Novel Approach Using Transoral Robotic Surgery for Resection of Cervical Spine Chordoma

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.