Outcomes following attempted en bloc resection of cervical chordomas in the C-1 and C-2 region versus the subaxial region: a multiinstitutional experience

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1–2 level versus the subaxial (SA) spine (C3–7).</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1–2 versus subaxial spine via a Student t-test.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1–2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1–2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1–2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1–2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1–2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1–2 tumors (C1–2: 29%; SA: 78%; p = 0.03). C1–2 tumors were associated with significantly higher rates of postoperative complications (C1–2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1–2 tumors (local C1–2: 29%; local SA: 11%; distant C1–2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1–2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1–2 versus subaxial disease, but larger studies are needed to further study survival differences.</jats:p></jats:sec>

Health-Related Quality of Life After Spine Surgery for Primary Bone Tumour

“…Dysphagia, dysphonia, pharyngeal erosion and permanent tracheostomy are described [33,[35][36][37][38]. Tumour location in the upper cervical spine was associated with increased complications compared to the subaxial spine in a retrospective review [35]. Wei et al [39] reported that 42.1 and 73.68 % of their patients experienced intraoperative and postoperative complications after intralesional spondylectomy of the upper cervical spine.…”

“…Vertebral artery sacrifice can result in significant morbidity in the absence of collateral flow. Dysphagia, dysphonia, pharyngeal erosion and permanent tracheostomy are described [33,[35][36][37][38]. Tumour location in the upper cervical spine was associated with increased complications compared to the subaxial spine in a retrospective review [35].…”

Spinal stereotactic body radiotherapy following intralesional curettage with separation surgery for initial or salvage chordoma treatment

“…33 Molina et al presented a multiinstitutional case series in which en bloc resection of cervical chordomas was attempted. 40 Upper cervical spine (C-1 and C-2) chordomas were associated with a dramatically higher rate of complications compared with subaxial chordomas (71% vs 22%, respectively) and higher rates of recurrence. Given the complex vascular, osseoligamentous, and important neuroanatomy that presents unique surgical challenges in cases of atlantoaxial chordomas, and given the significantly higher rate of complications, the authors advocated intralesional resection for C-1 and C-2 chordomas rather than en bloc resection.…”

“…C1-2 chordomas have been reported to have a 71% risk of complications. 40 The authors of a series reviewing the complications of 220 en bloc spinal operations reported that 33% of their patients had major surgical complications, with those harboring primary malignant spinal tumors having a higher risk of complications. 8 One study with long-term follow-up after proton radiotherapy for chordoma noted a Grade 3-4 toxicity risk of 13%.…”

En bloc resection of a C-1 lateral mass osteosarcoma: technical note

“…30 In a multiinstitutional study of 16 patients in whom C1-2 en bloc resections for chordoma were attempted, the likelihood of achieving the desired marginal margins was only 29% in contrast to a rate of 79% in a control population in which subaxial en bloc resections were attempted. Although the survival rate was not significantly different between the groups, there was a significantly higher rate of local and distant recurrence in the patients who underwent high cervical resections.…”