation. Although there are many reports on the accuracy and usefulness of a navigation system for pedicle screw placement, there are few reports on the application for spinal osteotomy. METHODS We report on 4 complex cases including 3 solitary malignant spinal tumors and 1 spinal kyphotic deformity of ankylosing spondylitis, which were treated surgically using a computer-assisted spinal osteotomy. The surgical technique and postoperative clinical and radiologic results are presented. RESULTS 3D spinal osteotomy under the guidance of a computer-assisted navigation system was performed successfully in 4 patients. All malignant tumors were resected en bloc, and the spinal deformity was corrected precisely according to the preoperative plan. Pathologic analysis confirmed the en bloc resection without tumor exposure in the 3 patients with a spinal tumor. CONCLUSION The use of a computer-assisted navigation system will help ensure the safety and efficacy of a complex 3D spinal osteotomy.
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Complicated surgical resection of malignant tumors in the upper cervical spine after failed ion-beam radiation therapy. Spine (Phila Pa 1976) 2010; 35:E505-9. [PMID: 20421861 DOI: 10.1097/brs.0b013e3181caa86c] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To report 3 cases of malignant tumors in the upper cervical spine that were treated surgically by a combination of posterior tumor resection and stabilization and anterior tumor resection through a mandible-splitting approach after failed ion-beam radiation therapy. SUMMARY OF BACKGROUND DATA Few clinical reports have described in detail the postoperative complications associated with transoral surgical resection of tumors in the upper cervical spine after unsuccessful ion-beam radiation therapy. METHODS Three patients with malignant tumors in the upper cervical spine who had undergone ion-beam radiotherapy and experienced tumor recurrence were treated by a combination of posterior and anterior surgery through a mandible-splitting approach. One patient (patient 1, a 32-year-old man) had a hemangioendothelioma at the C2 and C3 level, whereas the other 2 patients (patient 2, a 66-year-old woman and patient 3, a 65-year-old man) had a chordoma at the C2 and C3 level. RESULTS The intralesional but macroscopic total resection of the tumors was achieved in all 3 patients. However, serious complications developed after surgery, including deep wound infection, cerebrospinal fluid leakage, and meningitis in patient 1, prolonged swallowing difficulty, subsidence of the strut graft, and recurrence in patient 2, and deep wound infection and discitis causing progressive paralysis in patient 3. All patients underwent salvage surgery, including debridement of the wound in patient 1, posterior reinforcement using instrumentation and posterior tumor resection for the recurrent tumor in patient 2, and anterior debridement of the wound with a pedicle flap using the pectoral major muscle in patient 3 to address these problems. Patients 1 and 3 had no signs of recurrence at the time of a follow-up examination. CONCLUSION Severe complications, mainly associated with the disturbance in healing of the retropharyngeal wall, were observed in all 3 patients. A preventive method, such as primary repair of the retropharyngeal wall using muscular/musculocutaneous flaps, should be considered for patients undergoing resection through a transoral approach after ion-beam irradiation.
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Abstract
STUDY DESIGN Technical note. OBJECTIVE To introduce the application of navigation system with software for brain surgery to the upper cervical spine of patients who have previously had occipitocervical (O-C) fusion. SUMMARY OF BACKGROUND DATA The anterior approach to the spine using a navigation system with software for spine surgery is difficult because the registration tends to be inaccurate. However, after O-C fusion, the upper cervical spine is considered part of the skull, and a navigation system with software for brain surgery in which the registration is performed using the head with several markers attached to it can be applied. METHODS Three patients with previous O-C fusion-2 with upper cervical chordoma and 1 with a disc herniation at C2/3-were treated using this technique. RESULTS In the first case, with a huge retropharyngeal C1 chordoma, this technique was very helpful in blindly dissecting the nonvisible parts of the tumor. In the second case, with a C2 chordoma, the vertebral arteries were successfully exposed under the guidance of the navigation system at both primary and revision surgery. In the third case, with disc herniation at C2/3, the herniated disc was removed successfully with the totally fused spine. In this application, computed tomography images can be merged freely with magnetic resonance images, which is helpful to clarify the soft tissues such as tumor, disc herniation, or the dural tube. CONCLUSION This technique greatly supports surgeons inexperienced in the anterior approach to the upper cervical spine or surgeons at revision surgery who may be lost in and daunted by an unfamiliar operation field surrounded by important structures. Although an anterior approach to the upper cervical spine in the patient with O-C fusion may rarely be required, this application should be considered.
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Boriani S, Saravanja D, Yamada Y, Varga PP, Biagini R, Fisher CG. Challenges of local recurrence and cure in low grade malignant tumors of the spine. Spine (Phila Pa 1976) 2009; 34:S48-57. [PMID: 19829277 DOI: 10.1097/brs.0b013e3181b969ac] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review and ambispective multicenter cohort study. OBJECTIVE 1. To compare the effects of wide/marginal (en bloc) resection with intralesional resection on local recurrence and survival for chordomas and chondrosarcomas of the spine. 2. To determine the influence of radiation therapy in the management of chordomas and chondrosarcomas. SUMMARY OF BACKGROUND DATA Chordomas and chondrosarcomas of the spine are prone to local recurrence and death despite being low-grade malignant tumors. No study to date has enough numbers or adequate scientific rigor to determine the influence of resection or radiation therapy on outcome. METHODS A systematic review was performed to evaluate the 2 objectives. In addition an ambispective multicenter cohort analysis of chordomas and chondrosarcomas was performed. The GRADE system of analysis integrating the results of the systematic review, the multicenter cohort study and the expert opinion of the Spine Oncology Study Group (SOSG) was used to arrive at treatment recommendations. RESULTS A total of 63 articles were included in the systematic reviews. Evidence was low quality. En bloc resection appeared to improve both local recurrence and disease free survival in Chordoma and Chondrosarcoma. Radiation therapy had a positive impact on the management of Chordoma and Chondrosarcoma with predictably low side effects. The cohort analysis showed significantly decreased local recurrence for Chordoma (P < 0.0001) and Chondrosarcoma (P < 0.0001) with en bloc resection, and significantly decreased death for both Chordoma (P = 0.0001) and Chondrosarcoma (P = 0.0015) with en bloc resection. CONCLUSION When wide or marginal margins (en bloc) are achieved in surgical resection of chordomas and chondrosarcomas of the spine there is a decrease in local recurrence and mortality. Therefore, en bloc resection should be undertaken for the treatment of chordomas and chondrosarcomas of the spine. Strong Recommendation, Moderate Quality Evidence.Radiation therapy of at least 60 to 65 Gy equivalents is indicated as an adjuvant treatment for chordoma and chondrosarcoma of the spine when there has been incomplete resection or an intralesional margin. Weak Recommendation, Low Quality Evidence.
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Affiliation(s)
- Stefano Boriani
- Department of Orthopedic Oncology, Rizzoli Institute, Bologna, Italy
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[Transmaxillary approach to the skull base: surgical anatomy and guidelines]. Morphologie 2008; 92:181-7. [PMID: 19013095 DOI: 10.1016/j.morpho.2008.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND A surgical and anatomic approach to the skull base using the transmaxillary route is presented. This route is well-known and used for a long time for sinus conditions. METHOD This study was performed on injected cadavers. This study describes step by step this approach in microsurgical conditions following a vital lead: the infraorbital nerve. RESULTS Anatomical landmarks are located in order to avoid complications. These complications are on one hand, hemorrhages by vascular lesions and on the other, definitive nerve palsy. CONCLUSION Several skull base approaches exist, transfacial routes produce cosmetic damages. This route preserves the functional anatomy of the nose because it preserves the integrity of the lateral wall of the nasal cavity.
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