Cervical chordoma: Report of a case and the technique of transoral removal

Abstract

SUMMARYA case of cervical chordoma in a man of 27 years is described. The clinical features were of progressive spinal cord compression. Treatment was by transoral decompression of the second cervical vertebra and postoperative radiotherapy. The result was favourable and remained so at follow-up after 27 months. The relative merits and scope of the various approaches to the upper cervical vertebrae and the role of radiotherapy and chemotherapy are discussed. CHORDOMA is a rare tumour of the axial skeleton whose clinical features bring it within the scope of the ophthalmologist, otolaryngologist, neurosurgeon, orthopaedic surgeon and general surgeon.Since its identification in 1856 by Luschka, about 1000 cases have been reported and about 10-15 new cases are described each year. The most comprehensive recent review (Utne and Pugh, 1955) covers 505 cases from the world literature and 72 cases from the Mayo Clinic.Clinical features Statistically, chordoma accounts for 5 per cent of all benign bone tumours (Coley, 1960), less than 2 per cent of all nasopharyngeal tumours (Osborn, 1975) and less than 1 per cent of all central nervous system neoplasms (Poppen and King, 1952). The origin of a chordoma is from the notochord or its remnants (Wright, 1967).Any age group may be affected, though the peak incidence is in middle age. The sex distribution is not clear-cut, the series varying in their results. Most chordomas affect the craniocervical or the sacrococcygeal regions.The pathology and histology have been well described by Steegman (1971) and the ultrastructure by Gessaga et al. (1973). Metastasis is rare in head and neck chordoma but it may be local to lymph nodes or within the central nervous system (Holzner, 1954). Histology shows malignant features, but these correlate poorly with clinical behaviour.The diagnosis depends on radiological and histological findings. The clinical picture is one of a local space-occupying lesion arising in bone, usually without local or distant metastasis. Systemic features are undiagnostic, though lassitude and weight loss are fairly frequent. The results of haematological, serological and biochemical investigations are usually normal. There are no specific radiological changes that differentiate a chordoma from other bone tumours. Plain radiography with tomography and contrast studies are of great benefit in defining spread and involvement. Angiography is useful in that it not only excludes other pathological conditions, but also gives some indication as to the vascularity of the tumour.A biopsy may be a prelude to or accompany definitive surgery. Much has been made of the difficulty in diagnosis (Higinbotham et al., 1967), but given a good specimen, the features are unmistakable. TreatmentIncreasing optimism has been shown concerning the role of radiotherapy (Rosenqvist and Saltnan, 1959;Windeyer, 1959) as operation alone has proved inadequate. The latest reviews (Pearlman and Friedman, 1970; Pearlman et a]., 1972; Phillips and Newman, 1974) suggest that a combination of radical op...

Transoral operations for craniospinal malformations

“…We cannot report over experiences with prophylactic antibiotics which are recommended by several authors [17,24,49,65]. According to general experience the value of these measures is controversial with operations in the oral and pharyngeal cavity.…”

“…Other authors [12,65] regard a single layered closure as sufficient. In our opinion a loose single layered closure is preferable because the wound secretions will be able to drain more easily.…”

“…According to general experience the value of these measures is controversial with operations in the oral and pharyngeal cavity. The recommendations about alimentary abstinence after transoral operation vary from five [37] to ten [65] days. According to our experience it is possible to start oral nutrition with liquid food some days after the operation.…”

“…Preoperative tracheotomy [4,5,10,12,19,24,27,35,37,40,43,45,59,61] competes with oral intubation [12,58,64], incision of the soft palate [2,4,10,24,35,37,46,61] with blunt retraction of the soft palate [12,17,22,43,45,58], a multilayered suture technique of the pharyngeal wall [4,17,24,37,64] with a single layered suture [12,65]. Only some authors recommend prophylactic antibiotics [17,24,25,49,65]. Also the question remains open, after which time a complete oral nutrition becomes possible [4,22,35,38,63].…”

“…Originally the approach was used in treatment of infections of the upper cervical spine [19,49,63]. Up to now numerous communications exist, which recommend this approach for the treatment of basilar aneurysms [15,16,31,32,39,47,50,51,52,64,69,70], ventrally situated craniospinal tumours [2,5,9,10,25,27,36,38,42,43,44,46,53,57,61,64,65,68], and for the fusion or resection of fractured parts in craniospinal traumatic lesions [4,10,17,18,19,22,24,29,30,33,34,40,46,58,62,64]. This approach also allows a direct treatment of...…”