The Lateral Transfacetal Retrovascular Approach for an Anteriorly Located Chordoma Originating from the Second Cervical Vertebra

Summary

 Background. Anteriorly located lesions at the craniocervical junction (CCJ) require careful surgical planning to avoid neuraxis retraction. Several different routes have been described in the search for the most appropriate yet least invasive approach. However, most of these far-lateral posterior approaches are specifically tailored for non-osseous intradural tumours or chordomas with cephalad extension. We introduce an approach that allows for better access to laterally extending osseous tumours originating from the second cervical vertebra. Using this approach, the lesion is manipulated from a strictly lateral direction parallel to a plane through the articular pillar of the CCJ and the odontoid process, and the C1- and C2-laminae are spared for posterior fixation.

 Method. The application of this approach is demonstrated in detail by an illustrative case of a chordoma originating from C2 that presented with intradural mass effect, considerable bone destruction, far-lateral extension to the right, and vertebral artery involvement.

 Findings. The described approach gave ample access for total tumour resection. It allowed for safe control and displacement of the vertebral artery, spinal cord decompression, C2-corpectomy across the midline, and anterolateral bone reconstruction. No C1- or C2-hemilaminectomy was needed, and these bone elements could be used for posterior fixation (the patient presented in this study was referred to our institution after posterior fixation from the occiput to C3 had already been performed elsewhere). No intra-operative or postoperative complications occurred. At the 6-month follow-up, the patient was fully ambulatory with no neurological deficit.

 Interpretation. The described lateral transfacetal route is the method of choice for operating on laterally extending osseous tumours originating from the second cervical vertebra.