• History and Examination
    • 20yo M presents with progressively worsening neck pain over 5 months. This is now associated with R arm pain radiating down to the dorsal surface of his thumb. He was treated with PT, NSAIDs and a chiropractor. Had X-rays when he first developed symptoms that were interpreted as normal. Has new imaging now.
    • PMH – neg
    • PsurgHx – neg
    • Meds – Naproxen
    • PE
    • AF VSS
    • Neurologically intact

    Figure 1

    Figure 2

    Figure 3

    1. What muscle would likely be affected in the distribution of his pain?

    2. What surgical approach would you recommend?

    3. Review his pathology results in figure three. The cells were positive for brachyury. What is the likely diagnosis?

     

    4. What would you recommend next?

    5. Which of the following describes you?

    6. I practice in one of the following locations.

    7. Comments
     
    • PEEK cage and screws/ rods only
    • excellent case, thank you for encouraging us to study
    • BRACHYURY=?  BIOPSY after looking all cuts  nice!
    • Would consider enblock resection since it looks that there is involvement of posterior elements
    • Anterior cervical corpectomy and fusion, and followed, 1-2 weeks later, by posterior fusión.  After the surgeries, Proton Beam RT

     

     

     

     

    Case Explanation:

    • The patient presented with pain in a C6 distribution and the biceps muscle would most likely be affected if he had weakness.
    • The patient’s imaging shows a pathologic fracture. Tissue diagnosis prior to surgical planning would be ideal in case he needs an en bloc resection.
    • His pathology is consistent with chordoma. Brachyury is a useful test to distinguish between chordoma and chondrosarcoma
    • Proton beam radiotherapy is the adjuvant treatment of choice. Options include postop radiotherapy versus neoadjuvant radiotherapy followed by radiation boost after surgery.

     

    References:

    • Rosenberg et al. Chondrosarcoma of the base of the skull: a clinicopathologic study of 200 cases with emphasis on its distinction from chordoma. Am J Surg Pathol, 1999.
    • Rotondo et al. High dose proton based radiation therapy in the management of spine chordomas: outcomes and clinicopathological prognostic factors. JNS Spine, 2015.
    • Molina et al. Outcomes following attempted en bloc resection of cervical chordomas in the C1-2 region versus the subaxial region: a multiinstitutional experience. JNS Spine, 2014.
       

    Social Media:
    Continue the discussion on LinkedIn with our members-only Case of the Month Discussion Group. Create a dialogue and see how your recommendations compare with your colleagues across the globe.

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site here. Privacy Policy