Chordomas of the upper cervical spine: radiographic evaluation. Study of two cases and review of the literature

Chordomas are rare bony tumors, usually involving the skull base and sacrococcygeal spine, while least presented in cervical and thoracic spine. Chordomas of the cervical spine may cause variable neurological symptoms. Adult patients presenting with neck pain, paresthesias or limb paresis are further investigated. The history of progressive tetraparesis, however, implies a long-standing disease. Clinical presentation and imaging investigation of the cervical spine chordoma aims to alert the physicians for its early detection. Herein is reported the clinical presentation of two chordomas with progressive tetraparesis in two patients involving in both cases the third cervical vertebra. Plain radiographs, bone scintigraphy, CT and MR scanning were the imaging modalities depicting the mass, its prevertebral and intraspinal extension.     

Chordoma: Natural History and Results in 28 Patients Treated at a Single Institution

Background: The natural history of chordoma is characterized by a high failure rate and a poor functional outcome. The purpose of this study was to review the long-term outcome of our institutional experience.Methods: The clinical features, type of treatment, pathologic assessment, and follow-up of 56 consecutive patients with chordoma were reviewed.Results: Fifty sacral and six mobile spine chordomas (median size, 13 cm; range, 2–30 cm) were treated at our center between January 1933 and December 2000. Twenty-eight patients affected by sacrococcygeal chordoma and operated on after 1977 form the basis of our study. Surgical margins were rated as wide in 11 cases, marginal in 13 cases, and intralesional in 4 cases. The median follow-up was 71 months (range, 15–200 months). Seventeen patients disease recurred. Ten patients died as a result of disease. Nine patients remained continuously free of disease. The estimated 5- and 10-year overall survival was, respectively, 87.8% and 48.9%; disease-free survival was 60.6% and 24.2%. Radiotherapy was considered for marginal and intralesional resections.Conclusions: High sacral amputation can achieve a good rate of wide-margin resections for sacrococcygeal chordomas. Adjuvant radiotherapy may offset the negative effect in the prognosis of marginal resections.     

Timing of intervention for spinal injury in patients with polytrauma

ObjectiveThe optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.MethodsA narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995–2020) based on the keywords – polytrauma OR multiple trauma AND spine fracture AND timing, present in “All the fields” of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.ResultsSpine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, “damage control” internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.ConclusionRecognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.     

Cervical chordoma managed with multidisciplinary surgical approach

Background: This paper describes the interdisciplinary management of a 62‐year‐old man who presented with a cervical chordoma of C2/3. This is a rare neoplasm of the axial skeleton which is usually treated surgically. This is technically challenging due to the surrounding anatomy and requirement for wide exposure. A number of surgical approaches have been described to access the clivus and upper cervical spine. Methods: This case involved both the Orthopaedic and Otolaryngology Head and Neck Surgery departments. Trotter's surgical technique was used to gain access for excision of the cervical chordoma and there was collaboration with an Orthopaedic Biotechnology Company in which a bio‐model of the spine was created and a corpectomy cage specific to the patient developed. Results: This approach allowed excellent visualisation of the tumour and the unique cage and plate achieved immediate stability and long term fusion. Conclusion: An interdisciplinary approach should be used in the management of upper cervical chordomas to facilitate tumour resection and reduce the potential for recurrence.     

脊索瘤中增殖细胞核抗原表达与细胞凋亡检测的临床意义

目的：探讨脊索瘤的组织特性及预后判断。方法：用免疫组化法检测16例原发脊索瘤（其中典型脊索瘤10例,软骨样脊索瘤6例）中增殖细胞核抗原（PCNA）的表达,TUNEL法检测其肿瘤细胞的凋亡,电镜观察其超微结构。结果：典型脊索瘤与软骨样脊索瘤PCNA的表达差异无显著性,但复发者PCNA的标记率明显较未复发者为高（P＜0．05）。软骨样脊索瘤肿瘤细胞的凋亡率较典型脊索瘤为高,但复发者肿瘤细胞的凋亡率与未复者相比较并无显著性差异。根治术无复发间期平均为26个月,次全切除术无复发间期平均为8个月（P＜0．05）。术后加用大剂量放疗,较未使用者的复发率为低,但无显著性差异。结论：索脊瘤复发与否与PCNA的标记率及手术方式有关,软骨样脊索瘤的预后较典型脊索瘤要好。     

Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome

AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.RESULTS: Seven hundred and thirty-one articles were identified, using the search term “brachial plexus” and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or “birth palsy” (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy “brachial plexus” obstetric (35), “humeral osteotomy” and “brachial plexus” (17), and triangle tilt “brachial plexus” (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.     

Revision Surgery for Failed Cervical Spine Reconstruction: Review Article

Background

As the number of cervical spine procedures performed continues to increase, the need for revision surgery is also likely to increase. Surgeons need to understand the etiology of post-surgical changes, as well as have a treatment algorithm when evaluating these complex patients.

Questions/Purposes

This study aims to review the rates and etiology of revision cervical spine surgery as well as describe our treatment algorithm.

Methods

We used a narrative and literature review. We performed a MEDLINE (PubMed) search for “cervical” and “spine” and “revision” which returned 353 articles from 1993 through January 22, 2014. Abstracts were analyzed for relevance and 32 articles were reviewed.

Results

The rates of revision surgery on the cervical spine vary by the type and extent of procedure performed. Patient evaluation should include a detailed history and review of the indication for the index procedure, as well as lab work to rule out infection. Imaging studies including flexion/extension radiographs and computed tomography are obtained to evaluate potential pseudarthrosis. Magnetic resonance imaging is helpful to evaluate the disc, neural elements, soft tissue, and to differentiate scar from infection. Sagittal alignment should be corrected if necessary.

Conclusions

Recurrent or new symptoms after cervical spine reconstruction can be effectively treated with revision surgery after identifying the etiology, and completing the appropriate workup.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9394-8) contains supplementary material, which is available to authorized users.     

Chordoma in the cervical spine managed with en bloc excision.

STUDY DESIGN: En bloc resection of a chordoma in the midcervical vertebral spine was performed. OBJECTIVES: To document the surgical technique used for en bloc excision of a chordoma arising in the midcervical spine. SUMMARY OF BACKGROUND DATA: Malignant tumors arising in long bones are excised en bloc. The authors recently designed a technique for en bloc resection of malignant tumors in the thoracolumbar spine using the T-saw. However, this technique is difficult in tumors of the cervical spine, and there are no previous reports of successful en bloc resection of such tumors. METHODS: Using an anterior approach, the ipsilateral vertebral artery was ligated. This was followed by sharply cutting the pedicle of the cervical vertebra with a specially designed T-saw. RESULTS: En bloc excision of chordomas in the cervical spine was achieved using the T-saw. CONCLUSION: Although the surgical margin was intralesional in a small area, the technique used in this case study indicates that en bloc excision of such tumors can be used with a safety margin even in the cervical spine.     

Sacrococcigeal and vertebral chordomas. Report of three cases and review of the literature

Three cases of sacrococcygeal and vertebral chordoma are described. Histogenetic and anatomopathological aspects with particular reference to differential diagnosis from similarly distributed neoplasias are discussed. Anti-cytoskeleton monoclonal antibodies were used to this purpose. The clinical profile of sacrococcygeal and vertebral chordomas is characterized by a pronounced metastatic potential; radiation treatment can only partially counter their biological behaviour, while chemotherapy has proved little or no effectiveness. Where possible, radical surgery is currently the only treatment to guarantee long-term survival or complete cure. Palliative surgery, associate with efficient painkilling, offers a better quality of life and slows down the progress of the disease.     

Simultaneous Discovery of Cranial and Spinal Intradural Chordomas: Case Report

The present case illustrates the unexpected occurrence of intradural chordomas that were simultaneously discovered in cranial and spinal locations. A 63-year-old female presented with weakness in the left upper extremity. The patient visited a local doctor and underwent brain computerized tomography (CT). CT revealed a brain tumor, and she was referred to our hospital. Brain magnetic resonance imaging (MRI) demonstrated a midline intradural retroclival tumor in addition to an intradural extramedullary mass lesion at the level of C1–C2. The patient developed a spastic gait disturbance that forced her to use a cane. She underwent laminectomy at C1–C2 along with total removal of the tumor and showed no remarkable symptoms after surgery. Histopathological examination confirmed the diagnosis of chordoma. One month after the cervical surgery, the intracranial tumor was subtotally removed in intracranial surgery via the right subtemporal approach. Histopathological data were identical to that of the cervical tumor. The patient consulted another hospital and underwent gamma-knife surgery. Her neurological examination is relatively unchanged 20 months after the cervical surgery. This case suggests that neuroradiological evaluation should also be performed for an intradural spinal chordoma when an intracranial chordoma is detected. Careful determination of the tumor responsible for the symptoms is necessary if an intradural spinal chordoma is simultaneously detected with an intracranial chordoma.     

Upper cervical injuries – A rational approach to guide surgical management

Context

The complex anatomy and the importance of ligaments in providing stability at the upper cervical spine region (O–C1–C2) require the use of many imaging modalities to evaluate upper cervical injuries (UCI). While separate classifications have been developed for distinct injuries, a more practical treatment algorithm can be derived from the injury pattern in UCI.

Objective

To propose a practical treatment algorithm to guide treatment based on injuries characteristic of UCI.

Methods

A literature review was performed on the Pubmed database using the following keywords: (1) “occipital condyle injury”; (2) “craniocervical dislocation or atlanto-occipital dislocation or craniocervical dislocation”; (3) “atlas fractures”; and (4) “axis fractures”. Just articles containing the diagnosis, classification, and treatment of specific UCI were included. The data obtained were analyzed by the authors, dividing the UCI into two groups: Group 1 – patients with clear ligamentous injury and Group 2 – patients with fractures without ligament disruption.

Results

Injuries with ligamentous disruption, suggesting surgical treatment, include: atlanto-occipital dislocation, mid-substance transverse ligament injury, and C1–2 and C2–3 ligamentous injuries. In contrast, condyle, atlas, and axis fractures without significant displacement/misalignment can be initially treated using external orthoses. Odontoid fractures with risk factors for non-union are an exception in Group 2 once they are better treated surgically. Patients with neurological deficits may have more unstable injuries.

Conclusions

Ascertaining the status of relevant ligamentous structures, fracture patterns and alignment are important in determining surgical compared with non-surgical treatment for patients with UCI.     

Nasal Methicillin-Resistant S. Aureus is a Major Risk for Mediastinitis in Pediatric Cardiac Surgery

Background: Mediastinitis caused by methicillin-resistant Staphylococcus aureus (MRSA) is a serious complication after pediatric cardiac surgery. An outbreak of surgical site infections (SSIs) provided the motivation to implement SSI prevention measures in our institution.Methods: Subjects comprised 174 pediatric patients who underwent open-heart surgery after undergoing preoperative nasal culture screening. The incidence of SSIs and mediastinitis was compared between an early group, who underwent surgery before SSI measures (Group E, n = 73), and a recent group, who underwent surgery after these measures (Group R, n = 101), and factors contributing to the occurrence of mediastinitis were investigated.Results: The incidence of both SSIs and Mediastinitis has significantly decreased after SSI measures. With regard to factors that significantly affected mediastinitis, preoperative factors were “duration of preoperative hospitalization” and “preoperative MRSA colonization,” intraoperative factors were “Aristotle basic complexity score,” “operation time,” “cardiopulmonary bypass circuit volume” and “lowest rectal temperature.” And postoperative factor was “blood transfusion volume.” Patients whose preoperative nasal cultures were MRSA-positive suggested higher risk of MRSA mediastinitis.Conclusions: SSI prevention measures significantly reduced the occurrence of SSIs and mediastinitis. Preoperative MRSA colonization should be a serious risk factor for mediastinitis following pediatric cardiac surgeries.     

Scoring system for prediction of metastatic spine tumor prognosis

Assessing the prognosis before treatment for metastatic spine tumor is extremely important in therapy selection. Therefore, we review some prognostic scoring systems and their outcomes. Articles with combinations of two keywords among “metastatic spine tumor” and “prognosis”, “score”, “scoring system”, “predicting”, or “life expectancy” were searched for in PubMed. As a result, 236 articles were extracted. Those referring to representative scoring systems about predicting the survival of patients with metastatic spine tumors were used. The significance and limits of these scoring systems, and the future perspectives were described. Tokuhashi score, Tomita score, Baur score, Linden score, Rades score, and Katagiri score were introduced. They are all scoring systems prepared by combining factors that affect prognosis. The primary site of cancer and visceral metastasis were common factors in all of these scoring systems. Other factors selected to influence the prognosis varied. They were useful to roughly predict the survival period, such as, “more than one year or not” or “more than six months or not”. In particular, they were utilized for decision-making about operative indications and avoidance of excessive medical treatment. Because the function depended on the survival period in the patients with metastatic spine tumor, it was also utilized in assessing functional prognosis. However, no scoring system had more than 90% consistency between the predicted and actual survival periods. Future perspectives should adopt more oncological viewpoints with adjustment of the process of treatment for metastatic spine tumor.     

Management of skull base chordoma

Two management modalities appear to be important in treating skull base chordomas: surgery and radiation therapy. Radical resection of lesions of the distal sacrum (S3–S5) and coccyx may be curative, as total removal is often achieved. In contrast, complete resection of chordomas of the base of the skull is rarely successful because of the inability to achieve a true complete surgical resection. On the other hand, treatment of skull base chordomas by radiation therapy alone is often difficult owing to the large size of the lesion and the dose limitation imposed by the sensitivity of the adjacent structures. Local relapse is the predominant type of treatment failure of skull base chordoma. Skull base surgery and radiation therapy have significantly improved over the last 20 years. The following papers review the most significant recent analyses of therapeutic options in treating skull base chordomas. It seems that the combination of aggressive surgery followed by combined proton-photon radiation therapy offers the best chance of longterm local control to patients harboring cranial chordomas.     

Current rehabilitation strategy: clinical evidence for erection recovery after radical prostatectomy

Erectile function (EF) recovery remains a prominent functional outcome underachievement of radical prostatectomy (RP), despite the success of anatomic “nerve-sparing” technique and its recent refinements in the modern surgical era. Delayed (for as much as a few years) or incomplete (partial and unusable) EF recovery commonly occurs in many men still today undergoing this surgery. “Penile rehabilitation”, alternatively termed “EF rehabilitation”, originated formally as a therapeutic practice approximately 15 years ago for addressing post-RP erectile dysfunction (ED) beyond conventional ED management. Although the premise of this therapy is conceptually sound and generally accepted, in reference to the implementation of strategies for promoting EF recovery to a naturally functional level in the absence of erectile aids (distinct from the premise of conventional ED management), the optimal manner and efficacy of currently suggested therapeutic strategies are far less established. Such strategies include regimens of standard ED-specific therapies (e.g., oral, intracavernosal, and intraurethral pharmacotherapies; vacuum erection device therapy) and courses of innovative interventions (e.g., statins, erythropoietin, angiotensin receptor blockers). An endeavor in evolution, erection rehabilitation may ideally comprise an integrative program of sexual health management incorporating counseling, coaching, guidance toward general health optimization and application of demonstrably effective “rehabilitative” interventions. Ongoing intensive discovery and rigorous investigation are required to establish efficacy of therapeutic prospects that fulfill the intent of post-RP erection rehabilitation.     

Primary tumors of the cervical spine: surgical experience with 38 cases.

Thirty-eight primary tumors of the cervical spine were operated on in the Section of Neurosurgery, Department of Neurological Sciences, "La Sapienza" University of Rome between 1954 and 1988. Of these, 23 were malignant and 15 benign. The aims of surgical treatment in every case were tumor removal, decompression of the spinal cord, and conservation or restoration of vertebral stability. In no case was surgery confined to biopsy. Surgical stabilization was performed in 12 patients. Bone fusion was obtained with autologous bone (iliac crest, fibula) in benign tumors, whereas synthetic material (acrylic and metal) was used in malignant tumors. Past experience and greater awareness of the concrete possibilities of treating these tumors have led us to evolve the following strategy: 1. For aggressive benign tumors (osteoblastoma, giant cell tumors) and for malignancies in patients with fair life expectancy (solitary myeloma, chordoma): radical removal. 2. For benign tumors with low neoplastic potential and for malignant tumors in patients with poor life expectancy: conservative removal. Long-term results were gratifying in all benign lesions and low-grade malignancies even though two patients with chordomas needed reoperations. Sarcomas had relatively poor results.     

Radiology of sacrococcygeal chordoma. Difficulties in detecting soft tissue extension

Plain radiographs of seven patients with sacrococcygeal chordomas showed sacral destruction, enlarged sacral neural foramina, and, usually, a presacral mass. Conventional tomograms clarified these bone abnormalities, which were often poorly visible on the plain radiographs. Two radionuclide bone scans showed increased peripheral uptake around the lesion, and one showed decreased uptake in the area of destroyed bone. Angiograms demonstrated only vessel displacement, and barium enemas showed only displacement of bowel by large soft tissue masses. Five myelograms were normal. Adequate surgical treatment of sacral chordomas requires a wide radical resection that avoids contaminating the wound with tumor. Therefore, thorough preoperative radiologic evaluation of the anatomic extent of a chordoma is essential. Although computed tomograms in three patients provided the best delineation of the total extent of bone and soft tissue involvement, tumor extension into gluteal muscles and other tissues eluded radiographic detection. The widespread infiltrative growth pattern along soft tissue planes and nerves and into vessels, undetectable by the above listed studies, mandates a cautious approach and a wide surgical margin, to prevent wound contamination and subsequent recurrence.