Introduction: Surgical approaches to tumors of the upper anterior cervical spine require a thorough knowledge of the regional anatomy, consideration of the extent of disease, the intent of surgery, and what reconstruction and stabilization options are available. Often, for lower cervical spine, true paramedian approaches are sufficient. However, lesions involving the superior most vertebral bodies pose unique access challenges. We present a case study of a patient with recurrent C2-C3 chordoma that underwent aggressive resection using a Bernard George anterolateral transcervical approach followed by stabilization with an expandable cage.
Case history: A 67-year-old man presented with progressive quadriparesis due to a C2-3 chordoma, recurrent after two previous surgical resections that included a posterior C1-4 instrumented fusion, and adjuvant fractionated radiation therapy. A cervical MRI showed the rapid recurrence of a large T2 hyperintense and peripherally enhancing mass arising from C2-C3, projecting toward the spinal canal, resulting in moderate to several spinal cord compression.
Surgical findings: A horizontal incision superior to the insertion of the posterior and lateral neck muscles was carried anteriorly to join a postauricular incision extending to the posterior aspect of the mastoid tip and then curving infero-medially to allow a wide subplatysmal dissection. The spinal accessory nerve was identified coursing postero-inferiorly lateral and across the jugular vein, towards the posterior triangle of the neck. Along the posterior border of the sternocleidomastoid muscle (SCM), the spinal accessory nerve was again identified 1-2 cm above Erb’s point, traced and preserve distally to reach the trapezius muscle. The tendinous insertion of the sternocleidomastoid (SCM) muscle was then divided at the mastoid tip which helped retract the muscle anteriorly and away from the field. Similarly, the superomedial attachments of the trapezius muscle were also released and the muscle was reflected infero-laterally; thus, allowing a direct access to the transverse process of C1. The inferior and superior oblique muscles were released from the transverse process and reflected laterally. The vertebral artery was not patent in the upper cervical spine due to previous endovascular coiling, but it was identified and lateralized. Recurrent chordoma was identified at the level of the transverse process and body of C2 and C3, and was subsequently resected until ventral dura was visualized. The contralateral (left) vertebral artery was dissected free from the tumor– leaving a small residue traveling into the contralateral transverse foramen along the artery. Following resection, an expandable cage was placed within the tumor cavity. The patient tolerated the procedure well and had rapid improvement in quadriparesis, with no new neurologic deficits.
Conclusion: An anterolateral transcervical approach, as originally described by Bernard George, is a versatile approach providing access to vertebral artery, lateral mass of C1, the bodies and transverse processes of the cervical vertebrae up to the ventral aspect of spinal dura, allowing unique and comprehensive access to the challenging ventral upper cervical region.