Available online at www.sciencedirect.

com

Surgical Neurology 72 (2009) 409 – 413

www.surgicalneurology-online.com
Neoplasm
A combined posterior, lateral, and anterior approach to ventrolaterally
situated chordoma of the upper cervical spine☆,☆☆,★
Seung-Jae Hyun, MD a , Seung-Chul Rhim, MD, PhD a,⁎, K. Daniel Riew, MD b
a
Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, South Korea
b
Department of Orthopedic Surgery, Barnes-Jewish Hospital at Washington University School of Medicine, St Louis, MO 63110, USA
Received 16 September 2008; accepted 3 November 2008

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.
© 2009 Elsevier Inc. All rights reserved.
Keywords: Craniocervical junction; Lateral approach; Osseous tumors; Chordomas

Abbreviations: CCJ, craniocervical junction; CT, computed tomography;

1. Introduction
MR, magnetic resonance; SCM, sternocleidomastoid; T1WI, T1-weighted Chordomas are rare, slow-growing, but locally aggressive
images; VA, vertebral artery.
☆
This manuscript submitted does not contain information about
tumors that occur along the craniospinal axis and are thought
medical device(s)/drug(s). to originate from remnants of the primitive notochord [2]. In
☆☆
No funds were received in support of this work. No benefits in any chordomas originating from the cervical spine, considerable
form have been or will be received from a commercial party related directly bone destruction is already obvious when they become
or indirectly to the subject of this manuscript. clinically relevant and at diagnosis. The goal of surgery in
★
This manuscript has not been previously published in whole or in part
or submitted elsewhere for review. such cases is the total resection of all tumors involving
⁎ Corresponding author. Tel.: +82 2 3010 3554; fax: +82 2 476 6738. osseous structures and craniospinal reconstruction to restore
E-mail address: scrhim@amc.seoul.kr (S.-C. Rhim). and maintain spinal stability at the CCJ. However, the
0090-3019/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.surneu.2008.11.017
410 S.-J. Hyun et al. / Surgical Neurology 72 (2009) 409–413
complete resection of chordomas that involve the lateral mass
and posterior elements of a cervical vertebra is technically
demanding owing to the close proximity of the VA, the
cervical nerve roots, and the spinal cord. Moreover, lesions
situated ventrally and ventrolaterally to the upper spinal cord
at the CCJ require careful surgical planning to avoid
neuroaxis retraction [8]. Thus, a standard anterior or posterior
approach alone may not allow the best exposure for resection
of the tumor and craniospinal stabilization. We report the use
of a combined posterior, lateral, and anterior approach that
allows safe access to a ventrolaterally extending chordoma
originating from the second and third cervical vertebrae.
2. Case report
2.1 History and examination
A 31-year-old man presented with a 6-month history of
progressive motor weakness, tingling sensation in his left
Fig. 1. Preoperative sagittal (A,B) and axial (C,D) T2-weighted MR images showing an extensive lesion located ventrolaterally at the upper cervical spine with
spinal cord compression and involvement of the left VA.
arm and lower extremities, and spastic gait disturbance.
Neurologic examination revealed spasticity in all 4 limbs
with brisk deep tendon reflexes and grade 4/5 power in the
left upper and lower limbs. The CT scans of the cervical
spine showed a bone destructive lesion in the left side of the
second and third cervical vertebrae (Fig. 1A–C). The MR
imaging showed a lobulating contoured lesion in the left
neural foramen of C2 and C3, extending into the extrafora-
men and central canal through the vertebral body and
transverse foramen, with severe spinal cord compression and
with involvement of the left VA (Fig. 2). However, digital
subtraction angiography demonstrated orthograde flow in
both VAs with nodular staining of the mass (Fig. 1D and E).
The mass, which was hypointense on T1WI and hyper-
intense on T2-weighted images, extended ventrolaterally to
the upper spinal cord. Gadolinium-enhanced T1WI showed
no enhancement. Examination of a CT-guided biopsy sample
revealed a chordoma. Complete resection of the chordoma
was planned and performed using a combined approach.
 S.-J. Hyun et al. / Surgical Neurology 72 (2009) 409–413 411

Fig. 2. Three-dimensional reconstructed image (A) and axial images (B and C) of CT scans obtained before tumor resection showing bone destruction.
Preoperative digital subtraction angiography images (D and E) demonstrating the VA laterally displaced by the tumor with nodular tumoral staining (arrow).

2.2 Operation and technique 2.3 Postoperative course

As a first step, we performed a resection of the tumor Postoperatively, the patient's neurologic symptoms,
and posterior screw fixation from occiput to C5 using a including motor weakness and tingling sensation in his
conventional direct posterior approach. As expected, we left arm and lower extremities, were improved to nearly
were unable to reach a part of the tumor that extended normal levels. One week after surgery, an MR image of the
ventrally and far laterally on the left side with VA cervical spine showed a small residual tumor at the superior
involvement. To expose and resect this remaining tumor,
we used a lateral approach just posterior to the SCM
muscle. The patient was placed in a prone position, and a
linear skin incision was made after the posterior margin of
the SCM muscle from the C4 level to the mastoid process
(Fig. 3). The splenius capitis muscle and the SCM muscle
were detached from the occiput. The splenius capitis
muscle was deflected posteriorly; the SCM and levator
scapulae muscles were deflected anteriorly; and care was
taken to preserve the spinal accessory, great auricular, and
lesser occipital nerves. As the rod and screws came into
sight, the transverse process of C2 and C3 and the
remaining tumor were identified. In this patient, the
transverse process of the C2 was already destroyed by
the chordoma. 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, the SCM muscle and the
splenius capitis muscle were reattached. The wound was Fig. 3. Intraoperative photography obtained before a skin incision that
closed, and an anterior approach was used to resect the followed the posterior margin of the SCM muscle from the C4 level to the
mastoid process. The patient is placed in a prone position, and the surgeon
anterior tumor and fusion using the plate and screw system. operates from a lateral direction. Surgical orientations are as follows: the left
This maneuver included resection of the destroyed side of this photograph (cranial direction), right (caudal), up (posterior), and
tumorous C3 vertebral body by corpectomy. down (anterior).
412 S.-J. Hyun et al. / Surgical Neurology 72 (2009) 409–413

portion of the C2 vertebral body and the ventral portion of 3. Discussion

the C2 epidural area. The patient was referred to a radiation
oncologist for radiotherapy for the residual tumor [7]. After
radiotherapy, MR imaging of the cervical spine showed no
residual tumor or recurrent tumor growth (Fig. 4).
Clinically, the tingling sensation and spastic gait distur-
bance had vanished completely. One year after surgery, the
patient was fully recovered with no neurologic deficits. He
has experienced no craniocervical instability during a 2-year
follow-up period. However, plain films have shown a
loosening of the screws to the occiput, although the
loosening is not symptomatic.
Most lesions at the CCJ can be easily accessed by a
conventional posterior or posterolateral approach. However,
if the lesions are located ventral and/or ventrolateral to the
spinal cord at the CCJ, direct posterior approaches some-
times may not allow adequate visualization of the entire
tumor base without significant manipulation of the brain
stem and spinal cord. Although several variations of the
anterior transmucosal and anterolateral retropharyngeal
approaches allow resection of these ventrally situated
lesions, each has its own limitations and restrictions [9,10].

Fig. 4. Upper left and right panels are as follows: 2-year follow-up anteroposterior (left) and lateral (right) radiographs showing craniocervical reconstruction.
Lower left and right are as follows: sagittal (left) and axial (right) MR images of the cervical spine after surgery and radiotherapy showing no residual tumor or
recurrent tumor growth.
 S.-J. Hyun et al. / Surgical Neurology 72 (2009) 409–413
To avoid recurrence and further surgery, it is important that
the initial operation be sufficiently radical, thus, requiring
good exposure [16]. We considered that neither a posterior
nor an anterolateral approach alone would give adequate
access. In contrast, a combined posterior, lateral, and anterior
approach could allow for safe access to a ventrolaterally
extending chordoma originating from the second and third
cervical vertebrae.
Historically, in 1966, Whitesides and Kelly [17]
introduced the lateral approach to the upper cervical spine
as an alternative to the anterior transmucosal and ante-
rolateral retropharyngeal approaches. This approach was
based on that used by Henry [6] to expose the VA at the
upper cervical spine. The technique by Henry emphasized
the dorsal reflection of the SCM muscle after its division at
the mastoid process, thereby allowing direct lateral
exposure of the VA via blunt dissection. There have been
several modifications of the lateral approach for use on the
upper cervical spine [1,8,12-15]. Among these modifica-
tions, lateral exposure of the entire cervical spine posterior
to the carotid sheath with mobilization of the VA as done by
Verbiest [15] is similar to the transuncodiskal approach [5].
In each, the vertebral body is approached from a lateral
direction by working posterior to the carotid sheath. A
portion of the lateral vertebral body is removed by drilling,
and the VA is displaced to expose the ventral surface of the
dura. However, many neurosurgeons are unfamiliar with
these lateral approaches, thus, increasing the risk of injury
to the phrenic and accessory nerves, sympathetic plexus,
and VA. Furthermore, intraspinal access is limited [4,11].
One lateral approach resulting in improved access to the
cervical spine uses multilevel oblique corpectomies without
fusion for multisegmental cervical spondylotic myelopathy
and radiculopathy [3,4].
We used a lateral approach just posterior, not anterior, to
the SCM, which is more appropriate for ventrally or
ventrolaterally located extensive osseous lesions with VA
involvement. Moreover, this approach provides a sterile
surgical field and excellent exposure independent of
intradural involvement. It also offers wider exposure for
resecting the C2 and C3 corpus.
4. 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 offers 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 approaches.
413
References
[1] Al-Mefty O, Borba LAB, Aoki N, Angtuaco E, Pait TG. The
transcondylar approach to extradural nonneoplastic lesions of the
craniovertebral junction. J Neurosurg 1996;84:1-6.
[2] Chambers PW, Schwinn CP. Chordoma: a clinicopathologic study of
metastasis. Am J Clin Pathol 1979;72:765-76.
[3] George B, Gauthier N, Lot G. Multisegmental cervical spondylotic
myelopathy and radiculopathy treated by multilevel oblique corpec-
tomies without fusion. Neurosurgery 1999;44:81-90.
[4] George B, Zerah M, Lot G, Hurth M. Oblique transcorporeal approach
to anteriorly located lesions in the cervical spinal canal. Acta Neurochir
(Wien) 2003;121:187-90.
[5] Hakuba A. Trans-unco-discal approach: a combined anterior and
lateral approach to cervical discs. J Neurosurg 1976;45:284-91.
[6] Henry AK. Extensile exposure. 2nd ed. Edinburgh: Churchill
Livingstone; 1982.
[7] Kondziolka D, Lunsford LD, Flickinger JC. The role of radiosurgery in
the management of chordoma and chondrosarcoma of the cranial base.
Neurosurgery 1991;29:38-46.
[8] Kumar CV, Satyanarayana S, Rao BR, Palur RS. Extreme lateral
approach to ventral and ventrolaterally situated lesions of the lower
brainstem and upper cervical cord. Skull Base 2001;11:265-75.
[9] Laus M, Pignatti G, Malaguti MC, Alfonso C, Zappoli FA, Giunti A.
Anterior extraoral surgery to the upper cervical spine. Spine 1996;21:
1687-93.
[10] McAfee PC, Bohlman HH, Riley LH, Robinson RA, Southwick WO,
Nachlas NE. The anterior retropharyngeal approach to the upper part of
the cervical spine. J Bone Joint Surg Am 1987;69A:1371-83.
[11] McCormick PC. Surgical management of dumbbell tumors of the
cervical spine. Neurosurgery 1996;38:294-300.
[12] Mühlbauer M, Knosp E. The lateral transfacetal retrovascular approach
for an anteriorly located chordoma originating from the second cervical
vertebra. Acta Neurochir (Wien) 2001;143:369-76.
[13] Türe U, Pamir MN. Extreme lateral-transatlas approach for resection of
the dens of the axis. J Neurosurg 2002;96(2 Suppl):73-82.
[14] Türe U, Ozek M, Pamir MN. Lateral approach for resection of the C3
corpus: technical case report. Neurosurgery 2003;52:977-81.
[15] Verbiest JH. A lateral approach to the cervical spine: technique and
indications. J Neurosurg 1968;28:191-203.
[16] Weatherley CR, Jaffray D, O'Brien JP. Radical excision of an
osteoblastoma of the cervical spine. A combined anterior and posterior
approach. J Bone Joint Surg Br 1986;68:325-8.
[17] Whitesides Jr TE, Kelly RP. Lateral approach to the upper cervical
spine for anterior fusion. South Med J 1966;59:879-83.
Commentary
Chordomas in the high cervical region are difficult to
manage from a resection point of view. The authors have
correctly highlighted the need for several approaches to
excise the lesion and provide for stability. The vertebral
artery is always a major factor in the resection and may
sometimes have to be sacrificed.
Arnold H. Menezes, MD
Department of Neurosurgery
University of Iowa Hospital
Iowa City, IA 52242, USA