|Year : 2017 | Volume
| Issue : 2 | Page : 128-130
Anesthetic management of excision of recurrent C2 chordoma with extension into posterior pharyngeal wall
Vidhu Bhatnagar1, Abhijit A Karmarkar1, Deepak Dwivedi1, Arijit Ray2
1 Department of Anesthesiology and Critical Care, INHS Asvini, Mumbai, India
2 Department of Anesthesiology and Critical Care, AFMC, Pune, Maharashtra, India
|Date of Web Publication||13-Feb-2018|
Dr. Vidhu Bhatnagar
Department of Anesthesiology and Critical Care, INHS Asvini, Near RC Church, Colaba, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Tumors from remnants of the embryonic notochord are called as Chordomas. These are slow growing, yet aggressive tumors. Despite treatment, these, low grade, malignant tumors are very prone to recurrence and 6 years is approximately the median survival time. Though commonly located in the sacrococcygeal or sphenooccipital regions, their incidence in the cervical spine is around 7.5%. Treatment approaches vary from surgical excision to radiotherapy and chemotherapy. Outcome of these tumors depends on the size and location of tumour and the course of treatment delivered. Surgery is the treatment of choice with the goal to remove maximum tumor as possible and thereafter, patients are offered radiotherapy or chemotherapy. Due to the proximity of these tumors to various vital structures such as brain and spinal cord, the management requires the involvement of various subspecialties working in cohesion. We present the anesthetic management of a 32-year-old male patient who presented with recurrence of C2 chordoma postradiotherapy and was a challenge for airway management.
Keywords: Airway management, atlantoaxial, decompression, neoplasms, paresis, paresthesia, surgical
|How to cite this article:|
Bhatnagar V, Karmarkar AA, Dwivedi D, Ray A. Anesthetic management of excision of recurrent C2 chordoma with extension into posterior pharyngeal wall. J Mar Med Soc 2017;19:128-30
| Introduction|| |
Chordomas are low-grade malignant, locally invasive tumors arising from remnants of the embryonic notochord and account for around 1%–4% of all malignant bone tumors. Despite treatment, these tumors are very prone to recurrence and 6.3 years is estimated as the median survival time. Although the predominant location is in the clivus or sacral spine around six to 7.4% of them can be seen in cervical spine region. Treatment approaches vary from surgical excision to radiotherapy and chemotherapy. Outcome of these tumors depends on the size and location of tumor and also on the course of treatment delivered. Chordomas are highly challenging to manage and despite adequate management are very prone to recur at the same site. Surgery is the treatment of choice with the goal being to remove maximum tumor as possible. Complete resection provides maximum chances for long-term remission, but due to their close to various vital structures such as brainstem, spinal cord, nerves, it is not always possible.
Radiotherapy is offered to some for prolongation of survival and to decrease the risk of recurrence. Radiotherapy is even offered to those patients who are not candidates for surgical excision of tumor. Many patients present with repeated recurrence despite surgical decompression and radiotherapy. Chemotherapy is offered to patients with advanced or inoperable tumors to slow down the progression of tumor.
We present our experience with the anesthetic management of a patient with recurrent C2 Chordoma extending into anterior longitudinal ligament and emphasize on the importance of preoperative planning, interdepartmental coordination and the importance of a definite plan for airway management in this case.
| Case Report|| |
A 32-year-old, 74 kg male, previously operated for C2 chordoma presented with complaints of neck pain and bilateral paresthesia of the upper limb. On examination, the patient had decreased gag reflex and right XII cranial nerve paresis. Magnetic resonance imaging (MRI) cervical spine showed expansile lesion involving cervical vertebrae one and two with anterior bulging of the anterior longitudinal ligament causing anterior bulging of the posterior pharyngeal wall [Figure 1]. The patient was planned for transoralodontoidectomy and decompression under general anesthesia with controlled ventilation using awake fiberoptic oral intubation (FOB), invasive monitoring, and tracheostomy for postoperative ventilation. Other investigative parameters of the patient were within normal limits. The patient was accepted in ASA Physical Status III. Informed consent was obtained. Preinduction monitoring included electrocardiogram, noninvasive blood pressure, heart rate, and peripheral oxygen saturation. Venous access was established with 16G cannula. The airway was prepared for facilitating awake FOB. The patient was intubated using flexible fiberoptic bronchoscope with flexometallic endotracheal tube size seven. Correct placement of the tube was confirmed by capnography. Anesthesia was induced using Propofol (120 mg) and maintained using oxygen, air, and Sevoflurane. Muscle relaxation was achieved using Vecuronium. Surgery was performed in supine position and was uneventful. The duration of surgery was 6 h. Thereafter, the patient was shifted to Intensive Care Unit (ICU) for elective ventilation. The patient was weaned off from ventilator after 24 h. Placement of a nasogastric tube orally was a challenging task and was performed under vision, orally, with the help of video laryngoscope (King vision ™) just before extubation. Blind insertion of nasogastric tube was not performed so as to prevent any injury to the operated site.
|Figure 1: Magnetic resonance imaging cervical spine showed expansile lesion involving cervical vertebrae 1 and 2 with anterior bulging of the anterior longitudinal ligament causing anterior bulging of the posterior pharyngeal wall.|
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| Discussion|| |
Chordomas constitute around 1%–4% of bony neoplasm and constitute around 2%–4% of the malignant neoplasms. Most commonly, they are located in the region of remnants of embryonic notochord, on either end of the spinal axis, i.e., clivus or sacral spine. The incidence of the location of chordomas is around 29% sacrococcygeal, 32% clival and 32% are spinal. Very rarely, they are found in cervical spine region (incidence 6%). Treatment of choice is radical resection and adjuvant therapies such as radiotherapy or chemotherapy for recurrence or tumors which are inoperable. These tumors are locally invasive and have great propensity for recurrence. Cervical spine chordomas present a challenging situation for resection due to proximity to many vital structures. Tumor extension into epidural or paravertebral compartment is also possible at the time for the initial presentation. Thus, en bloc resection may not be feasible and gross total resection is considered the choice of treatment with adjuvant therapy. They also pose a challenge to anesthesiologist presenting as difficult airway.,
Our patient was previously managed with gross total resection of the tumor followed by 23 cycles of radiotherapy. He presented after 1 year to us with complaints of paresthesia of both upper limbs and neck pain. On radiological investigation, recurrence was detected with an expansile lesion involving cervical vertebrae one and two with anterior bulging of the anterior longitudinal ligament causing anterior bulging of the posterior pharyngeal wall. The patient was planned for transoralodontoidectomy and tumor decompression. Airway management was carefully keeping in view anticipated difficult airway. This tumor was encroaching in the posterior pharyngeal wall; patient was postradiotherapy; hence, the area of interest for securing airway was friable, more prone for injury if adequate care was not taken during FOB assisted intubation. The patient had minimal cervical spine extension due to previous occipito C3–C4 fixation with instrumentation of the cervical spine.
A nasal intubation was not considered in this case because of the anterior bulging of the posterior pharyngeal wall caused by the expansile lesion, which can be well appreciated in the MRI [Figure 1]. Nasal intubation would have left the ET tube encroaching in the surgical field and hindering the surgical access [Figure 2]. Another dilemma was regarding surgical airway (tracheostomy) before surgery by ENT surgical team, under monitored anesthesia care. However, it was decided that an attempt for awake FOB-assisted intubation will be made if the tumor encroachment is very extensive then decision for surgical airway will be taken on the table.
|Figure 2: Transoralodontoidectomy and decompression under general anesthesia showing the placement of oral endotracheal tube orally.|
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Some cases of failed nasal FOB intubation due to nasopharyngeal extension of growth have been reported; thus, MRI spine was used for planning definitive airway management in this case. A preoperative tracheostomy may have been necessary if pharyngeal opening was severely compromised on imaging which was not so in our case. Barrenechea et al. mentioned the use of FOB for intubation in cases of chordoma with cervical instability. The rest of the anesthetic course was uneventful; the patient was planned for elective postoperative ventilation for 24 h. The patient was extubated after 24 h uneventfully in the ICU.
Understanding and planning ahead for the possible perioperative complications is of paramount importance for practicing safe anesthesia. The tumor was extending anteriorly, causing bulging of the posterior pharyngeal wall and was in direct route of placement of endotracheal tube, thus creating difficulties in securing the airway. A thorough and comprehensive preoperative evaluation along with meticulous planning with the surgical team was our key to successful management of this procedure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]