A giant lumbar chordoma: A case report

Sclerotic lumbar chordoma: A case report

Chordoma is a rare tumor, often occurring in the cervical spine and sacrococcygeal spine with a lytic appearance, but rarely in the thoracolumbar spine. Chordomas can occasionally be sclerotic and are included in the differential diagnosis for an ivory vertebra. We present a case of a sclerotic chordoma in an upper lumbar vertebral body with corresponding multimodality imaging. This case demonstrates that chordoma should be a concern for an older adult with a sclerotic vertebral lesion, particularly if it is a solitary lesion. Knowledge of the variable location and appearance of chordomas is critical so it is not mistaken for a metastasis.

Exophytic Lumbar Vertebral Body Mass in an Adult with Back Pain

Chordomas are rare primary bone malignancies derived from notochord remnants. The tumors often are slow-growing and often present with indolent, nonspecific symptoms. Nevertheless, chordomas are locally aggressive and highly prone to local recurrence, necessitating precise planning before biopsy and/or surgical resection. Familiarity with the imaging features of chordomas is, therefore, essential. This case highlights the typical imaging and pathologic features of a spinal chordoma as well as the surgical approach and the patient's subsequent outcome.

Navigated Ultrasonic Osteotomy to Aid in En Bloc Chordoma Resection via Spondylectomy

BACKGROUND

Chordomas are rare, locally malignant tumors derived from remnants of the notochord that can manifest anywhere in the spine or base of the skull. Surgical treatment for chordomas of the lumbar spine often fails to achieve successful en bloc resection, which is critical to minimizing recurrence risk.

CASE DESCRIPTION

In this case report, the authors describe total en bloc resection of a lumbar vertebral body chordoma via the first documented approach of navigated ultrasonic osteotomy for spondylectomy. The patient is a 43-year-old man with end-stage renal disease, requiring dialysis, secondary to diabetes mellitus. The lesion in question was incidentally discovered in the L5 vertebral body during full body scanning for evaluation for a renal transplant. The lesion was diagnosed as a chordoma via percutaneous coaxial needle biopsy. Allogeneic renal transplant was canceled pending treatment of this newly discovered lesion. A combined, staged approach of L3-pelvis posterior instrumented fusion, L5 laminectomy and spondylectomy, and anterior L5 cage reconstruction with L4-S1 fusion was planned. Intraoperative computed tomography scan was performed and stereotactic osteotomies were planned. Ultrasonic osteotome (SONOPET Ultrasonic Aspirator) was registered as a navigation tool and employed, after verification, to complete the posterior stereotactic osteotomies, with postoperative computed tomography, magnetic resonance imaging, and pathology demonstrating successful en bloc resection. The navigated osteotome provided a critical combination of surgical precision and efficiency intraoperatively.

CONCLUSIONS

This approach offers a promising technological adjunct for the treatment of complex spine tumors requiring precise resection and reconstruction.

Surgical treatment of giant chordoma in the thoracic spine combining thoracoscopic and posterior spinal surgery: A case report

RATIONALE

Giant thoracic chordoma is a highly unusual disease with no standard curative managements yet. The objective of this study is to report a very rare case of giant thoracic chordoma successfully operated by combination of thoracoscopic surgery together with posterior spinal surgery. The management of these unique cases has yet to be well-documented.

PATIENT CONCERNS

A 64-year-old man presented with a 4-month history of continuous and progressive back pain. The patient, who had been diagnosed of sacral chordoma for 2 years, received surgical treatment of posterior sacral tumor resection and instrumentation. A lytic, expanding lesion of the T5 and T6 vertebral and paraspinal region with mild epidural spinal cord compression was identified.

DIAGNOSIS

MRI of spine and PET/CT showed spinal cord compression secondary to the epidural component of the T5 and T6 mass, with increased metastatic marrow infiltration of the left T5 and T6 vertebral and paravertebral region, which presented as a solid tumor. Postoperative pathology confirmed the diagnosis of thoracic chordoma.

INTERVENTIONS

The patient underwent 1-stage thoracoscopic release of vertebral and paravertebral tumors, posterior resection of T5-T6 vertebral and paravertebral tumors, T4-T7 spinal canal decompression, and T2-T9 pedicle screw fixation procedure via a posterior approach.

OUTCOMES

The patient's neurological deficits improved significantly after the surgery, and the postoperative period was uneventful at the 3-month and 6-month follow-up visit. There were no other complications associated with the operation during the follow-up period.

LESSONS

Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Combined efforts of specialists from orthopedics, thoracic surgery, neurosurgery, and medical oncology led to the successful diagnosis and management of this patient. Giant thoracic chordoma, although rare, should be part of the differential diagnosis when the patient has a history of sacral chordoma and presents with back pain and radiculopathy. We recommend the posterior approach for spinal decompression of the giant thoracic chordoma when the tumor has caused neurological deficits. One-stage thoracoscopic release or resection of vertebral and paravertebral tumor is also a good choice for surgical treatment.