SPINE Operative Technique

Sequentially Staged Resection and 2-Column

Reconstruction for C2 Tumors Through
a Combined Anterior Retropharyngeal–Posterior
Approach: Surgical Technique and Results in
11 Patients
Xinghai Yang, MD*
Zhipeng Wu, MD*
Jianru Xiao, MD*
Honglin Teng, MD‡
Dapeng Feng, MD*
Wending Huang, MD*
Huajiang Chen, MD*
Xinwei Wang, MD*
Wen Yuan, MD*
Lianshun Jia, MD*
*Department of Orthopedics, Shanghai
Changzheng Hospital, Second Military
Medical University, Shanghai, China;
‡Department of Spine Surgery, First
Affiliated Hospital of Wenzhou Medical
College, Wenzhou, Zhejiang, China
Correspondence:
Jianru Xiao, MD,
Department of Orthopedics,
Shanghai Changzheng Hospital,
Second Military Medical University,
No. 415 Fengyang Rd,
Shanghai 200003, China.
E-mail: Jianruxiao83@163.com
Received, August 22, 2010.
Accepted, February 22, 2011.
Published Online, April 14, 2011.
BACKGROUND: Surgical treatment of C2 tumors remains challenging. Because of the
deep location and unique anatomical complexity, anterior exposure in this region is
considered difficult and dangerous, and few reports concerning anterior tumor resection
and reconstruction exist.
OBJECTIVE: To describe a technique of sequentially staged resection and 2-column
reconstruction for C2 tumors through a combined anterior retropharyngeal–posterior
approach.
METHODS: Eleven patients with C2 tumors underwent sequentially staged tumor resection
and 2-column reconstruction in our institute. Eight primary lesions and 3 metastases were
involved. Tumor resections and anterior reconstructions with conventional constructs were
accomplished by an anterior retropharyngeal approach, and occipitocervical fusions
through posterior access were performed in the same anesthesia.
RESULTS: No operative mortality occurred in this series. All patients experienced pain
relief and neurological improvement after surgery. Except for 1 incidence of screw
pullout, which was corrected by revision surgery, solid fusion was achieved in all
patients. A follow-up period of 12 to 37 months was available for this study. Two patients
with chordoma relapsed; 1 died of disease, and the other was alive with disease. Two
patients with metastasis died of multiple remote metastases. No evidence of local
recurrence was found in the other patients.
CONCLUSION: The anterior retropharyngeal approach is a favorable route to treat tumor
lesions of the C2 vertebral body that allows tumor resection and placement of anterior
constructs between C1 and the subaxial vertebral body. Tumor resection and 2-column
reconstruction could safely be accomplished simultaneously through the combined
anterior retropharyngeal–posterior approach.
KEY WORDS: Approach, Axis, Operative procedure, Spinal neoplasms, Spinal reconstruction, Upper cervical
spine

Copyright ª 2011 by the Neurosurgery 69[ONS Suppl 2]:ons184–ons194, 2011 DOI: 10.1227/NEU.0b013e31821bc7f9
Congress of Neurological Surgeons

A
nterior exposure of the upper cervical
spine is considered difficult and danger-
ous because of the anatomical complex-
ity, deep location, and proximity to vital
neurovascular structures of this region. Although
several accesses have been described in the lit-
erature,1-12 some controversy remains regarding
the best approach for selected lesions. The
transoral approach is a popular anterior access to
the upper cervical spine that provides direct
exposure for anterior decompression of the spinal
cord and the brainstem.2-4 However, dis-
advantages of the transoral access such as risk of
infection, limited exposure, and difficulties in
postoperative recovery have also been mentioned
in the literature. To achieve total resection of
C2 tumor lesions, mandibulotomy or mandib-
ulotomy plus glossotomy for wide exposure is

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required in a transoral procedure,8-10 which may increase the risk
for more potential complications. The anterior retropharyngeal
approach is an alternative to transoral access that can provide
similar exposure to that obtained by the transoral route and avoid
the risks and limitations of transoral surgery. Recently, some
studies demonstrated that anterior fixation could be accom-
plished simultaneously through the anterior retropharyngeal
route to treat trauma, deformity, and chronic inflammatory
diseases of C2.13,14 However, to the best of our knowledge, there
has been no published report describing excision and anterior
fixation for C2 tumor lesions through the anterior retro-
pharyngeal approach. In this study, we present our experience
with resection and 2-column reconstruction to treat bone tumor
lesions of the axis by a combined anterior retropharyngeal–
posterior approach.
MATERIALS AND METHODS
Patients
From March 2007 to April 2009, 11 patients with tumor lesions at the
axis were identified as candidates for resection and 2-column re-
construction through the combined anterior retropharyngeal–posterior
approach in our institute. This series included 7 male and 4 female
patients. The mean age was 50 years, ranging from 23 to 77 years.
Encountered lesions included chordoma (2 cases), solitary plasmacytoma
(2 cases), giant-cell tumor (2 cases), eosinophilic granuloma (1 case),
hemangio-perithelioma (1 case), and metastasis (3 cases). The distri-
bution of the series is shown in Table 1.
All patients complained of chronic, gradually progressive local or
radicular pain. Three patients with a metastatic lesion suffered from
severe pain, which required oral application of codeine or morphine to
control. Seven patients presented motor deficit caused by spinal cord
compression that was classified as C grade (n = 3) and D grade (n = 4)
according to the Frankel scale (Table 1).
Staging
From both magnetic resonance imaging and computed tomography
findings, the extent of the lesions was delineated according to the
Weinstein-Boriani-Biagini staging.15 According to this system, the in-
volvement zones were anterior column alone (Weinstein-Boriani-Biagini
sectors 4-9) in 6 cases and both anterior and posterior columns in 5 cases
(Table 1).
Surgery
All patients underwent tumor resection and 2-column reconstruction
though a combined anterior retropharyngeal–posterior approach.
Nasal endotracheal intubation is performed with the aid of a bron-
chofibroscope for general anesthesia. The patient is positioned supine,
with the head slightly extended and rotated contralateral to the surgical
approach. (To ensure neck mobility for this position, the anterior
procedure was performed before the posterior operation.) A modified
submandibular incision was adopted (Figure 1).
The anterior retropharyngeal approach to the upper cervical spine has
previously been described in detail.13,16-18 The skin and superficial fascia
are incised in line with the incision. The platysma is divided and ret-
racted, exposing the inferior edge of the submandibular gland. Then the
NEUROSURGERY
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TWO-COLUMN RECONSTRUCTION OF C2 TUMORS
submandibular gland is elevated, and the fascial capsule is opened and
dissected horizontally. The facial artery and vein are identified and
dissected free in the field of dissection posterior and lateral to the gland.
The tendon of the digastric muscle is identified under the inferior edge of
the submandibular gland. Transecting the fascial sling between digastric
tendon and the hyoid bone frees the digastric muscle. The muscle bellies
are then retracted upward to reveal the external and internal carotids and
the hypoglossal trunk. The hypoglossal nerve is gently dissected along its
course and carefully retracted superiorly. The fascia between the hyoid
bone and carotid sheath is incised, and the carotid sheath is then re-
tracted laterally. The superior laryngeal nerve, which courses deeply and
parallel to the superior thyroid artery in the paratracheal fascia, is
identified and preserved. Retraction of the visceral sheath opens the
retropharyngeal space and exposes the alar fascia, precervical fascia, and
longus colli muscles. The longus colli muscles are dissected from the
anterior arch of C1 and the surface of vertebral bodies and then elevated
in a lateral and cephalad direction. Thus, a satisfactory exposure con-
taining the anterior arch of C1 and vertebral bodies of C2 and lower
cervical vertebrae is obtained (Figure 2).
Tumor resection is performed in a piecemeal fashion. Good he-
mostasis can be achieved with the use of bipolar electrocoagulation and
absorbable hemostatic gauze. The headlight and 2.5 3 binocular
magnifier improve the surgeon’s vision during the procedure. The
excision is continued until the entire involved vertebral body is re-
moved. For cases with transverse process involvement, the involved
transverse process is also removed. Care must be taken to preserve the
vertebral artery in these cases. Opening the transverse foramen and
exposing the vertebral artery beforehand is helpful. After removal of the
tumor lesion, the cavity is irrigated copiously with deionized water and
saline in sequence in an effort to minimize the possible contamination
of tumor cells.
Anterior reconstruction is accomplished in 2 fashions: titanium mesh
cage plus titanium locking plate or titanium mesh cage alone. In the
former manner, the defect is reconstructed with a 12-mm-diameter
titanium mesh cage filled with autologous iliac crest bone graft. The cage
is carefully wedged in the space between the arch of C1 and the upper
endplate of the subaxial vertebral body. A titanium locking plate suitable
for the distance from the C1 arch to the subaxial vertebral body is used.
The cephalic end of the plate can be fixed with 2 screws to the C1 anterior
arch vertically or to the C1 unilateral mass obliquely (Figure 3A and 3B).
The caudal end of the plate is fixed to the subaxial vertebral body with
routine methods. In the latter fashion, a 14-mm-diameter titanium mesh
cage filled with autologous bone graft is used alone. The cage is carefully
trimmed so that its main body can be wedged into the space between the
C1 arch and the upper endplate of the subaxial vertebral body, and the
anterior overhanging edges allow screw fixation to the C1 arch and
subaxial vertebral body (Figure 3C). Routing drainage and closure of the
anterior retropharyngeal approach is then performed.
The patient is then turned prone, with staff taking extreme care to
keep the head fixed in a neutral position with a gypsum mold that is
prepared before surgery. A standard midline posterior approach is
adopted in the posterior procedure. The exposure extends from the
occiput to the second spinous process below the pathological vertebrae.
The spinous process, lamina, and involved lateral mass of the patho-
logical vertebrae are removed. The posterior reconstruction is achieved
with occipitocervical fixation extending down to the first 2 or 3 healthy
segments below the lesion. Autograft bone is placed between the de-
corticated surfaces of the occiput and the first healthy subaxial vertebrae.
The wound is closed in a routine fashion.
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YANG ET AL
TABLE 1. Clinical Data of a Series of 11 Patients With C2 Tumorsa
Preoperative
Age, Staging Preoperative Neurological Postoperative Postoperative Follow-
Patient Sex y Diagnosis (WBB) FS Symptoms Reconstruction Care Complications FS up, mo Results
1 M 74 C2-3 chordoma 2-9/B-D C Neck pain, (A)C1-34+ (P) Extubation Trouble D 37 Pain relieved;
tetraparesis O-C345 after 24 h, swallowing UE and LE
nasogastric liquids strength
feeding for improved;
1 wk anterior screw
pullout, solid
fusion after
revision; LR;
AWD
2 M 70 C2 metastasis 3-8/A-D E Severe neck (A)C1-34+ (P) Extubation after None E 12 Pain relieved;
(lung) pain, UE O-C345 12 h remained
numbness neurologically
intact; solid
fusion; DOD
3 F 62 C2 solitary 2-9/A-D E Neck pain, (A)C1-3+ (P) Extubation after None E 30 Pain relieved;
plasmacytoma torticollis, O-C345 12 h remained
UE neurologically
numbness intact; solid
fusion; NED
4 F 25 C2-3 chordoma 4-9/A-D C Neck pain, (A)C1-4+ (P) Extubation Retropharyngeal E 28 Pain relieved;
tetraparesis O-C456 after 24 h, CSF cyst, complete
nasogastric dysphagia, neurologic
feeding for slight recovery; solid
3 wk dyspnea fusion; LR, DOD
5 M 24 C2 eosinophilic 4-9/A-D D Neck pain, (A)C1-3+ (P) Extubation at None E 27 Pain relieved;
granuloma UE and LE O-C345 12 h complete
weakness neurologic
recovery; solid
fusion; NED
6 M 77 C2 metastasis 5-8/A-D D Severe neck (A)C1-3+ (P) Extubation at None E 18 Pain relieved;
(prostate) pain, UE and O-C345 12 h complete
LE weakness neurologic
recovery; solid
fusion; DOD
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7 M 55 C2 metastasis 4-12/A-D E Severe neck (A)C1-3+ (P) Extubation None E 20 Pain relieved;
(nasopharyngeal) pain, O-C345 after 12 h remained
torticollis neurologically
intact; solid
fusion; NED

(Continues)

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NEUROSURGERY

TABLE 1. Continued
Preoperative
Age, Staging Preoperative Neurological Postoperative Postoperative Follow-
Patient Sex y Diagnosis (WBB) FS Symptoms Reconstruction Care Complications FS up, mo Results
8b M 41 C2-4 giant-cell 3-11/A-D D Neck pain, (A)C1-5+ (P) Extubation None E 16 Pain relieved;
tumor UE and LE O-C1-C56 after 72 h, complete
weakness nasogastric neurologic
feeding for 3 d recovery; solid
fusion; NED
9b M 41 C2 solitary 4-9/B-C D Neck pain, (A)C1-3+ (P) Extubation None E 15 Pain relieved;
plasmacytoma UE and LE O-C345 after 12 h complete
weakness neurologic
recovery; solid
fusion; NED
10 F 56 C2 giant-cell 4-9/B-C E neck pain (A)C1-3+ (P) Extubation Deep vein E 13 Pain relieved;
tumor O-C1-C34 after 12 h thrombosis remained
neurologically
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intact; solid
fusion; NED
11b F 23 C2 hemangio- 4-9/B-C C neck pain, (A)C1-3+ (P) Extubation Trouble D 12 Pain relieved; LE
perithelioma tetraparesis O-C1-34 after 12 h, swallowing strength
nasogastric liquids improved; solid
feeding for fusion; NED
1 wk

TWO-COLUMN RECONSTRUCTION OF C2 TUMORS

a
A, anterior fusion; AWD, alive with disease; DOD, died of disease; FS, Frankel scale; LE, lower extremities; LR, local recurrence; NED, no evidence of disease; O, occipital; P, posterior fusion; UE, upper extremities;
WBB, Weinstein-Boriani-Biagini staging.
b
Anterior fusion by screw and trimmed titanium mesh.

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YANG ET AL
FIGURE 1. Marking of the modified submandibular skin incision. The skin
incision begins 2 fingerbreadths in front of the angle of mandible, proceeds 1
fingerbreadth below the mandible, and curves downward across the sub-
mandibular triangle and carotid triangle.
Postoperative Management
Intubation was preserved for 12 to 72 hours after surgery to prevent
possible airway obstruction, which might be caused by edema in the
pharynx and retropharyngeal space. Initial parenteral nutrition was ad-
ministered for the first 2 postoperative days, and then nasogastric feeding
(in 4 cases) or liquid diet (in 7 cases) was begun. Nutrition supple-
mentation gradually progressed to a regular diet thereafter. Patients
FIGURE 2. The anatomic relationships in the anterior retropharyngeal exposure. A, artery; M, muscle; N, nerve; V, vein.
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remained in a hard cervical collar for 3 months and then underwent
clinical and radiographic evaluation. All but 1 patient who had eosin-
ophilic granuloma received fractionated stereotactic radiotherapy with
a total dose ranging from 40 to 55 Gy as adjuvant treatment 4 to 6 weeks
postoperatively. In addition, chemotherapy and hormone therapy were
administered to the patient with lung metastasis and the patient with
prostate metastasis, respectively. The follow-up evaluations were taken
regularly 3, 6, and 12 months after surgery in the first year, every
6 months for another 2 years, and then annually for life.
RESULTS
The anterior retropharyngeal approach provided adequate
exposure to the anterior part of C1 and C2 and subaxial vertebrae.
The combination of the anterior retropharyngeal approach and
the posterior route allowed resection and 2-column recons-
truction for C2 tumor lesions.
In the present series, anterior fusion of C1-3, C1-34, C1-4, or
C1-5 and posterior fusion of O-C345, O-C1-C34, O-C456, or O-
C1-C56 were performed. Anterior fusions were achieved with
titanium mesh cage plus titanium locking plate in 8 cases and with
titanium mesh cage alone in 3 cases. The operation time ranged
from 240 to 380 minutes, with an average of 320 minutes. The
average blood loss was 1327 mL, ranging from 1000 to 1900 mL.
The surgical and pathological data from this series are reported
in Table 1. There was no perioperative mortality in this series.
No complications related to the marginal mandibular branch
and hypoglossal nerve occurred. Two patients had trouble
swallowing liquids, which might have been caused by retrac-
tion; they recovered 2 weeks after surgery. Deep vein throm-
bosis occurred in 1 patient, and anticoagulation therapy
was administered. Cerebral spinal fluid (CSF) leak occurred in
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 TWO-COLUMN RECONSTRUCTION OF C2 TUMORS

FIGURE 3. Three options for anterior fusion with conventional construct after tumor resection at C2 through the anterior retropharyngeal approach: A, using a titanium mesh
cage plus titanium locking plate, with the cephalic end of the plate fixed to the C1 anterior arch vertically; B, using a titanium mesh cage plus titanium locking plate, with the
cephalic end of the plate fixed to C1 unilateral mass obliquely; C, using a carefully trimmed titanium mesh cage alone, with the anterior overhanging edges of the cage fixed to
the C1 anterior arch.

1 patient (patient 4), which formed a CSF cyst in the retro-
pharyngeal space. The patient felt dysphagia and slight dyspnea
on postoperative day 7. Magnetic resonance imaging scans
confirmed the CSF leak, and the patient underwent reoperation
anteriorly for debridement and drainage. A lumbar fluid
drainage and reinforced antibiotic therapy were managed after
this reoperation. Lumbar drainage was retained for 12 days.
Fortunately, no infection occurred, and the wound healed 14
days later. The patient recovered well, with the symptoms of
dysphagia and dyspnea having resolved (Figures 4 and 5).
This study includes a follow-up period of 12 to 37 months
with clinical and radiographic evaluation. Neurological status did
not worsen in the early postoperative course of this series. At
reevaluation 3 months after surgery, pain was relieved to various
degrees in all patients. Seven patients showing neurological deficit
before surgery experienced significant improvement in neuro-
logical function after tumor removal by at least 1 level on the
Frankel scale. The other 4 patients with no neurological in-
volvement before surgery remained neurologically intact. One
patient experienced anterior screw pullout 1 month post-
operatively and underwent revision surgery to fix the plate
obliquely to C1 unilateral mass. Solid fusion was achieved in all
other cases, and patients regained their normal function.
Two patients with chordoma relapsed at 13 and 18 months
postoperatively; 1 patient deteriorated with high paraplegia and
died of respiratory failure, and the other was alive with asymp-
tomatic disease at the latest follow-up. Two patients with me-
tastasis from lung and prostate developed multiple remote

FIGURE 4. Case 4: a 25-year-old woman with C2-3 chordoma. Preoperative sagittal view of the magnetic resonance imaging (A). She underwent sequentially staged C2-3
tumor resection and 2-column reconstruction through the combined anterior retropharyngeal–posterior approach. Postoperative lateral view of the x-ray (B). Cerebral spinal
fluid leak occurred and formed a cyst in the retropharyngeal space on postoperative day 7 (C). The patient underwent anterior reoperation for debridement and drainage, and
the wound healed well after continuous lumbar fluid drainage (D).

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YANG ET AL

FIGURE 5. Case 8: a 41-year-old man with a C2-4 giant-cell tumor that developed from a recurrent C3 lesion after the initial
operation. Lateral view of the x-ray (A) and sagittal view of the magnetic resonance imaging (B) before revision. Intraoperative
image of anterior C1-C5 fusion with a carefully trimmed titanium mesh cage alone through the anterior retropharyngeal
approach (C). Lateral view of the x-ray (D) and sagittal view of the magnetic resonance imaging after revision (E).

metastases and died of systemic failure 12 and 18 months
postoperatively, respectively. No evidence of local recurrence was
detected in other patients. The patient outcomes are summarized
in Tables 1 and 2.
DISCUSSION
Surgical treatment of bone tumors at the spine column always
requires wide exposure to achieve total resection and robust re-
construction. However, the complex anatomical properties make
wide exposure of the upper cervical spine difficult. Tumor lesions
of the axis body, although rare, present one of the most chal-
lenging fields in spine surgery.
As a popular access to the upper cervical spine, the transoral
approach provides a rapid and effective route to the anterior
aspect of the lower clivus and the upper cervical spine, as reported
by many authors.2-4 However, the disadvantages such as limited
exposure, risk of infection, and difficulties in treating CSF
leakage are also mentioned in the literature. Although recent
reports5,6 on endoscopically assisted procedures and highly
technical intensive care demonstrate a lower incidence of in-
fection than was previously reported, the infection risk and
postoperative dysphagia still pose serious concerns. Furthermore,
the caudal exposure of a standard transoral approach could reach
only the middle of the axis body1,7 because of the obstacle posed
by the mandible. This exposure may match the requirement of
surgical treatment for some nontumorous conditions but hardly
for tumor lesions of the C2 body, which usually require a wide
exposure to achieve total resection and reconstruction. Although
its modifications as transoral-mandibulotomy or transoral-man-
dibulotomy-glossotomy provide an extensive caudal exposure
and have been advocated to treat tumors of the axis body in a few
reports,8-10 the invasion and approach-related morbidity are also
dramatically increased. Complications such as velopharyngeal
dysfunction, pharyngeal wound dehiscence, lingual neuropath,
and cosmetic deformity have been reported in the literature.9,11
Contamination of the oral cavity and scarce layer covering also
increase the risk of infection to anterior instrumentations in
a transoral procedure. Fixations had to be performed through the
posterior approach in a second stage. After anterior tumor
resection, patients were maintained in traction for a few days and
returned to the operating room for a posterior occipitocervical
fusion procedure. This might increase healthcare costs and
hospital length of stay.

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TABLE 2. Anterior Reconstructive Fashions and Outcomes
Reconstructive
Fashions Cases, n
Titanium mesh cage plus titanium locking plate (screws inserted
into C1 arch)
Titanium mesh cage plus titanium locking plate (screws inserted
into C1 lateral mass and arch)
Titanium mesh cage alone
The lateral retropharyngeal approach also has been used to
treat bone tumors at the occipitocervical junction. As an extraoral
access avoiding the contamination from oral cavity, it presents
a lower incidence of infection with bone grafting than the
transoral route. George et al12 reported a series of 41 patients with
bone tumors at the craniocervical junction who underwent tumor
resection through the same lateral approach. They believed that
this approach could provide a wide exposure with safe control of
the vertebral artery and advocated it to treat occipitocervical
lesions. However, it is not as direct as the anterior route. The
contralateral lesion is out of reach via the single lateral approach.
In our opinion, the lateral approach is suitable to treat lesions of
the lateral mass but not anterior lesions with bilateral invasion. In
the series of George et al,12 most lesions located in the lateral
portion of the vertebrae and all 5 tumors located at the C2
vertebral body were benign lesions. Despite this, the lateral ap-
proach is a complex route and associated with potential risk of
injury to the lower cranial nerves.19
The retropharyngeal approach is an alternative to the transoral
access that offers the same direct access to the anterior part of the
upper cervical spine as the transoral route. Moreover, this
approach allows a greater degree of bilateral exposure than the
transoral route, thus facilitating complete resection of tumor
lesions. Another advantage of the retropharyngeal approach over
the transoral route is that it avoids entry into the bacteria-
contaminated environment of the oral cavity and pharynx. This
allows simultaneous instrumentation during the primary surgical
procedure and provides a safer environment for intradural pro-
cedure and management of a CSF fistula. In addition, no tra-
cheostomy is required in this procedure; thus, the complications
of that procedure are avoided. The disadvantages of this approach
originate from the complex anatomy involved in access. Although
rare, this approach carries an inherent risk of injury to the
marginal mandibular branch, hypoglossal, and superior laryngeal
nerves because these nerves traversing the operative field might be
mistaken for blood vessels and could be ligated incidentally.
Excessive retraction of the hypoglossal nerve and superior
laryngeal nerve may cause nerve palsy. Transient dysphagia and
dysphonia are common problems related to this approach and
often last only a few days but sometimes persist for several
months. A good knowledge and precise identification of the
NEUROSURGERY
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TWO-COLUMN RECONSTRUCTION OF C2 TUMORS
Outcome
3 One incidence of screw pullout, solid fusion after a revision surgery
changing to the second fashion
5 Solid fusion
3 Solid fusion
anatomical structures encountered during the procedure are es-
sential to prevent injury. Wide, sharp dissection of each fascial
plane may reduce the risk of retraction-related injury because less
force is then required in retraction. A horizontal incision has been
widely used in the anterior retropharyngeal approach.13,16,18,20
This transverse incision limits caudal extension, which is usually
required in an anterior procedure for tumor lesions. To resolve
this problem, a ‘‘T-shaped’’ incision consisting of a common
horizontal incision and a vertical incision was adopted in the
McAfee et al report.16 Considering the looseness of skin in this
location, we modified the skin incision to a less invasive curving
one (Figure 1) in an effort to make the caudal extension easier.
The caudal exposure can be extended easily if needed. Downward
extension of the incision connects with the routing anterior
cervical approach, which offers caudal exposure for lower cervical
vertebral bodies. A revision operation of a giant-cell tumor with
involvement of C2-4 was successfully accomplished in which
tumor resection and C1-C5 anterior reconstruction were ach-
ieved in the same approach (Figure 5). Park et al18 advocated
a standard exposure from the patient’s left side to decrease the risk
of injury to the recurrent laryngeal nerve. They believed that the
left recurrent laryngeal nerve is less vulnerable to injury than the
right because it is vertical and ascends to the tracheoesophageal
groove. However, the axis is sufficiently superior to the right
recurrent laryngeal nerve. We agree with McAfee et al16 that
a right-sided exposure in the upper cervical spine, which is
convenient for a right-handed surgeon, will not increase the risk
of damage to the recurrent laryngeal nerve. All patients in the
present study underwent a right-sided anterior procedure, and no
injury to the recurrent laryngeal nerve occurred.
Although the purely posterior approaches also have been used
to treat ventrally located upper cervical spine tumors in a few
reports,21,22 the anterior approaches are still the gold standard for
ventral pathology in the cervical spine. Through a posterior-
lateral approach, tumor resection and posterior reconstruction
can be performed in 1 procedure, and the typical complications of
anterior approaches are avoided. However, the exposure of the
posterior lateral approach to the ventrally located vertebral body is
narrow and deep. The exposure is opened among the nerve roots,
vertebral artery, and spinal cord, making them vulnerable to
injury. It is difficult to resect the ventral lesion around the
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YANG ET AL
anterior midline through the indirect exposure provided by the
posterior lateral approach. For ventral lesions, the purely posterior
approaches can be an option in cases when retraction of the
trachea and esophagus is difficult and when gross total resection
cannot be done because of the patient’s poor medical condition.
Patients with a metastatic lesion in this location have a poor
prognosis and may be candidates for posterior palliative de-
compression and reconstruction. We advocate gross total tumor
resection and reconstruction in patients with primary tumor, for
their lifespan is relatively long. To achieve this goal, a combined
anteroposterior approach is required.
In our series, CSF leak occurred in 1 patient (patient 4) who
had experienced at another institution an unsuccessful posterior
operation with mass remnant of tumor lesion and then received
radiotherapy before the present surgery. During the anterior
surgery, a tumor lesion was found with tight dural adhesion. The
dura was carefully protected during the operation, and no obvious
CSF leak could be seen after tumor resection. Although fibrin
glue was used to reinforce the dura, CSF leak occurred and
formed a cyst in the retropharyngeal space on postoperative day 7,
as mentioned previously, which caused symptoms of dysphagia
and slight dyspnea. Then the anterior debridement, lumbar fluid
drainage, and reinforced antibiotic therapy were managed, and
the patient recovered well. We think that the uncontaminated
environment and multilayer wound contribute to the relatively
easy management of CSF leak. In a transoral surgery, CSF leak
might lead to a poor outcome. The repair of the pharyngeal
wound would be extremely difficult to undertake because the
only layer of pharyngeal wall that was incised in transoral access
can rarely be completely approximated. Although a vascularized
radial forearm flap anastomosed with the facial vessels has been
used to reconstruct the pharyngeal wall,23,24 the procedure in-
creases donor-site morbidity and requires multidisciplinary co-
operation. In addition, CSF leak in a contaminated oral cavity
might cause meningitis,25 which has a high mortality. The ret-
ropharyngeal route could avoid this complex repair and provide
a safe environment. If the dura is deficient, repair with fascial and
subcutaneous fat grafts and fibrin glue may be necessary. We
assume that the recovered CSF pressure postoperatively con-
tributed to the CSF leak in this patient. Therefore, we advocate
the use of lumbar drainage in patients with tight dural adhesion to
prevent CSF leak, even if no obvious dural defect can be found
after tumor resection.
Removal of tumor lesions at the C2 body could cause spinal
instability. In the past, such instability was corrected by an
occipitocervical fusion during a separate surgical procedure.26
However, both anterior and posterior columns are involved in
a total spondylectomy procedure for tumor lesions of the spine.
Without the support of anterior fixation, an extended occipito-
cervical construct is required. Shin et al27 suggested that the
occipitocervical construct should extend to the C7 posterior
elements in patients with a deficient anterior column resulting
from C2 body removal. Therefore, a combined fixation that can
provide adequate stability is biomechanically suitable. However,
ons192 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
because of the anatomical complexity of the atlantoaxial region,
anterior instrumentation poses a unique challenge. The caudal
end of the graft material can be fixed to the subaxial vertebral
body as in a routine subaxial procedure. Establishing an effective
connection at the cranial end of the implant to the atlas presents
challenges because the atlas lacks a vertebral body. Previously,
a few reports in the literature described the efficacy of anterior
fixation through the retropharyngeal access to treat trauma, de-
formity, and chronic inflammatory diseases13,14,18 and in which
the inclusion of arthrodesis and placement of instrumentation
during the primary surgical procedure obviated the need for
a posterior procedure. For tumor lesions of the C2 body, an
anterior fixation may reinforce spinal stability when the patient is
changed from the supine to the prone position after the anterior
procedure to make simultaneous posterior procedure safer.
Although a few constructs designed for reconstructing the C2
vertebra have previously been described,28,29 few of them are
available in most countries. In the present series, 2 types of
anterior fusion were performed with conventional constructs.
Using the titanium locking plate can reduce screw loosening in
the first type; however, the cranial end of the anterior cervical
plate could not match the wide distance between C1 lateral
masses. The screws have to be inserted into the slim anterior arch
of C1, and the fixation strength is limited. One incidence of screw
pullout from the anterior fixation occurred in our series, and the
patient underwent revision surgery to fix the plate obliquely to
C1 unilateral mass and gained solid fusion. Inserting one of the
upper screws into lateral mass may reinforce the fixation strength,
which requires relatively oblique placement of the plate. We
attempted this in 5 cases, and none of the 5 patients developed
fixation failure. Carefully trimmed titanium mesh avoids the need
for plate fixation, which could minimize the space-occupying
effect of the anterior construct. However, lacking a locking de-
vice, the titanium mesh alone has a potential risk of screw
loosening. With the augmentation of posterior instrumentation,
all 3 anterior reconstructions with titanium mesh alone resulted
in solid fusion in the present study.
Unlike treatment for other conditions, the treatment for tumor
lesions that require total resection would cause severe instability,
and single anterior reconstruction is mechanically insufficient.30
Posterior instrumentation and fusion must be added to augment
the anterior construct. Although a sound 3-column reconstruc-
tion has been reported,31 we believe the combined anteropos-
terior 2-column reconstruction is relatively simple and adequate
biomechanical support after C2 spondylectomy.
CONCLUSION
The anterior retropharyngeal approach is an effective alter-
native to transoral access in the surgical treatment of tumor
lesions at the C2 body. The excellent exposure of this approach
allows tumor excision and placement of anterior constructs
between C1 and the subaxial vertebral body. Sequentially staged
resection and 2-column reconstruction can be accomplished
www.neurosurgery-online.com

safely and successfully through the combined anterior retro-
pharyngeal–posterior approach.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
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TWO-COLUMN RECONSTRUCTION OF C2 TUMORS
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COMMENTS
T he authors present a retrospective case series of 11 patients treated
with the anterior retropharyngeal approach for C2 tumors. They
nicely describe the advantages of this approach, including anterior re-
construction. The need for anterior tumor resection and reconstruction
is questionable for metastatic lesions when the main palliative issue is
often spinal stability, which can be achieved solely from a posterior
approach.1–3 If anterior resection is required, in my experience, it is
advantageous to perform the posterior stage first to ensure spinal stability
during the anterior stage and the repositioning between stages. A ret-
ropharyngeal exposure requires extension and rotation of the head and
therefore is not feasible after posterior occipitocervical fixation.
Daryl Fourney
Saskatoon, Saskatchewan, Canada
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in the surgical treatment of cervical spine metastases. Spine. 2009;34(22)(suppl):
S108-S117.
2. Fourney DR, York JE, Cohen ZR, Suki D, Rhines LD, Gokaslan ZL. Management
of atlantoaxial metastases with posterior occipitocervical stabilization. J Neurosurg.
2003;98(2)(suppl):165-160.
3. Bilsky MH, Shannon FJ, Sheppard S, Prabhu V, Boland PJ. Diagnosis and
management of a metastatic tumor in the atlantoaxial spine. Spine. 2002;27(10):
1062-1069.
I n their series, Yang et al present 11 patients with tumors arising from
C2 treated with surgery by a sequentially staged resection and 2-
column reconstruction. In contrast to the traditional transoral, trans-
pharyngeal approach or to the more complex transmandibular, cir-
cumglossal retropharyngeal approach,1 the authors used an anterior
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YANG ET AL
retropharyngeal approach to the ventral surface of the spine. This ap-
proach has the advantage of avoiding contact with the oral cavity while
still providing bilateral anterior exposure. It is also notable that none of
the patients required tracheostomy. This approach appears to be a useful
alternative for tumors that can be resected in a piecemeal fashion and
require subsequent instrumented stabilization. For tumors such as
chordomas in which en bloc resection affords the greatest chance for
surgical cure,2 the degree of exposure attained with this approach may be
too limited.
ons194 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.
Pablo F. Recinos
Michael Lim
Baltimore, Maryland
1. Hsu W, Wolinsky JP, Gokaslan ZL, Sciubba DM. Transoral approaches to the
cervical spine. Neurosurgery. 2010;66(3)(suppl):119-125.
2. Hsieh PC, Galia GL, Sciubba DM, et al. En-bloc excision of chordomas in the
cervical spine: review of 5 consecutive cases with over 4-year follow-up [published
online ahead of print February 1, 2011]. Spine (Phila Pa 1976).
www.neurosurgery-online.com