Surgeons from the University of Maryland Medical Center (UMMC) have succeeded in using a first-ever transorbital approach to remove a rare cancerous tumor around the spine—via a patient’s eye socket.
First, explain what a transorbital approach is.
The official name: Superior eyelid endoscope transorbital approach (SETOA).What it is: A minimally-invasive procedure that removes tumors around the eye by accessing the skull base and brain in the anterior and middle cranial fossae, to be precise.
What this involves: Making small incisions around the eye socket to give surgeons access to lesions (tumors and aneurysms, for example).
- Notably: The neurosurgical procedure is often used in conjunction with endoscope techniques to improve visualization and precision.
Now to this patient case.
The patient was a 19-year-old female with a chordoma (a rare, slow-growing developmental bone tumor) in her spine as well as a “very large” chordoma wrapped around her brain stem.
Specifically: The spinal tumor, positioned just below the base of the skull, was wrapped around the patient’s spine and spinal cord, and had invaded the vertebrae of her neck, according to Mohamed A.M. Labib, MD, CM.
- Note: Having previously researched this surgical technique, Dr. Labib, a neurosurgeon at UMCC and an assistant professor of neurosurgery at the University of Maryland School of Medicine (UMSOM), developed the patient’s surgical plan to remove her tumor and was part of the team to conduct the actual surgery.
As for her ocular symptoms: She reported experiencing double vision at age 18 and was referred to Dr. Labib by her ophthalmologist.
So how was the surgery conducted?
To remove the spinal tumor, surgeons navigated through the bottom of the eye socket by creating a large surgical corridor.The advantage of this: Bypassing the patient’s back allowed them to avoid disrupting or damaging “key structures,” including:
- Eustachian tube
- Major blood vessels (jugular vein and internal carotid artery)
- Nerves (responsible for swallowing and speech)
Nice! And how was that second chordoma removed?
The patient actually underwent two separate procedures to remove the tumor wrapped around her brain stem—though the eye socket wasn’t involved this time.
What it involved: Surgeons removed part of the tumor by first opening her skull (via a standard craniotomy method) before taking out the remainder of it via access through her nose (called an “endonasal” procedure).
- To note: Both the endonasal and transorbital techniques utilized an endoscope.
After these procedures, how is the patient doing?
Just over a year after the surgeries—in addition to receiving proton radiation therapy to destroy any remaining cancer cells as well as fusing two vertebrae in her neck to stabilize the spine—the patient is “doing very well,” according to Dr. Labib.
One remaining symptom to note: She reportedly has “lingering issues” with moving her left eye due to nerve damage from one of the tumors (at the brain stem).
Great to hear, on the whole. So how else have transorbital procedures been used?
While, as we mentioned, this was the first instance of using a transorbital technique to remove a tumor, the procedure itself has previously been utilized at UMSOM.
- Per UMSOM, Dr. Labib worked with Kalpesh T. Vakharia, MD, a UMMC-based facial and reconstructive surgeon, to conduct the procedure by making incisions next to or above the eye.
What did this entail?
First: Cutting through the conjunctiva inside the lower eyelid—without disrupting the eye—as well as making an incision inside a patient’s mouth
Then: The bottom of the eye socket and a segment of the cheekbone is removed to create a pathway large enough to give surgeons room to thread surgical tools into the sinus in order to reach the cervical spine.
- The benefits of this: No external scarring for the patient.
And outside UMSOM?
As previous research has reported, this neurosurgical-based transorbital approach has been proposed and utilized for therapeutic surgeries, in addition to ophthalmic, such as :
- Otolaryngologic
- Maximillofacial
And in general: Though still considered a new procedure, investigators concluded that it represents a major advance in neurosurgery by “providing a safe, minimally invasive, and versatile alternative to traditional open cranial approaches.”