Spinal and Sacral Chordomas: Overview With Imaging Review

Spinal chordomas are rare, malignant bone tumors originating from notochordal remnants, primarily affecting the sacrum, clivus, and spine. Despite their low prevalence, they present significant diagnostic and therapeutic challenges due to their local aggressiveness, high recurrence rate, and imaging similarities to other tumors, such as chondrosarcomas. Advances in imaging technologies, particularly high-resolution magnetic resonance imaging and computed tomography (CT), have improved the ability to visualize chordomas and enhance the precision of surgical planning. Additionally, newer imaging modalities, including diffusion-weighted imaging and positron emission tomography/CT, offer more refined diagnostic capabilities, though differentiation from other similar lesions remains difficult. Histologically, chordomas are marked by physaliphorous cells and a myxoid stroma, with the brachyury gene playing a key role in tumorigenesis and serving as a potential therapeutic target. The pathophysiology and molecular landscape of chordomas further complicate diagnosis and treatment. This review examines the current state of imaging advancements, challenges in diagnosis, and their impact on clinical management. It highlights the importance of combining various imaging modalities to improve diagnostic accuracy, aid surgical resection planning, and reduce recurrence. Additionally, it discusses the ongoing need for more targeted therapies and improved imaging techniques to optimize patient outcomes in spinal chordoma management.