OPERATIVE TECHNIQUE
En Bloc Resection of Upper Thoracic Chordoma via a Combined Simultaneous Anterolateral Thoracoscopic and Posterior Approach Mark E. Oppenlander, MD*‡ Christopher M. Maulucci, MD* George M. Ghobrial, MD* Nathaniel R. Evans III, MD§ James S. Harrop, MD* Srinivas K. Prasad, MD* *Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; ‡Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, Arizona; §Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Correspondence: Mark E. Oppenlander, MD, Barrow Neurological Institute, 350 W. Thomas Road, Phoenix AZ 85013. E-mail: [email protected] Received, December 13, 2013. Accepted, March 30, 2014. Published Online, April 15, 2014. Copyright © 2014 by the Congress of Neurological Surgeons.
BACKGROUND: En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved. OBJECTIVE: To show the feasibility, safety, and utility of performing a thoracoscopyassisted en bloc resection of a chordoma involving the upper thoracic spine. METHODS: A case study is presented of a patient with biopsy-proven chordoma of T2-3 with predominantly paravertebral involvement who underwent multilevel en bloc resection via a simultaneous combined anterolateral thoracoscopic and posterior approach. Thoracoscopic assistance achieved separation of the tumor and ventral spine from the adjacent mediastinal structures. En bloc resection proceeded without complication. The spine was stabilized with posterior instrumentation. RESULTS: A multilevel en bloc resection was achieved with negative margins, preserving more than half of the remaining vertebral bodies and allowing short segment posterior fixation without extension into the cervical spine. The patient remained neurologically intact. CONCLUSION: A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach. KEY WORDS: Chordoma, En bloc resection, Simultaneous anterior-posterior approach, Spine, Thoracoscopic Operative Neurosurgery 10:380–386, 2014
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hordomas are rare tumors affecting approximately 1 per million people annually.1-3 Chordomas in the mobile spine account for 15% of these tumors and are believed to arise from notochordal rest cells in the vertebral body.3-5 En bloc resection of chordomas has been associated with prolonged patient overall survival and progression-free survival, 6,7 and numerous reports have outlined strategies for achieving
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DOI: 10.1227/NEU.0000000000000368
en bloc resection.8-11 Depending on the location and extent of tumor involvement, innovative strategies for achieving en bloc resection, while minimizing surgical morbidity, may be necessary. The authors describe herein a combined simultaneous thoracoscopic and posterior approach for en bloc resection of an upper thoracic chordoma. This case of a T2-3 chordoma with predominantly paravertebral involvement was amenable to the combined approach. The described technique was found to be effective in achieving en bloc tumor resection, while increasing the safety of the osteotomies and minimizing the morbidity of a transthoracic approach.
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THORACOSCOPIC-ASSISTED CHORDOMA RESECTION
FIGURE 1. Preoperative magnetic resonance imaging. T2 sagittal (A), T1 axial pre-contrast (B), and post-contrast (C) images reveal a left paravertebral mass at T2 and T3 that is T2-hyperintense and with mild enhancement.
CASE REPORT AND SURGICAL TECHNIQUE Clinical Presentation A 51-year-old man with no medical history underwent cervical magnetic resonance imaging performed by his primary care physician as part of a workup for neck pain but no neurological deficit. This led to the discovery of a left paravertebral tumor adjacent to T2 and T3. Magnetic resonance imaging showed the mass to be T2 hyperintense, with mild enhancement on T1-weighted sequences (Figure 1). A computed tomography (CT) scan revealed relative preservation of bony architecture (Figure 2). CT-guided biopsy was performed, and the specimen was examined by 2 different pathology labs,
confirming a histopathological diagnosis of chordoma. The patient underwent a fluorine-18-fluorodeoxyglucose positron emission tomography scan, which ruled out systemic disease. The chordoma was Enneking grade 1B.12 The case was presented at a multidisciplinary conference that included the spinal surgeons, medical and radiation oncologists, radiologists, and a pathologist. The consensus of the meeting was to attempt en bloc resection of the tumor. Because there was no appreciable osseous disruption on CT imaging, this was thought to represent an extraskeletal chordoma, although its adjacency to the spine mandated at least partial vertebrectomy. Total en bloc spondylectomy was thought to require
FIGURE 2. Preoperative coronal (A) and axial (B) computed tomography scan shows relative preservation of bony architecture despite a paravertebral mass extending rostrally to the level of the left T2 pedicle and caudally to the midbody of T3.
OPERATIVE NEUROSURGERY
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FIGURE 3. Patient positioning for the combined simultaneous thoracoscopic and posterior approach to the T2-3 chordoma. A, the patient is prone on a Jackson table with Mayfield pin fixation. Note the left arm supported in a sling outside of the Jackson table, allowing for the left thoracoscopic approach. B, position after preparation and draping.
more definitive stabilization from the midcervical spine to the lower thoracic spine, distal to the thoracic apex. Because of the upper thoracic location and unilateral paraspinal involvement, a combined simultaneous anterolateral thoracoscopic and posterior approach was chosen for en bloc resection with partial vertebrectomy and short-segment stabilization (see Video, Supplemental Digital Content, demonstrating dissection of a plane between the tumor and mediastinum, protection of the esophagus and great vessels during osteotomies, and en bloc resection of the tumor http://links.lww.com/NEU/A654). Surgical Procedure After general anesthesia was induced, the patient was intubated with a double-lumen endotracheal tube. Somatosensory evoked potential and motor evoked potential monitoring was established. The patient was placed prone on the Jackson table. The left arm was hung off the table in a sling to access the left midaxillary line (Figure 3). The right arm was tucked by his side. After standard preparation and draping, 3 ports were used for the thoracoscopic approach: 1 in the midaxillary line in the fourth intercostal space,
1 in the seventh intercostal space in the posterior axillary line, and 1 off the tip of the scapula. A thoracic surgeon (N.R.E.) performed the thoracoscopic approach. The chest was insufflated with 8 cm of pressure with CO2, and this exposed the lesion at the T2-3 costovertebral angle. A plane was established between the tumor and the mediastinal structures; the insufflation pressure facilitated dissection of these planes. The esophagus and left subclavian artery were visualized ventrally. The thoracic duct was not directly visualized, but its location posterior to the aortic arch and the left subclavian artery, on the left side of the esophagus, was carefully heeded. Similarly, the superior intercostal artery, a branch of the costocervical trunk supplying the upper thoracic segments, was not directly visualized. The left segmental vessels of T2 and T3 were sacrificed. The pleura was incised surrounding the lesion. A fan blade retractor was then placed over the esophagus and left subclavian artery in preparation for the osteotomies. The posterior approach was undertaken simultaneously with the patient in the prone position. A linear incision was made from the C7 level down to the T5 level. Subperiosteal dissection was
FIGURE 4. Intraoperative photographs. A, thoracoscopic visualization of osteotomy. Note the fan retractor deep to the osteotome, protecting the mediastinum. B, thoracoscopic view of the resection cavity. C, resection cavity from posterior approach. Note the lung re-expanded in the thoracic cavity, the spinal cord medially, and the image guidance used for tailoring the osteotomies.
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THORACOSCOPIC-ASSISTED CHORDOMA RESECTION
performed to elevate the paravertebral musculature off the midline structures. A registration frame was applied to the T5 spinous process, and O-Arm imaging (Medtronic, Memphis, Tennessee) was obtained to enable intraoperative navigation. On the left side, an eccentric exposure was performed exposing about 6 cm of the second and third ribs. The ribs were divided 6 cm away from midline. Left-sided hemilaminectomies at T2 and T3, including inferior T1 and superior T4 hemilaminectomies, were performed. Left facetectomies at T1-2 and T3-4 were performed. At this point, the dura of the spinal cord and the left-sided pedicles of T1-4 were visible. The left T2 and T3 nerve roots were divided, whereas the T1 nerve root was meticulously preserved. Three osteotomy cuts were made in total: 2 axial-plane cuts above and below the tumor and 1 sagittal plane cut through the midbodies of T2 and T3. A high-speed burr was used to initiate the osteotomies. Superiorly, the osteotomy began just caudal to the T1 pedicle and nerve root. Inferiorly, the osteotomy began at the superior portion of the T4 vertebral body. The sagittal-plane osteotomy was made just medial to the pedicles of T2 and T3 obliquely traversing these vertebral bodies and their adjacent intervertebral discs. The osteotomies were completed with an osteotome and mallet under direct thoracoscopic vision anteriorly (Figure 4). The fan retractor protected the esophagus and great vessels during completion of the osteotomies (Figure 5). In addition, image guidance was used periodically to ensure precise trajectories of the osteotomies without violation of the tumor capsule. After completion of the osteotomies, the T2 and T3 vertebral bodies were readily reflected off the adjacent bodies into the chest cavity. The tumor, with adjacent vertebral bodies, rib heads, and transverse processes, was removed en bloc and sent for pathological evaluation (Figure 6). Instrumentation was then applied. Pedicle screws were placed at T1 and T4 bilaterally and on the right at T2 and T3. A collagen matrix onlay was performed over the pleural defect from the posterior exposure before wound closure. The posterior wound was irrigated and closed in layers. A chest tube was placed, and the thoracoscopic ports were closed in a standard fashion. Neuromonitoring was stable throughout the procedure. The estimated blood loss was 900 mL, and the length of surgery 7 hours. Postoperative Course The patient remained neurologically intact. The chest tube was removed on postoperative day 3, and the patient was discharged to home on postoperative day 5. Pathological examination of the tumor revealed wide margins free of tumor, and imaging confirmed complete resection (Figure 7). At 6-month followup, spinal alignment was maintained based on radiographic imaging, and no local tumor recurrence or distal metastasis was identified on magnetic resonance imaging.
DISCUSSION Chordomas occur more rarely in the mobile spine compared with sacral and cranial base locations.3,5 Recurrence tends to occur
OPERATIVE NEUROSURGERY
FIGURE 5. Anatomic illustration at the T2-3 level of the left paravertebral chordoma and the sagittal-plane osteotomy. The left hemilaminectomies were performed, and the T2 nerve root was divided. The osteotomies were completed with osteotome and mallet, under direct thoracoscopic vision anteriorly. The fan retractor protected the esophagus and great vessels during completion of the osteotomies.
after subtotal or intralesional resection,2,7 and metastases have been reported in the adjacent spine, lung, and other organs.13,14 In the largest series to date of patients with chordomas of the mobile spine, Boriani et al7 found tumor recurrence after less than 2 years in all patients who underwent radiation alone, intralesional excision, or a combination of these modalities. In contrast, margin-free en bloc resection was the only treatment resulting in long-term disease-free survival (12 of 18 patients after en bloc resection continuously disease-free at average 8-year follow-up). This finding of en bloc resection portending a survival advantage has been recapitulated by multiple authors studying chordoma.2,15,16 A chordoma in the upper thoracic spine presents unique surgical challenges. Adequate anterior surgical access is often limited given the close approximation of the esophagus and great vessels. In addition, the degree of kyphosis at the upper thoracic segment may increase surgical complexity if performing posterolateral
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FIGURE 6. A, B, Gross specimen after en bloc resection.
approaches. These issues are compounded by the fact that upper thoracic chordomas appear less frequently than chordomas at other spinal segments: In the Boriani et al series of 52 mobile spine chordomas accumulated over a 50-year period, only 1 tumor was located between C6 and T9.7 A number of authors have detailed their experience with chordomas in the upper thoracic spine, thus providing a basis for treatment options through sporadic case reports.9,17-20 Historically, these lesions were reported as rare tumors in the differential diagnosis for mediastinal masses. For example, Cotler et al17 in 1983 reported the eighth case of thoracic chordoma presenting as a mediastinal tumor. A 14-year-old girl underwent thoracotomy for excision of the tumor between T2 and T4. No spinal instrumentation or arthrodesis was performed. More recently, Selvaraj20 reported on a 33-year-old woman with a bilobed paravertebral mass of the upper mediastinum. She underwent unilateral thoracotomy for excisional biopsy, then, after the pathological diagnosis of chordoma, 2 additional open transthoracic procedures for resection. In their elegant technical report of a 26-year-old woman with a T1-5 chordoma, Sciubba et al9 provided documentation of the techniques required to
perform a 5-level en bloc spondylectomy in this region. Three stages were required: posterior release and instrumentation, followed by a right and then left thoracotomy for tumor removal. Clearly, given the scant literature addressing this topic, potential exists for new strategies to achieve safe en bloc resection of upper thoracic chordomas. Although previous reports of thoracic chordomas have described both a posterior and transthoracic approach for resection,9,21 this report is the first to describe the use of thoracoscopy in a combined simultaneous approach with posterior resection. During positioning, the use of an arm sling on the Jackson table exposes the left mid-axillary line and enables the thoracoscopic procedure to proceed with the patient in the prone position, thus allowing simultaneous visualization anterolaterally and posteriorly throughout removal of the tumor. The unique characteristics of this patient’s chordoma, being unilateral and essentially paravertebral in the upper thoracic spine, permitted the described technique to be feasible and effective. A partial vertebrectomy, instead of total en bloc spondylectomy, was deemed appropriate for achieving wide margins by the authors and consulting oncologists because of the
FIGURE 7. Postoperative imaging. A, anteroposterior x-ray shows pedicle screw fixation from T1 to T4. Axial (B) and coronal (C) computed tomography images show the bony defect after tumor resection. D, magnetic resonance imaging post-contrast reveals gross total resection of the tumor.
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tumor’s extraskeletal and unilateral location. Additionally, the partial vertebrectomy allowed for shorter segmental instrumentation; a total en bloc spondylectomy would have required fixation into the cervical spine and down to the lower thoracic spine beyond the thoracic apex. Combining thoracoscopic and posterior approaches was previously described in spinal surgery for indications other than chordoma. Many of these combined approaches are in the setting of deformity surgery, with thoracoscopy allowing the surgeon to perform an anterior release before posterior fixation. This technique has been successful for underlying pathologies of neuromuscular scoliosis,22,23 adolescent idiopathic scoliosis,24,25 Scheuermann’s kyphosis,23,26 and tuberculosisinduced kyphosis.27 In addition, Cappuccio et al28 described thoracoscopy-assisted en bloc resection of a spinal tumor in 2 patients, including colon cancer metastasis at T11 and a sarcoma at T5-6. Their technique involved placing the patient in the lateral position for thoracoscopic anterior release of the tumor; this was followed by repositioning of the patient into the prone position for a posterior approach. The current technique differs in that the patient is prone throughout the procedure, allowing for simultaneous thoracoscopic and posterior approaches. The benefit of using thoracoscopy in this case was to facilitate establishment of a clear plane between the tumor and mediastinal contents. The simultaneous posterior approach was then made safer by allowing the osteotomies to proceed over a fan blade retractor instead of onto an exposed mediastinum. Additionally, using thoracoscopy for the anterior portion of this procedure potentially resulted in less morbidity compared with a thoracotomy approach. Accordingly, previous reports suggest less blood loss and shorter hospital stay when a thoracoscopic approach is used instead of thoracotomy, as well as reduced pain, size of incision, and dissection of the chest wall.29,30 Although this report has limited long-term patient follow-up, its aim is to describe a combined thoracoscopic and posterior approach for en bloc resection of a rare tumor in a rare location. This case involved a unilaterally exophytic chordoma, but it is feasible for the technique described herein to be expanded to bilateral thoracoscopic assistance for thoracic tumors with bilateral paravertebral involvement. In the case of an extensive multilevel en bloc spondylectomy, however, the specimen may require removal from an open anterolateral approach to avoid manipulation of the spinal cord posteriorly. Further experience is required to establish the indications, efficacy, and long-term outcomes of patients undergoing thoracoscopy-assisted combined approaches for select thoracic pathologies.
CONCLUSION A combined simultaneous thoracoscopic and posterior approach appears to be safe and effective for en bloc resection of a multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the
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tumor and the mediastinum, thus assisting with safe osteotomies from the posterior direction. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Boriani S, Chevalley F, Weinstein JN, et al. Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases. Spine (Phila Pa 1976). 1996;21(13): 1569-1577. 2. Bergh P, Kindblom LG, Gunterberg B, Remotti F, Ryd W, Meis-Kindblom JM. Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Cancer. 2000;88(9):2122-2134. 3. Mindell ER. Chordoma. J Bone Joint Surg Am. 1981;63(3):501-505. 4. Dahlin DC, Maccarty CS. Chordoma. Cancer. 1952;5(6):1170-1178. 5. Bjornsson J, Wold LE, Ebersold MJ, Laws ER. Chordoma of the mobile spine. A clinicopathologic analysis of 40 patients. Cancer. 1993;71(3):735-740. 6. Schwab JH, Healey JH, Rose P, Casas-Ganem J, Boland PJ. The surgical management of sacral chordomas. Spine (Phila Pa 1976). 2009;34(24): 2700-2704. 7. Boriani S, Bandiera S, Biagini R, et al. Chordoma of the mobile spine: fifty years of experience. Spine (Phila Pa 1976). 2006;31(4):493-503. 8. Clarke MJ, Hsu W, Suk I, et al. Three-level en bloc spondylectomy for chordoma. Neurosurgery. 2011;68(2 suppl operative):ons325-ons333. 9. Sciubba DM, Gokaslan ZL, Black JH III, et al. 5-level spondylectomy for en bloc resection of thoracic chordoma. Neurosurgery. 2011;69(2 suppl operative): onsE248-onsE255. 10. Hsieh PC, Gallia GL, Sciubba DM, et al. En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up. Spine (Phila Pa 1976). 2011;36(24):E1581-E1587. 11. Currier BL, Papagelopoulos PJ, Krauss WE, Unni KK, Yaszemski MJ. Total en bloc spondylectomy of C5 vertebra for chordoma. Spine (Phila Pa 1976). 2007;32 (9):E294-E299. 12. Enneking WF, Spanier SS, Goodman MA. A System for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 1980;153:106-120. 13. Sundaresan N, Huvos AG, Krol G, Lane JM, Brennan M. Surgical treatment of spinal chordomas. Arch Surg. 1987;122(12):1479-1482. 14. Chambers PW, Schwinn CP. Chordoma. A clinicopathologic study of metastasis. Am J Clin Pathol. 1979;72(5):765-776. 15. Hsu KY, Zucherman JF, Mortensen N, Johnston JO, Gartland J. Follow-up evaluation of resected lumbar vertebral chordoma over 11 years: a case report. Spine (Phila Pa 1976). 2000;25(19):2537-2540. 16. Sundaresan N, Steinberger AA, Moore F, et al. Indications and results of combined anterior-posterior approaches for spine tumor surgery. J Neurosurg. 1996;85(3): 438-446. 17. Cotler HB, Cotler JM, Cohn HE, Israel HI, Gartland JJ. Intrathoracic chordoma presenting as a posterior superior mediastinal tumor. Spine (Phila Pa 1976). 1983; 8(7):781-786. 18. Levowitz BS, Khan MY, Rand E, Hurwitz A. Thoracic vertebral chordoma presenting as a posterior mediastinal tumor. Ann Thorac Surg. 1966;2(1): 75-81. 19. Crowe GG, Muldoon PB. Thoracic chordoma. Thorax. 1951;6(4):403-407. 20. Selvaraj A. Superior mediastinal chordoma presenting as a bilobed paravertebral mass. Eur J Cardiothorac Surg. 2003;23(2):248-250. 21. Gregorius FK, Batzdorf U. Removal of thoracic chordoma by staged laminectomy and thoracotomy: a case report. Am Surg. 1977;43(9):631-634. 22. Newton PO, White KK, Faro F, Gaynor T. The success of thoracoscopic anterior fusion in a consecutive series of 112 pediatric spinal deformity cases. Spine (Phila Pa 1976). 2005;30(4):392-398. 23. Arlet V. Anterior thoracoscopic spine release in deformity surgery: a meta-analysis and review. Eur Spine J. 2000;9(suppl 1):S17-S23. 24. Norton RP, Patel D, Kurd MF, Picetti GD, Vaccaro AR. The use of thoracoscopy in the management of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2007; 32(24):2777-2785.
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25. Son-Hing JP, Blakemore LC, Poe-Kochert C, Thompson GH. Video-assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve. Spine (Phila Pa 1976). 2007;32(6):703-707. 26. Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, Crawford AH. Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann’s kyphosis. Spine (Phila Pa 1976). 2005;30 (19):2176-2181. 27. Zheng C, Li P, Kan W. Video-assisted thoracoscopic anterior surgery combined posterior instrumentation for children with spinal tuberculosis. Eur J Pediatr Surg. 2014;24(1):83-87. 28. Cappuccio M, Gasbarrini A, Donthineni R, Beisse R, Boriani S. Thoracoscopic assisted en bloc resection of a spine tumor. Eur Spine J. 2011;20(suppl 2):202-205. 29. Oppenlander ME, Clark JC, Kalyvas J, Dickman CA. Surgical management and clinical outcomes of multiple-level symptomatic herniated thoracic discs. J Neurosurg Spine. 2013;19(6):774-783. 30. Han PP, Kenny K, Dickman CA. Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures. Neurosurgery. 2002;51(suppl 5): S88-S95.
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COMMENTS
T
his is a very interesting article with good illustrations of a multidisciplinary approach with a thoracoscopy-assisted posterior en bloc resection of a chordoma. The authors use high-quality video and schematic illustrations to demonstrate the procedure well. Daniel Refai Atlanta, Georgia
T
he authors present a case of a laterally exophytic chordoma at T2-3 treated with a simultaneous, combined anterolateral thoracoscopic and open posterior approach for en bloc resection. Details of the technique are described in the text and illustrated with figures and video of the thoracoscopic technique. In essence, the thoracoscopic approach was used to free the tumor from adjacent mediastinal visceral and vascular structures and to protect these structures during the osteotomies. The open posterior approach was used for the laminectomy, nerve root ligation, osteotomies,
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and spinal stabilization. The authors are to be congratulated for using a well-planned, multidisciplinary surgical approach to manage a rare tumor in a challenging location. Using their technique, they were able to achieve a safe, oncologically appropriate resection, while avoiding the potential additional morbidity of an open transthoracic approach. Although it is true that combined thoracoscopic and open approaches have been previously reported in spinal surgery for both deformity and tumor, this is the first report of a tumor resection using these 2 approaches simultaneously in the prone position. The authors appropriately indicate that this tumor was particularly amenable to this type of strategy given its relatively small size and lateral exophytic location. Application of these combined techniques to larger tumors with greater vertebral involvement or more significant paraspinal extension will need to be approached cautiously given the significant negative consequences of tumor violation during surgery. The value of using minimally invasive approaches in the management of primary spinal tumors will clearly need further evaluation with longer follow-up. Not only will the advantage of these approaches need to be documented in terms of decreased morbidity and improved long-term function, but they must achieve local control similar to that with traditional open approaches. Efforts to reduce the morbidity of these large en bloc resections with less invasive surgical techniques, as the authors have demonstrated, are laudable. Laurence Rhines Houston, Texas
C
ombining thoracoscopic surgery with open approaches has been previously described for spine tumors; however, I believe this is the first report of their simultaneous use with the patient in the prone position. The authors have shown a great example of what can be accomplished when surgery is well planned with multidisciplinary input. It is highly satisfactory when minimally invasive techniques can be used to accomplish the same goals as an entirely open procedure. However, the versatility of this technique remains to be seen. I think this worked for this particular case because the tumor was relatively small and lateral in location. Daryl Fourney Saskatoon, Saskatchewan, Canada
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En Bloc Resection of Upper Thoracic Chordoma via a Combined Simultaneous Anterolateral Thoracoscopic and Posterior Approach Mark E. Oppenlander, MD*‡ Christopher M. Maulucci, MD* George M. Ghobrial, MD* Nathaniel R. Evans III, MD§ James S. Harrop, MD* Srinivas K. Prasad, MD* *Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; ‡Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph Hospital and Medical Center, Phoenix, Arizona; §Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania Correspondence: Mark E. Oppenlander, MD, Barrow Neurological Institute, 350 W. Thomas Road, Phoenix AZ 85013. E-mail: [email protected] Received, December 13, 2013. Accepted, March 30, 2014. Published Online, April 15, 2014. Copyright © 2014 by the Congress of Neurological Surgeons.
BACKGROUND: En bloc resection of chordomas is associated with increased patient survival. Achievement of en bloc resection, however, may present a great surgical challenge, particularly in the mobile spine. Novel multidisciplinary techniques may enable en bloc resection of lesions presenting in anatomically challenging locations. A combined simultaneous thoracoscopic and posterior approach in a patient with an upper thoracic chordoma is presented; en bloc resection was achieved. OBJECTIVE: To show the feasibility, safety, and utility of performing a thoracoscopyassisted en bloc resection of a chordoma involving the upper thoracic spine. METHODS: A case study is presented of a patient with biopsy-proven chordoma of T2-3 with predominantly paravertebral involvement who underwent multilevel en bloc resection via a simultaneous combined anterolateral thoracoscopic and posterior approach. Thoracoscopic assistance achieved separation of the tumor and ventral spine from the adjacent mediastinal structures. En bloc resection proceeded without complication. The spine was stabilized with posterior instrumentation. RESULTS: A multilevel en bloc resection was achieved with negative margins, preserving more than half of the remaining vertebral bodies and allowing short segment posterior fixation without extension into the cervical spine. The patient remained neurologically intact. CONCLUSION: A combined simultaneous thoracoscopic and posterior approach is safe and effective for en bloc resection of multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the tumor and the mediastinum, thus assisting with safe osteotomies via the posterior approach. KEY WORDS: Chordoma, En bloc resection, Simultaneous anterior-posterior approach, Spine, Thoracoscopic Operative Neurosurgery 10:380–386, 2014
C WHAT IS THIS BOX? A QR Code is a matrix barcode readable by QR scanners, mobile phones with cameras, and smartphones. The QR Code above links to Supplemental Digital Content from this article.
hordomas are rare tumors affecting approximately 1 per million people annually.1-3 Chordomas in the mobile spine account for 15% of these tumors and are believed to arise from notochordal rest cells in the vertebral body.3-5 En bloc resection of chordomas has been associated with prolonged patient overall survival and progression-free survival, 6,7 and numerous reports have outlined strategies for achieving
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.neurosurgery-online.com).
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DOI: 10.1227/NEU.0000000000000368
en bloc resection.8-11 Depending on the location and extent of tumor involvement, innovative strategies for achieving en bloc resection, while minimizing surgical morbidity, may be necessary. The authors describe herein a combined simultaneous thoracoscopic and posterior approach for en bloc resection of an upper thoracic chordoma. This case of a T2-3 chordoma with predominantly paravertebral involvement was amenable to the combined approach. The described technique was found to be effective in achieving en bloc tumor resection, while increasing the safety of the osteotomies and minimizing the morbidity of a transthoracic approach.
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FIGURE 1. Preoperative magnetic resonance imaging. T2 sagittal (A), T1 axial pre-contrast (B), and post-contrast (C) images reveal a left paravertebral mass at T2 and T3 that is T2-hyperintense and with mild enhancement.
CASE REPORT AND SURGICAL TECHNIQUE Clinical Presentation A 51-year-old man with no medical history underwent cervical magnetic resonance imaging performed by his primary care physician as part of a workup for neck pain but no neurological deficit. This led to the discovery of a left paravertebral tumor adjacent to T2 and T3. Magnetic resonance imaging showed the mass to be T2 hyperintense, with mild enhancement on T1-weighted sequences (Figure 1). A computed tomography (CT) scan revealed relative preservation of bony architecture (Figure 2). CT-guided biopsy was performed, and the specimen was examined by 2 different pathology labs,
confirming a histopathological diagnosis of chordoma. The patient underwent a fluorine-18-fluorodeoxyglucose positron emission tomography scan, which ruled out systemic disease. The chordoma was Enneking grade 1B.12 The case was presented at a multidisciplinary conference that included the spinal surgeons, medical and radiation oncologists, radiologists, and a pathologist. The consensus of the meeting was to attempt en bloc resection of the tumor. Because there was no appreciable osseous disruption on CT imaging, this was thought to represent an extraskeletal chordoma, although its adjacency to the spine mandated at least partial vertebrectomy. Total en bloc spondylectomy was thought to require
FIGURE 2. Preoperative coronal (A) and axial (B) computed tomography scan shows relative preservation of bony architecture despite a paravertebral mass extending rostrally to the level of the left T2 pedicle and caudally to the midbody of T3.
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FIGURE 3. Patient positioning for the combined simultaneous thoracoscopic and posterior approach to the T2-3 chordoma. A, the patient is prone on a Jackson table with Mayfield pin fixation. Note the left arm supported in a sling outside of the Jackson table, allowing for the left thoracoscopic approach. B, position after preparation and draping.
more definitive stabilization from the midcervical spine to the lower thoracic spine, distal to the thoracic apex. Because of the upper thoracic location and unilateral paraspinal involvement, a combined simultaneous anterolateral thoracoscopic and posterior approach was chosen for en bloc resection with partial vertebrectomy and short-segment stabilization (see Video, Supplemental Digital Content, demonstrating dissection of a plane between the tumor and mediastinum, protection of the esophagus and great vessels during osteotomies, and en bloc resection of the tumor http://links.lww.com/NEU/A654). Surgical Procedure After general anesthesia was induced, the patient was intubated with a double-lumen endotracheal tube. Somatosensory evoked potential and motor evoked potential monitoring was established. The patient was placed prone on the Jackson table. The left arm was hung off the table in a sling to access the left midaxillary line (Figure 3). The right arm was tucked by his side. After standard preparation and draping, 3 ports were used for the thoracoscopic approach: 1 in the midaxillary line in the fourth intercostal space,
1 in the seventh intercostal space in the posterior axillary line, and 1 off the tip of the scapula. A thoracic surgeon (N.R.E.) performed the thoracoscopic approach. The chest was insufflated with 8 cm of pressure with CO2, and this exposed the lesion at the T2-3 costovertebral angle. A plane was established between the tumor and the mediastinal structures; the insufflation pressure facilitated dissection of these planes. The esophagus and left subclavian artery were visualized ventrally. The thoracic duct was not directly visualized, but its location posterior to the aortic arch and the left subclavian artery, on the left side of the esophagus, was carefully heeded. Similarly, the superior intercostal artery, a branch of the costocervical trunk supplying the upper thoracic segments, was not directly visualized. The left segmental vessels of T2 and T3 were sacrificed. The pleura was incised surrounding the lesion. A fan blade retractor was then placed over the esophagus and left subclavian artery in preparation for the osteotomies. The posterior approach was undertaken simultaneously with the patient in the prone position. A linear incision was made from the C7 level down to the T5 level. Subperiosteal dissection was
FIGURE 4. Intraoperative photographs. A, thoracoscopic visualization of osteotomy. Note the fan retractor deep to the osteotome, protecting the mediastinum. B, thoracoscopic view of the resection cavity. C, resection cavity from posterior approach. Note the lung re-expanded in the thoracic cavity, the spinal cord medially, and the image guidance used for tailoring the osteotomies.
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performed to elevate the paravertebral musculature off the midline structures. A registration frame was applied to the T5 spinous process, and O-Arm imaging (Medtronic, Memphis, Tennessee) was obtained to enable intraoperative navigation. On the left side, an eccentric exposure was performed exposing about 6 cm of the second and third ribs. The ribs were divided 6 cm away from midline. Left-sided hemilaminectomies at T2 and T3, including inferior T1 and superior T4 hemilaminectomies, were performed. Left facetectomies at T1-2 and T3-4 were performed. At this point, the dura of the spinal cord and the left-sided pedicles of T1-4 were visible. The left T2 and T3 nerve roots were divided, whereas the T1 nerve root was meticulously preserved. Three osteotomy cuts were made in total: 2 axial-plane cuts above and below the tumor and 1 sagittal plane cut through the midbodies of T2 and T3. A high-speed burr was used to initiate the osteotomies. Superiorly, the osteotomy began just caudal to the T1 pedicle and nerve root. Inferiorly, the osteotomy began at the superior portion of the T4 vertebral body. The sagittal-plane osteotomy was made just medial to the pedicles of T2 and T3 obliquely traversing these vertebral bodies and their adjacent intervertebral discs. The osteotomies were completed with an osteotome and mallet under direct thoracoscopic vision anteriorly (Figure 4). The fan retractor protected the esophagus and great vessels during completion of the osteotomies (Figure 5). In addition, image guidance was used periodically to ensure precise trajectories of the osteotomies without violation of the tumor capsule. After completion of the osteotomies, the T2 and T3 vertebral bodies were readily reflected off the adjacent bodies into the chest cavity. The tumor, with adjacent vertebral bodies, rib heads, and transverse processes, was removed en bloc and sent for pathological evaluation (Figure 6). Instrumentation was then applied. Pedicle screws were placed at T1 and T4 bilaterally and on the right at T2 and T3. A collagen matrix onlay was performed over the pleural defect from the posterior exposure before wound closure. The posterior wound was irrigated and closed in layers. A chest tube was placed, and the thoracoscopic ports were closed in a standard fashion. Neuromonitoring was stable throughout the procedure. The estimated blood loss was 900 mL, and the length of surgery 7 hours. Postoperative Course The patient remained neurologically intact. The chest tube was removed on postoperative day 3, and the patient was discharged to home on postoperative day 5. Pathological examination of the tumor revealed wide margins free of tumor, and imaging confirmed complete resection (Figure 7). At 6-month followup, spinal alignment was maintained based on radiographic imaging, and no local tumor recurrence or distal metastasis was identified on magnetic resonance imaging.
DISCUSSION Chordomas occur more rarely in the mobile spine compared with sacral and cranial base locations.3,5 Recurrence tends to occur
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FIGURE 5. Anatomic illustration at the T2-3 level of the left paravertebral chordoma and the sagittal-plane osteotomy. The left hemilaminectomies were performed, and the T2 nerve root was divided. The osteotomies were completed with osteotome and mallet, under direct thoracoscopic vision anteriorly. The fan retractor protected the esophagus and great vessels during completion of the osteotomies.
after subtotal or intralesional resection,2,7 and metastases have been reported in the adjacent spine, lung, and other organs.13,14 In the largest series to date of patients with chordomas of the mobile spine, Boriani et al7 found tumor recurrence after less than 2 years in all patients who underwent radiation alone, intralesional excision, or a combination of these modalities. In contrast, margin-free en bloc resection was the only treatment resulting in long-term disease-free survival (12 of 18 patients after en bloc resection continuously disease-free at average 8-year follow-up). This finding of en bloc resection portending a survival advantage has been recapitulated by multiple authors studying chordoma.2,15,16 A chordoma in the upper thoracic spine presents unique surgical challenges. Adequate anterior surgical access is often limited given the close approximation of the esophagus and great vessels. In addition, the degree of kyphosis at the upper thoracic segment may increase surgical complexity if performing posterolateral
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FIGURE 6. A, B, Gross specimen after en bloc resection.
approaches. These issues are compounded by the fact that upper thoracic chordomas appear less frequently than chordomas at other spinal segments: In the Boriani et al series of 52 mobile spine chordomas accumulated over a 50-year period, only 1 tumor was located between C6 and T9.7 A number of authors have detailed their experience with chordomas in the upper thoracic spine, thus providing a basis for treatment options through sporadic case reports.9,17-20 Historically, these lesions were reported as rare tumors in the differential diagnosis for mediastinal masses. For example, Cotler et al17 in 1983 reported the eighth case of thoracic chordoma presenting as a mediastinal tumor. A 14-year-old girl underwent thoracotomy for excision of the tumor between T2 and T4. No spinal instrumentation or arthrodesis was performed. More recently, Selvaraj20 reported on a 33-year-old woman with a bilobed paravertebral mass of the upper mediastinum. She underwent unilateral thoracotomy for excisional biopsy, then, after the pathological diagnosis of chordoma, 2 additional open transthoracic procedures for resection. In their elegant technical report of a 26-year-old woman with a T1-5 chordoma, Sciubba et al9 provided documentation of the techniques required to
perform a 5-level en bloc spondylectomy in this region. Three stages were required: posterior release and instrumentation, followed by a right and then left thoracotomy for tumor removal. Clearly, given the scant literature addressing this topic, potential exists for new strategies to achieve safe en bloc resection of upper thoracic chordomas. Although previous reports of thoracic chordomas have described both a posterior and transthoracic approach for resection,9,21 this report is the first to describe the use of thoracoscopy in a combined simultaneous approach with posterior resection. During positioning, the use of an arm sling on the Jackson table exposes the left mid-axillary line and enables the thoracoscopic procedure to proceed with the patient in the prone position, thus allowing simultaneous visualization anterolaterally and posteriorly throughout removal of the tumor. The unique characteristics of this patient’s chordoma, being unilateral and essentially paravertebral in the upper thoracic spine, permitted the described technique to be feasible and effective. A partial vertebrectomy, instead of total en bloc spondylectomy, was deemed appropriate for achieving wide margins by the authors and consulting oncologists because of the
FIGURE 7. Postoperative imaging. A, anteroposterior x-ray shows pedicle screw fixation from T1 to T4. Axial (B) and coronal (C) computed tomography images show the bony defect after tumor resection. D, magnetic resonance imaging post-contrast reveals gross total resection of the tumor.
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tumor’s extraskeletal and unilateral location. Additionally, the partial vertebrectomy allowed for shorter segmental instrumentation; a total en bloc spondylectomy would have required fixation into the cervical spine and down to the lower thoracic spine beyond the thoracic apex. Combining thoracoscopic and posterior approaches was previously described in spinal surgery for indications other than chordoma. Many of these combined approaches are in the setting of deformity surgery, with thoracoscopy allowing the surgeon to perform an anterior release before posterior fixation. This technique has been successful for underlying pathologies of neuromuscular scoliosis,22,23 adolescent idiopathic scoliosis,24,25 Scheuermann’s kyphosis,23,26 and tuberculosisinduced kyphosis.27 In addition, Cappuccio et al28 described thoracoscopy-assisted en bloc resection of a spinal tumor in 2 patients, including colon cancer metastasis at T11 and a sarcoma at T5-6. Their technique involved placing the patient in the lateral position for thoracoscopic anterior release of the tumor; this was followed by repositioning of the patient into the prone position for a posterior approach. The current technique differs in that the patient is prone throughout the procedure, allowing for simultaneous thoracoscopic and posterior approaches. The benefit of using thoracoscopy in this case was to facilitate establishment of a clear plane between the tumor and mediastinal contents. The simultaneous posterior approach was then made safer by allowing the osteotomies to proceed over a fan blade retractor instead of onto an exposed mediastinum. Additionally, using thoracoscopy for the anterior portion of this procedure potentially resulted in less morbidity compared with a thoracotomy approach. Accordingly, previous reports suggest less blood loss and shorter hospital stay when a thoracoscopic approach is used instead of thoracotomy, as well as reduced pain, size of incision, and dissection of the chest wall.29,30 Although this report has limited long-term patient follow-up, its aim is to describe a combined thoracoscopic and posterior approach for en bloc resection of a rare tumor in a rare location. This case involved a unilaterally exophytic chordoma, but it is feasible for the technique described herein to be expanded to bilateral thoracoscopic assistance for thoracic tumors with bilateral paravertebral involvement. In the case of an extensive multilevel en bloc spondylectomy, however, the specimen may require removal from an open anterolateral approach to avoid manipulation of the spinal cord posteriorly. Further experience is required to establish the indications, efficacy, and long-term outcomes of patients undergoing thoracoscopy-assisted combined approaches for select thoracic pathologies.
CONCLUSION A combined simultaneous thoracoscopic and posterior approach appears to be safe and effective for en bloc resection of a multilevel chordoma involving the upper thoracic spine. This technique allows for a plane to be established ventrally between the
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tumor and the mediastinum, thus assisting with safe osteotomies from the posterior direction. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
REFERENCES 1. Boriani S, Chevalley F, Weinstein JN, et al. Chordoma of the spine above the sacrum. Treatment and outcome in 21 cases. Spine (Phila Pa 1976). 1996;21(13): 1569-1577. 2. Bergh P, Kindblom LG, Gunterberg B, Remotti F, Ryd W, Meis-Kindblom JM. Prognostic factors in chordoma of the sacrum and mobile spine: a study of 39 patients. Cancer. 2000;88(9):2122-2134. 3. Mindell ER. Chordoma. J Bone Joint Surg Am. 1981;63(3):501-505. 4. Dahlin DC, Maccarty CS. Chordoma. Cancer. 1952;5(6):1170-1178. 5. Bjornsson J, Wold LE, Ebersold MJ, Laws ER. Chordoma of the mobile spine. A clinicopathologic analysis of 40 patients. Cancer. 1993;71(3):735-740. 6. Schwab JH, Healey JH, Rose P, Casas-Ganem J, Boland PJ. The surgical management of sacral chordomas. Spine (Phila Pa 1976). 2009;34(24): 2700-2704. 7. Boriani S, Bandiera S, Biagini R, et al. Chordoma of the mobile spine: fifty years of experience. Spine (Phila Pa 1976). 2006;31(4):493-503. 8. Clarke MJ, Hsu W, Suk I, et al. Three-level en bloc spondylectomy for chordoma. Neurosurgery. 2011;68(2 suppl operative):ons325-ons333. 9. Sciubba DM, Gokaslan ZL, Black JH III, et al. 5-level spondylectomy for en bloc resection of thoracic chordoma. Neurosurgery. 2011;69(2 suppl operative): onsE248-onsE255. 10. Hsieh PC, Gallia GL, Sciubba DM, et al. En bloc excisions of chordomas in the cervical spine: review of five consecutive cases with more than 4-year follow-up. Spine (Phila Pa 1976). 2011;36(24):E1581-E1587. 11. Currier BL, Papagelopoulos PJ, Krauss WE, Unni KK, Yaszemski MJ. Total en bloc spondylectomy of C5 vertebra for chordoma. Spine (Phila Pa 1976). 2007;32 (9):E294-E299. 12. Enneking WF, Spanier SS, Goodman MA. A System for the surgical staging of musculoskeletal sarcoma. Clin Orthop Relat Res. 1980;153:106-120. 13. Sundaresan N, Huvos AG, Krol G, Lane JM, Brennan M. Surgical treatment of spinal chordomas. Arch Surg. 1987;122(12):1479-1482. 14. Chambers PW, Schwinn CP. Chordoma. A clinicopathologic study of metastasis. Am J Clin Pathol. 1979;72(5):765-776. 15. Hsu KY, Zucherman JF, Mortensen N, Johnston JO, Gartland J. Follow-up evaluation of resected lumbar vertebral chordoma over 11 years: a case report. Spine (Phila Pa 1976). 2000;25(19):2537-2540. 16. Sundaresan N, Steinberger AA, Moore F, et al. Indications and results of combined anterior-posterior approaches for spine tumor surgery. J Neurosurg. 1996;85(3): 438-446. 17. Cotler HB, Cotler JM, Cohn HE, Israel HI, Gartland JJ. Intrathoracic chordoma presenting as a posterior superior mediastinal tumor. Spine (Phila Pa 1976). 1983; 8(7):781-786. 18. Levowitz BS, Khan MY, Rand E, Hurwitz A. Thoracic vertebral chordoma presenting as a posterior mediastinal tumor. Ann Thorac Surg. 1966;2(1): 75-81. 19. Crowe GG, Muldoon PB. Thoracic chordoma. Thorax. 1951;6(4):403-407. 20. Selvaraj A. Superior mediastinal chordoma presenting as a bilobed paravertebral mass. Eur J Cardiothorac Surg. 2003;23(2):248-250. 21. Gregorius FK, Batzdorf U. Removal of thoracic chordoma by staged laminectomy and thoracotomy: a case report. Am Surg. 1977;43(9):631-634. 22. Newton PO, White KK, Faro F, Gaynor T. The success of thoracoscopic anterior fusion in a consecutive series of 112 pediatric spinal deformity cases. Spine (Phila Pa 1976). 2005;30(4):392-398. 23. Arlet V. Anterior thoracoscopic spine release in deformity surgery: a meta-analysis and review. Eur Spine J. 2000;9(suppl 1):S17-S23. 24. Norton RP, Patel D, Kurd MF, Picetti GD, Vaccaro AR. The use of thoracoscopy in the management of adolescent idiopathic scoliosis. Spine (Phila Pa 1976). 2007; 32(24):2777-2785.
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25. Son-Hing JP, Blakemore LC, Poe-Kochert C, Thompson GH. Video-assisted thoracoscopic surgery in idiopathic scoliosis: evaluation of the learning curve. Spine (Phila Pa 1976). 2007;32(6):703-707. 26. Herrera-Soto JA, Parikh SN, Al-Sayyad MJ, Crawford AH. Experience with combined video-assisted thoracoscopic surgery (VATS) anterior spinal release and posterior spinal fusion in Scheuermann’s kyphosis. Spine (Phila Pa 1976). 2005;30 (19):2176-2181. 27. Zheng C, Li P, Kan W. Video-assisted thoracoscopic anterior surgery combined posterior instrumentation for children with spinal tuberculosis. Eur J Pediatr Surg. 2014;24(1):83-87. 28. Cappuccio M, Gasbarrini A, Donthineni R, Beisse R, Boriani S. Thoracoscopic assisted en bloc resection of a spine tumor. Eur Spine J. 2011;20(suppl 2):202-205. 29. Oppenlander ME, Clark JC, Kalyvas J, Dickman CA. Surgical management and clinical outcomes of multiple-level symptomatic herniated thoracic discs. J Neurosurg Spine. 2013;19(6):774-783. 30. Han PP, Kenny K, Dickman CA. Thoracoscopic approaches to the thoracic spine: experience with 241 surgical procedures. Neurosurgery. 2002;51(suppl 5): S88-S95.
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COMMENTS
T
his is a very interesting article with good illustrations of a multidisciplinary approach with a thoracoscopy-assisted posterior en bloc resection of a chordoma. The authors use high-quality video and schematic illustrations to demonstrate the procedure well. Daniel Refai Atlanta, Georgia
T
he authors present a case of a laterally exophytic chordoma at T2-3 treated with a simultaneous, combined anterolateral thoracoscopic and open posterior approach for en bloc resection. Details of the technique are described in the text and illustrated with figures and video of the thoracoscopic technique. In essence, the thoracoscopic approach was used to free the tumor from adjacent mediastinal visceral and vascular structures and to protect these structures during the osteotomies. The open posterior approach was used for the laminectomy, nerve root ligation, osteotomies,
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and spinal stabilization. The authors are to be congratulated for using a well-planned, multidisciplinary surgical approach to manage a rare tumor in a challenging location. Using their technique, they were able to achieve a safe, oncologically appropriate resection, while avoiding the potential additional morbidity of an open transthoracic approach. Although it is true that combined thoracoscopic and open approaches have been previously reported in spinal surgery for both deformity and tumor, this is the first report of a tumor resection using these 2 approaches simultaneously in the prone position. The authors appropriately indicate that this tumor was particularly amenable to this type of strategy given its relatively small size and lateral exophytic location. Application of these combined techniques to larger tumors with greater vertebral involvement or more significant paraspinal extension will need to be approached cautiously given the significant negative consequences of tumor violation during surgery. The value of using minimally invasive approaches in the management of primary spinal tumors will clearly need further evaluation with longer follow-up. Not only will the advantage of these approaches need to be documented in terms of decreased morbidity and improved long-term function, but they must achieve local control similar to that with traditional open approaches. Efforts to reduce the morbidity of these large en bloc resections with less invasive surgical techniques, as the authors have demonstrated, are laudable. Laurence Rhines Houston, Texas
C
ombining thoracoscopic surgery with open approaches has been previously described for spine tumors; however, I believe this is the first report of their simultaneous use with the patient in the prone position. The authors have shown a great example of what can be accomplished when surgery is well planned with multidisciplinary input. It is highly satisfactory when minimally invasive techniques can be used to accomplish the same goals as an entirely open procedure. However, the versatility of this technique remains to be seen. I think this worked for this particular case because the tumor was relatively small and lateral in location. Daryl Fourney Saskatoon, Saskatchewan, Canada
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