A combined posterior, lateral, and anterior approach to ventrolaterally situated chordoma of the upper cervical spine

Abstract

Background Lesions ventral and ventrolateral to the neuraxis at the CCJ can pose a significant management problem owing to their strategic location. Conventional direct posterior approaches sometimes may not allow adequate visualization of the entire tumor base without significant manipulation of the brain stem and spinal cord. Here, we describe an approach that allows safe access to a ventrolaterally extending chordoma originating from the second and third cervical vertebrae. Case Description A 31-year-old man was admitted to our institution with progressive motor weakness in his left arm and lower extremities and spastic gait disturbance. Neuroradiologic examination revealed an osseous tumor at the C2-3 level that presented with severe spinal cord compression and considerable bone destruction. We performed a resection of the tumor and posterior screw fixation from occiput to C5 using a conventional direct posterior approach. However, we were unable to reach a part of the tumor that extended far laterally to the left side with VA involvement. To expose and resect this remaining tumor, we used a far-lateral approach just posterior to the SCM muscle. Resecting the transverse processes of C2 and C3 and mobilizing the V2 segment of the VA adequately exposed the tumor for resection. After resection of the remaining posterior-lateral tumor, we closed and made the final approach anteriorly to resect the anterior tumor via an anterior corpectomy and fusion. No postoperative complications occurred, and the patient's neurologic status improved after surgery. He has had no craniocervical instability during the 2-year follow-up period. Conclusion When a direct posterior approach makes it difficult or impossible to reach tumors extending to the far lateral margins of the spine and soft tissues, the posterior-lateral approach described here allows excellent visualization and safe access with minimal neural retraction for treating these laterally situated lesions. We describe the surgical technique for a combined approach as an alternative to the direct posterior or anterior retropharyngeal approach.