Far Medial Endoscopic Transcervical Approach for Excision of a Recurrent Clival Chordoma Involving the Parapharyngeal and Prevertebral Spaces

BACKGROUND AND IMPORTANCE: Chordoma is a rare, malignant neoplasm arising from notochordal remnants. Addressing recurrent disease is challenging due to scar tissue formation, proximity to neurovascular structures, and altered clinical anatomy from prior surgery and/or radiation therapy. Herein, this work describes technical considerations and operative principles utilized in endoscopic transcervical resection for recurrent craniocervical chordoma extending into the right prevertebral/parapharyngeal space. CLINICAL PRESENTATION: A 16-year-old male with a history of clival chordoma was found to have an expansile mass spanning the C1-C2 levels in the right prevertebral/parapharyngeal space on surveillance MRI. He had previously undergone definitive chemoradiation therapy as this tumor was initially misdiagnosed as rhabdomyosarcoma in another country at 13 years of age. He subsequently underwent multiple surgical procedures and treatments, including far lateral craniotomy with occiput-to-C2 posterior spinal fusion, combined endoscopic endonasal and transoral resection, and definitive proton therapy at our institution. An endoscopic transcervical approach was selected for salvage surgery as this provided an unoperated corridor with direct access to the neoplastic focus. The patient underwent uncomplicated gross total resection of recurrent chordoma. CONCLUSION: This case demonstrates the safety and efficacy of far medial endoscopic neck dissection for recurrent craniocervical chordoma extending into parapharyngeal/retropharyngeal space in a pediatric patient. Key advantages of this approach include early identification and control of proximal great vessels and lower cranial nerves, dynamic visualization, bimanual surgical technique, and low risk of suboptimal wound healing by avoiding previously operated and/or irradiated tissue.