Detailing long-term functional morbidity after resecting mobile spine chordomas across 35 patients

Surgery for mobile spine chordomas poses a challenge as en bloc resection often requires nerve root resection. Decision-making is challenging for patients because of this inherent high risk of postoperative deficits, and data demonstrating long-term postoperative functional outcomes are lacking. Here, the authors aimed to show the postoperative functional morbidity of a large series of patients with mobile spine chordomas and detail what was achieved intraoperatively and what nerve root(s) were deemed appropriate for sacrifice in each case.

A retrospective analysis was conducted of all patients who underwent follow-up for mobile spine chordomas at a quaternary spinal oncology center from 2008 to 2023. Data including intraoperative nerve sacrifices, adjuvant treatments, and functional outcomes at last follow-up were collected. Primary outcomes were neck/back pain and all-cause motor weakness and sensory deficits at last follow-up, while secondary outcomes were overall survival and local recurrence.

Thirty-five patients were included in this cohort with a median follow-up of 5.4 (IQR 4.9-9.0) years. Resections were Enneking appropriate (EA) in 23 (65.7%) of the 35 patients, with 13 cases involving nerve root sacrifice. Three of the 12 Enneking inappropriate (EI) cases also had nerve root sacrifice. The proportion of patients with long-term postoperative weakness was similar between patients receiving EA and those receiving EI resection (47.8% vs 41.7%, p > 0.99) as were the rates of nerve root sacrifice (56.5% vs 25.0%, p = 0.152). Notably, 36.8% of patients with no nerve root sacrifice developed unplanned long-term weakness, which highlights how causes of long-term weakness are multifactorial. Nerve root sacrifice was more common in the thoracic spine than cervical or lumbar spine, and lesions in areas of the subaxial cervical and lumbar spines with functional nerve roots did receive surgeries with fewer nerve root sacrifices. At the time of census, 7 (20.0%) patients had died and 14 (40.0%) experienced recurrence.

Surgeons must consider the costs and benefits of sacrificing nerve roots to achieve en bloc resection for mobile spine chordomas. Here, the authors catalog a series of mobile spine chordoma resections to help illustrate what is considered acceptable functional morbidity to achieve en bloc results at a large quaternary referral center. They demonstrate that EA surgery is not associated with higher rates of motor weakness and has rates of nerve root sacrifice that are similar to those of to EI surgery.