Suboccipital and cervical chordomas: radical resection with vertebral artery control

Radical resection of chordomas seems to improve a patient's long-term prognosis. At the suboccipital and cervical levels, the vertebral artery (VA) is often considered as a limit in surgical possibilities. The authors report on the management of the VA in a series of 36 patients with chordomas located in the cervical region.

Over an 11-year period, 36 patients with chordomas located at the suboccipital (28 patients) or cervical (eight patients) level were treated in the authors' neurosurgical department. In 30 patients, the tumors extended laterally toward the VA and required surgical control of the VA. Sixteen of these 30 patients harbored primary tumor, whereas 14 were treated for recurrent disease. The VA was encased in the tumor in 23 patients, with stenosis in six cases. A balloon occlusion test was performed in seven patients and the VA was resected in four. Extensive resection, via a lateral approach on one (22 cases) or on both (eight cases) sides, did not cause any permanent postoperative deficits. In five patients a complementary approach was performed: posterolateral in one and transoral in four. Spinal fixation was performed via the lateral approach (eight cases) or via a complementary posterior approach (five cases). All but two patients underwent radiotherapy, including 10 who underwent proton-beam radiotherapy.

Chordomas extending laterally to the VA can be radically resected via a lateral approach without causing significant morbidity. A complementary approach is often necessary. The best results are achieved in patients with primary compared with recurrent tumor.