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Chapter Summary
• Context: Complex cervical tumor surgery brings together oncologic, neurologic, vascular, and biomechanical challenges in a region of high anatomical density. Lesions of the craniovertebral junction and upper cervical spine may closely involve the clivus, pharynx, dura mater, spinal cord, nerve roots, cranial nerves, and vertebral arteries, whereas subaxial tumors present critical relationships with the brachial plexus, laryngeal nerves, carotid sheath, and esophagotracheal structures. Approach selection depends on tumor location and extension, potentially requiring transoral, translabiomandibular, maxillary, retropharyngeal, or combined anteroposterior routes. Oncologic resection can induce significant instability requiring simultaneous reconstruction. Gaining access to the tumor is only part of the problem: preserving neural and vascular function, obtaining clear margins when feasible, reconstructing the spine, and managing pharyngeal, dural, and infectious complications constitute inseparable components of multidisciplinary treatment.
• Chapter Objective: To present the anatomical and strategic principles of complex surgery for cervical spine tumors. The reader will understand how to select and expand ventral approaches to the craniovertebral junction, recognize limitations and risks of each approach, plan upper and subaxial cervical resections, integrate vertebral artery management into oncologic and mechanical strategies, and anticipate needs for reconstruction, dural repair, and complication management.
• Approach Must Follow Tumor AnatomyVentral approaches to the craniovertebral junction offer direct access to lesions of the lower clivus, atlas, and axis. The spectrum of exposure ranges from transoral approach to palate split, translabiomandibular approach, or maxillotomies. Planning must consider the available anatomical trajectory. The transoral transpharyngeal approach remains key for central ventral lesions, with direct access as its main advantage, and limited lateral exposure, infectious risk, and difficulty with vascular control as its limitations. Extensive dural invasion also modifies its suitability.
• Expanding Exposure Increases MorbidityWhen conventional transoral exposure is insufficient, lip-split mandibuloglossotomy significantly widens the surgical corridor, as does maxillotomy with Le Fort I osteotomy. However, this greater exposure carries functional costs: dysphagia, velopharyngeal insufficiency, speech and occlusal disturbances, fistulae, and wound breakdown. Therefore, surgical corridor expansion must be strictly proportional to oncological necessity.
• Resection and Reconstruction Form a Single PlanIn upper cervical spine tumors, the strategy may require a staged posterior procedure for decompression, vascular mobilization, and stabilization prior to the anterior stage. In the subaxial spine, combined posterior and anterior approaches are utilized to control tumor, neural elements, and spinal stability. Reconstructions employ expandable or mesh cages and supplemental instrumentation tailored to the extent of resection.
• Vertebral Artery is Part of Oncologic StrategyVertebral artery involvement must be evaluated preoperatively in terms of oncologic behavior, mechanical feasibility, and vascular safety. Depending on the vessel's relationship with the tumor, options include mobilization, skeletonization, sacrifice, or vascular reconstruction. Decision-making requires preoperative evaluation of cerebral circulation (e.g., balloon test occlusion) and collateral flow.
• Complications are Integral to ManagementSalivary fistulae, deep wound infection, dysphagia, wound healing failure, dural tears, and laryngeal or hypoglossal nerve palsies are major complications. Duraplasty principles and pharyngeal repair techniques must be mastered. Oncologic resection, biomechanical reconstruction, and complication management may require multiple interventions to achieve long-term local disease control and functional preservation.
• Clinical Application: In practice, planning begins with 3D definition of the relationship between tumor, spinal cord, dura, vertebral arteries, skull base, and aerodigestive structures. The central question is which corridor achieves oncologic goals with minimal neurological, vascular, and functional morbidity. Tumors compromising structural integrity require reconstruction planning prior to resection. When vertebral artery sacrifice is contemplated, cerebral circulation and contralateral vertebral competence must be established. Multidisciplinary planning involving spine surgery, neurosurgery, head and neck surgery, vascular surgery, and oncology is essential.
