Skip to main content
SpringerLink
Log in

The timing of fusion surgery for clival chordoma with occipito-cervical joint instability: before or after tumor resection?

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Clival chordoma with occipito-cervical (OC) joint invasion can result in preoperative and postoperative instability. The authors investigate the appropriate timing of OC fusion to prevent instability-, fusion-, and surgery time-related morbidity. Twenty-two consecutive patients underwent surgery for clival chordoma from December 2008 to September 2014. OC fusion was performed for patients with OC joint invasion and instability due to preoperative destruction of the occipital condyle or extensive postoperative condylectomy. The data in relation to OC joint instability, fusion, and surgery time were analyzed retrospectively and compared between OC fusion before and after tumor resection. Of the 22 patients, 8 with tumor invasion of the OC joint underwent OC fusion. OC fusion was performed after tumor resection in one-stage for four patients and before tumor resection in two-stage for four patients. There was OC joint instability from tumor destruction of the occipital condyle in seven patients (87.5%). Patients with OC fusion after tumor resection encountered complications such as surgery site wound dehiscence, encephalitis, and cardiac arrest with consequent mortality in one patient. These complications were avoided in subsequent patients where OC fusion was performed before tumor resection. There were no differences in the extent of tumor resection between OC fusion before and after tumor resection. Two-stage OC fusion before tumor resection can reduce instability-, fusion-, and surgery time-related morbidity and achieve feasible tumor resection when OC joint instability is expected. The extent of tumor invasion and brain stem compression should be considered when fusion precedes tumor resection.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Explore related subjects

Discover the latest articles, news and stories from top researchers in related subjects.

References

  1. Allen F (1931) Respiratory complications in relation to the administration of anesthetics. N Engl J Med 204:1288–1293

    Google Scholar 

  2. Al-Mefty O, Borba LA, Aoki N, Angtuaco E, Pait TG (1996) The transcondylar approach to extradural nonneoplastic lesions of the craniovertebral junction. J Neurosurg 84:1–6

    CAS  PubMed  Google Scholar 

  3. Apostolides PJ, Dickman CA, Golfinos JG, Papadopoulos SM, Sonntag VKH (1996) Threaded Steinmann pin fusion of the craniovertebral junction. Spine 21:1630–1637

    CAS  PubMed  Google Scholar 

  4. Ball CG, Pitt HA, Kilbane ME, Dixon E, Sutherland FR, Lillemoe KD (2010) Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy. HPB (Oxford) 12:465–471

    Google Scholar 

  5. Bejjani GK, Sekhar LN, Riedel CJ (2000) Occipitocervical fusion following the extreme lateral transcondylar approach. Surg Neurol 54:109–115

    CAS  PubMed  Google Scholar 

  6. Benke M, Yu WD, Peden SC, O’Brien JR (2011) Occipitocervical junction: imaging, pathology, instrumentation. Am J Orthop 40:E205–E215

    PubMed  Google Scholar 

  7. Benzel E (1995) Stability and instability of the spine. In: Biomechanics of spine stabilization: principles and clinical practice. New York, McGraw-Hill Health Professions Division, pp 25–38

    Google Scholar 

  8. Boruk M, Chernobilsky B, Rosenfeld RM, Har-El G (2005) Age as a prognostic factor for complications of major head and neck surgery. Arch Otolaryngol Head Neck Surg 131:605–609

    PubMed  Google Scholar 

  9. Crockard HA (1993) Transoral approach to intra/extradural tumors. In: Surgery of cranial base tumors. Raven Press, New York, pp 225–234

    Google Scholar 

  10. Dexter SP, Martin IG, Marton J, McMahon MJ (1997) Long operation and the risk of complications from laparoscopic cholecystectomy. Br J Surg 84:464–466

    CAS  PubMed  Google Scholar 

  11. Dickman CA, Crawford NR, Brantley AGU, Sonntag VKH, Koenman JB (1995) Biomechanical effects of transoral odontoidectomy. Neurosurgery 36:1146–1153

    CAS  PubMed  Google Scholar 

  12. Dmitriev AE, Lehman RA Jr, Helgeson MD, Sasso RC, Kuhns C, Riew DK (2009) Acute and long-term stability of atlantoaxial fixation methods: a biomechanical comparison of pars, pedicle, and intralaminar fixation in an intact and odontoid fracture model. Spine (Phila Pa 1976) 34:365–370

    Google Scholar 

  13. Fielding JW, Hawkins RJ (1997) Atlanto-axial rotatory fixation. Fixed rotatory subluxation of the atlanto-axial joint. J Bone Joint Surg Am 59:37–44

    Google Scholar 

  14. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH (2010) Endoscopic endonasal transclival resection of chordomas: operative technique, clinical outcome, and review of the literature. J Neurosurg 112:1061–1069

    PubMed  Google Scholar 

  15. Garrett M, Consiglieri G, Kakarla UK, Chang SW, Dickman CA (2010) Occipitoatlantal dislocation. Neurosurgery 66:48–55

    PubMed  Google Scholar 

  16. Gire JD, Roberto RF, Bobinski M, Klineberg EO, Durbin-Johnson B (2013) The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J 13:510–519

    PubMed  Google Scholar 

  17. Harris JH, Carson GC, Wagner LK (1994) Radiologic diagnosis of traumatic occipitovertebral dissociation: 1. Normal occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 162:881–886

    PubMed  Google Scholar 

  18. Harris JH, Carson GC, Wagner LK, Kerr N (1994) Radiologic diagnosis of traumatic occipitovertebral dissociation: 2. Comparison of three methods of detecting occipitovertebral relationships on lateral radiographs of supine subjects. AJR Am J Roentgenol 162:887–892

    PubMed  Google Scholar 

  19. Higinbotham NL, Phillips RF, Farr HW, Hustu HO (1967) Chordoma. Thirty-five year study at memorial hospital. Cancer 20:1841–1850

    CAS  PubMed  Google Scholar 

  20. Hurlbert RJ, Crawford NR, Choi WG, Dickman CA (1999) A biomechanical evaluation of occipitocervical instrumentation: screw compared with wire fixation. J Neurosurg 90(1 Suppl):84–90

    CAS  PubMed  Google Scholar 

  21. Johnson AS, Lombard HL (1941) The estimation of operative risk in patients with cancer. N Engl J Med 224:759–762

    Google Scholar 

  22. Kim BD, Ver Halen JP, Grant DW, Kim JY (2014) Anesthesia duration as an independent risk factor for postoperative complications in free flap surgery: a review of 1,305 surgical cases. J Reconstr Microsurg 30:217–226

    PubMed  Google Scholar 

  23. Kim YH, Jeon C, Se YB, Hong SD, Seol HJ, Lee JII, Park CK, Kim DG, Jung HW, Han DH, Nam DH, Kong DS (2018) Clinical outcomes of an endoscopic transclival and transpetrosal approach for primary skull base malignancies involving the clivus. J Neurosurg 128:1454–1462

    PubMed  Google Scholar 

  24. Kooshkabadi A, Choi PA, Koutourousiou M, Snyderman CH, Wang EW, Fernandez-Miranda JC, Gardner PA (2015) Atlanto-occipital instability following endoscopic endonasal approach for lower clival lesions: experience with 212 cases. Neurosurgery 77:888–897; discussion 897. https://doi.org/10.1227/NEU.0000000000000922

    Article  PubMed  Google Scholar 

  25. Lehman RA Jr, Dmitriev AE, Helgeson MD, Sasso RC, Kuklo RT, Riew KD (2008) Salvage of C2 pedicle and pars screws using the intralaminar technique: a biomechanical analysis. Spine (Phila Pa 1976) 33:960–965

    Google Scholar 

  26. Mazur MD, Ravindra VM, Brockmeyer DL (2015) Unilateral fixation for treatment of occipitocervical instability in children with congenital vertebral anomalies of the craniocervical junction. Neurosurg Focus 38(4):E9

    PubMed  Google Scholar 

  27. McMaster ML, Goldstein AM, Bromley CM, Ishibe N, Parry DM (2001) Chordomas: incidence and survival patterns in the United States, 1973-1995. Cancer Causes Control 12:1–11

    CAS  PubMed  Google Scholar 

  28. Menezes AH, Traynelis VC, Gantz BJ (1994) Surgical approaches to the craniovertebral junction. Clin Neurosurg 41:187–203

    CAS  PubMed  Google Scholar 

  29. Nichols RL (1982) Postoperative wound infection. N Engl J Med 307:1701–1702

    CAS  PubMed  Google Scholar 

  30. Oda I, Abumi K, Sell LC, Haggerty CJ, Cunningham BW, Mc-Afee PC (1999) Biomechanical evaluation of five different occipitoatlanto-axial fixation techniques. Spine 24:2377–2382

    CAS  PubMed  Google Scholar 

  31. Pang D, Nemzek WR, Zovickian J (2007) Atlanto-occipital dislocation: part 1- normal occipital condyle-C1 interval in 89 children. Neurosurgery 61:514–521 discussion 521

    PubMed  Google Scholar 

  32. Pang D, Nemzek WR, Zovickian J (2007) Atlanto-occipital dislocation: part 2 - the clinical use of (occipital) condyle-C1 interval, comparison with other diagnostic methods, and the manifestation, management, and outcome of atlanto-occipital dislocation in children. Neurosurgery 61:995–1015 discussion 1015

    PubMed  Google Scholar 

  33. Park HH, Lee KS, Hong CK (2016) Vertebral artery transposition via an extreme-lateral approach for anterior foramen magnum meningioma or craniocervical junction tumors. World Neurosurg 88:154–165

    PubMed  Google Scholar 

  34. Peersman G, Laskin R, Davis J, Peterson MG, Richart T (2006) Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS J 2:70–72

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Powers B, Miller MD, Kramer RS, Martinez S, Gehweiler JA (1979) Traumatic anterior atlanto-occipital dislocation. Neurosurgery 4:12–17

    CAS  PubMed  Google Scholar 

  36. Procter LD, Davenport DL, Bernard AC, Zwischenberger JB (2010) General surgical operative duration is associated with increased risk adjusted infectious complication rates and length of hospital stay. J Am Coll Surg 210:60–65

    PubMed  Google Scholar 

  37. Puttlitz CM, Goel VK, Traynelis VC, Clark CR (2001) A finite element investigation of upper cervical instrumentation. Spine (Phila Pa 1976) 26:2449–2455

    CAS  Google Scholar 

  38. Rahme RJ, Arnaout OM, Sanusi OR, Kesavabhotla K, Chandler JP (2018) Endoscopic approach to clival chordomas: the northwestern experience. World Neurosurg. 110:e231–e238. https://doi.org/10.1016/j.wneu.2017.10.146

    Article  PubMed  Google Scholar 

  39. Rupp R, Ebraheim NA, Savolaine ER, Jackson WT (1993) Magnetic resonance imaging evaluation of the spine with metal implants. General safety and superior imaging with titanium. Spine 18:379–385

    CAS  PubMed  Google Scholar 

  40. Sanusi O, Arnaout O, Rahme RJ, Horbinski C, Chandler JP (2018) Surgical resection and adjuvant radiation therapy in the treatment of skull base chordomas. World Neurosurg 115:e13–e21

    PubMed  Google Scholar 

  41. Selim M (2007) Perioperative stroke. N Engl J Med 356:706–713

    CAS  PubMed  Google Scholar 

  42. Shin H, Barrenechea IJ, Lesser J, Sen C, Perin NI (2006) Occipitocervical fusion after resection of craniovertebral junction tumors. J Neurosurg Spine 4:137–144

    PubMed  Google Scholar 

  43. Vishteh AG, Crawford NR, Melton MS, Spetzler RF, Sonntag VKH, Dickman CA (1999) Stability of the craniovertebral junction after unilateral occipital condyle resection: a biomechanical study. J Neurosurg 90:91–98

    CAS  PubMed  Google Scholar 

  44. Wackenheim A (1997) Roentgen diagnosis of the cranio-vertebral region. Springer-Verlag, New York

    Google Scholar 

  45. Waldvogel FA, Medoff G, Swartz MN (1970) Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (second of three parts). N Engl J Med 282:260–266

    CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Dong-Su Jang, MFA, (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Korea) for his help with the illustrations.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea

    Hun Ho Park, Kyu-Sung Lee & Chang-Ki Hong

  2. Department of Spine Surgery, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea

    Jeong-Yoon Park & Dong-Kyu Chin

Authors
  1. Hun Ho Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jeong-Yoon Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dong-Kyu Chin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kyu-Sung Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Chang-Ki Hong
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chang-Ki Hong.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. The approval number of the institution’s ethic committee is 3-2018-0118.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Park, H.H., Park, JY., Chin, DK. et al. The timing of fusion surgery for clival chordoma with occipito-cervical joint instability: before or after tumor resection?. Neurosurg Rev 43, 119–129 (2020). https://doi.org/10.1007/s10143-018-1020-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-018-1020-7

Keywords

Search

Navigation