Resection of a Recurrent Lumbar Chordoma With Intradural Extension and Complex Dural Repair: 2-Dimensional Operative Video

Chordomas are derived from embryonic notochord remnants and comprise 1%-4% of all bone tumors.(1) Nearly all chordomas arise in the axial skeleton, with 50% in the sacrococcygeal region, 35% in the skull base and 15% within mobile spine vertebrae.(1,2) Regional recurrence after en bloc surgery is common and 30%-40% of patients develop metastatic disease.(3-6) In this operative video, we present a 41-year old man who previously underwent en bloc lateral L1 corpectomy and received high-dose hybrid photon and proton radiation therapy for treatment of his L1 chordoma. On surveillance imaging, 2 years post op MRI revealed recurrence of the chordoma, now extending to the L2-3 epidural space. Further radiation alone was considered but was not performed due to lack of separation between the tumor and neural elements, thus increasing the risk of radiation-induced neurological injury. Combination revision surgical resection with subsequent boost radiation therapy was pursued instead. The technical nuances to achieve complex ventral and dorsal dural repair after removal of a transdural lumbar chordoma are shown in detail. Postoperatively, the patient had no new neurological deficits. At 13 months postoperatively, he reports no new pain, can ambulate without assistance, and completed 33 treatments of radiation therapy with proton beam. The patient consented to the procedure and to the publication of his image.