Background Chordomas are rare infiltrative neoplasms arising from remnants of the notochord
and are predominantly located in the sacrum or clivus, whereas only 6% are located
in the cervical spine. Surgical resection is the mainstay of treatment; however, tumor
location and access often prove challenging, especially when attempting gross total
resection. Due to limited visualization, a traditional approach often requires mandibulotomy,
palatotomy, or glossotomy which introduce significant morbidity to the patient. Here,
we present the first case in which transoral robotic surgery (TORS) was utilized for
the resection of a midline C2 chordoma.
Case Report The patient is a 27-year-old man with incidentally discovered chordoma located in
the midline C2 spine. The mass was noted to be small and did not involve critical
surrounding structures on imaging; therefore, our goal was to obtain cure through
en bloc resection with negative margins. Anterior approach preceded by posterior laminectomy
was performed via TORS technique with assistance from image guidance technology to
obtain exposure through the mouth. After gross total resection, reconstruction was
performed with anterior and posterior spinal fusion with hardware and iliac spine
bone graft. Temporary tracheostomy was performed and feeding tube placed. Closure
achieved with local tissue myofascial advancement.
Conclusion Tumors of the axial spine are associated with perceived higher operative difficulty
due to the complex anatomy of the upper cervical spine and restricted access. Amount
of tumor resection is one of the most important prognostic factors affecting patient
outcomes. TORS has been utilized extensively for access to the oropharynx due to superior
visualization and maneuverability, primarily for resecting malignancy but also for
benign disease. En bloc resection of a chordoma is limited by invasion of surrounding
critical structures and by issues with access. By employing TORS approach, we overcame
limitations due to access without introducing morbidity from traditional approaches.
In this case, we avoided the need for mandibulotomy, palatotomy, and glossotomy. We
advocate for the use of TORS for approach to the midline cervical spine and encourage
providers to consider utilizing this technique.
