Introduction: Results on surgical treatment of chordomas from series published in the literature are disappointing with survival rate of 50% and 35% respectively at 5 and 10 years. In most reports, surgical resection is limited to a palliative decompression or at best to a subtotal resection. The purpose of this study is to evaluate the results of patients treated aggressively by several surgeries and radiotherapy from 1989 to 2000.

Methods: From a series of 36 patients presenting with cervical (N=8) or suboccipital (N=28) chordomas, 22 were referred primarily while 14 were sent to us for a recurrence after a previous partial surgical resection. In both groups of patients, we proposed as radical a surgical resection as possible realized in one to four surgical stages followed by radiotherapy (and protontherapy for the more recent cases).

Results: Patients seen at first presentation (group A) underwent 1,9 surgeries in average and 10 of them could have a protontherapy while in group B patients referred after recurrence, 1,4 surgeries were carried out and 3 could have a protontherapy. Follow-up extends from 1 to 11 years (mean 4 years).

Actuarial survival rate was 80 and 65 % respectively at 5 and 10 years in group A as compared to 50 and 0% in group B. Actuarial recurrence free rate was 70 and 35% at 5 and 10 years in group A and 0% at 3 years in group B. Disease related mortality was 15% in group A and 63% in group B. The rate of recurrence per year was 0,15 in group A and 0,62 in group B. The mean delay before the first recurrence was 43 months in group A and 15 months in group B.

Factors such as sex, age, duration of symptoms, severity of symptoms, extent of tumor, histological type or grading have no influence on the survival rate and the recurrence free rate. Even the comparison between patients having received or not radiotherapy and patients treated or not by protontherapy failed to show any difference. However these groups of patients are very small and include group A and group B patients.

Conclusion: Aggressive surgical treatment at first presentation of patients with chordomas seems to provide better results in term of survival and recurrence. However it requires several surgical stages (up to four) followed by radio and protontherapy. No others factors has proven to influence the prognosis. In case of patients already presenting a recurrence this aggressiveness does not seem to be justified. Therefore after this study, aggressive surgical treatment was only proposed to primary patients (N=12) and not on patients with recurrence (N=7).

Introduction: Oblique corpectomy is a surgical technique of spinal cord decompression through a limited bone resection of the postero lateral corner of the vertebral bodies. In this study the results of this technique applied in cases of spondylotic myelopathy and tumors are presented.

Methods: The oblique corpectomy is achieved through a lateral approach with control and sometimes transposition of the VA. It can be used at any level from C2 to T1 and on as many levels as required from 1 to 5. It was mostly applied on cervical spondylotic myelopathy (N=157) or radiculopathy (N=89) but also on hourglass tumors (neurinomas N=67, meningiomas N=7, hemangioblastoma N=1, paraganglioma N=1) and different tumors N=49 involving the lateral part of the vertebral body such as osteoïd osteomas N=8, chordomas N=11, aneurysmal cyst N=3, sarcomas N=4. The total series includes 126 tumors. In most cases preservation of the main part of the vertebral bodies permitted to avoid bone grafting and plating. However stabilization procedure is still necessary when more than one disc are resected and when the discs are soft and not collapsed.

Results: Excellent decompression was obtained in every case of spondylotic myelopathy and radiculopathy. Clinical results are similar to those obtained by any other techniques of decompression through anterior approach but without the complications related to grafting and plating. Improvement of the preoperative score was noted in 79% of patients with myelopathy stabilization in 13% and worsening in 8%. In patients with radiculopathy, good and excellent results were obtained in 85%. A better decompression of the intervertebral foramen is achieved through the oblique corpectomy since the whole length of the cervical nerve root from the dural sac to the vertebral artery can be decompressed. Instability requiring further stabilization procedure was observed only in 3 cases which in fact were preoperatively unstable.

Complete tumor resection was achieved in every case especially for the lateral part located into the intervertebral foramen and around the vertebral artery. Even tumors extending from the outside of the spine to the intradural space could be entirely removed through the same approach. Grafting and plating were realized in 13 out of the 126 cases of tumor.

Conclusion: Oblique corpectomy techniques is a safe technique which permits to decompress the spinal cord and cervical nerve roots from spondylotic elements and tumors. As compared to other techniques, it achieves a better decompression on the lateral part of the spinal canal and on the intervertebral foramen up to the vertebral artery. In many cases it does not require any complementary stabilization technique and avoids the use of instrumentation.

Introduction: Standard approaches to the craniocervical junction (CCJ) includes the midline posterior approach and the transoral approach. Both of them are limited laterally because of the Vertebral Artery (VA). Lateral approaches in which the VA is controlled and sometimes mobilized or transposed have been developed to reach the lateral corner of the CCJ. The surgical technique and personal experience are presented.

Methods: From our experience in the VA surgical exposure, we developed since 1980 two lateral approaches directed towards the CCJ: the posterolateral and the anterolateral approach. The posterolateral approach is a lateral extension of the midline posterior approach with control of the VA above the arch of atlas and opening of the CCJ up to the VA. Minimal drilling of the arch of atlas and occipital condyle is realized. It is mostly applied on intradural tumors but also in some extradural posterolateral lesions.

The anterolateral approach is a superior extension of the lateral approach used to control the VA from the C6 to C2 levels. The field is opened between the sternomastoïd muscle and the internal jugular vein. Then the VA is exposed between C1 and C2 transverse processes and above C1. It is essentially applied on extradural and bony lesions around the CCJ.

Experience: Posterolateral approach was applied on 109 tumors, mostly meningiomas (N=78) and neurinomas (N=22) and 4 bony malformations compressing the VA or the neuraxis. Excellent results were obtained with complete tumoral resection (Simpson grade I or II for meningioma) with only one case of worsening of the neurological condition and two cases with stabilization.

Anterolateral approach was used on 139 patients with different types of tumors including neuromeningeal tumors N=36, primary bone tumors N=51, sarcoma N=16 and others types N=21, and on 3 cases of VA compression by bone malformations. Satisfying tumoral resection could be achieved in almost all cases. Sacrifice of the VA was deliberately realized in 5 patients to ensure as radical a resection as possible in case of malignant tumors or chordomas.

There was no mortality in this series. Morbidity is very limited; injury of the VA was observed in two cases in which repair of the vessel could be done successfully. Stretching of the XI nerve was the cause of pain along the trapezius muscle in 5 patients.

Conclusion: Lateral approach to the CCJ can be realized through two different axis of work: the posterolateral and the anterolateral approach. These approaches gives very nice and safe access to the lateral aspect of the CCJ. They complete the other approaches to the CCJ and may be used in association with them.