WATCH: A Multidisciplinary Panel's Expert Insights on Four Complex Spine Tumor Surgery Cases

In this roundtable conversation, Dr. Gavin Britz, neurosurgeon and director of the Houston Methodist Neurological Institute, moderates a panel discussion focused on four spinal tumor case studies, with diagnoses including chordoma, schwannoma and meningioma.

Panel participants include:

• Dr. Sean Barber, neurosurgeon, assistant professor of Neurosurgery, Houston Methodist Neurological Institute

• Dr. Paul Holman, chair of Spine & Peripheral Nerve Center, assistant professor of Clinical Neurosurgery, Houston Methodist Neurological Institute

• Dr. Ziya L. Gokaslan, chief of Neurosurgery, clinical director of the Norman Prince Neurosciences Institute, Brown University Health

Case 1: Chordoma diagnosis highlights the value of biopsy

A 55‑year‑old man with no significant medical history presented with lower back and leg pain. Imaging suggested a chordoma, and the mass was needle‑biopsied. When asked about the tumor seeding risk, Dr. Gokaslan noted that the dual‑needle technique mitigates this concern by protecting tissue as the sample is withdrawn.

Dr. Britz challenged whether a biopsy was truly necessary when the clinical consensus leaned toward chordoma — a malignancy whose treatment is surgical resection.

Dr. Barber explained why confirmation still matters: "We thought it was, yes, but there are other pathologies where you wouldn't put a patient through an en bloc spondylectomy, where you might consider systemic therappy first," he says.

The differential matters: multiple myeloma or plasmacytoma may be treated with radiation or systemic therapy; renal cell carcinoma may require embolization before surgery; osteogenic sarcoma benefits from presurgical chemotherapy. Without biopsy, any of these could be mismanaged by going straight to surgery.

The panel expanded the discussion to core surgical considerations:

• Whether margin sampling in the operating room meaningfully contributes to final pathology

• How image‑guided navigation improves surgical precision

• How intraoperative CT scanning helps verify completeness of resection

• Why chordoma surgery carries such high stakes and requires subspecialized expertise

• Strategies to minimize rod fracture risk following lower lumbar spondylectomy

(Related: Modern Treatment Paradigms for Chordoma)

Case 2: Team-based approach helps manage a tricky location

A 74‑year‑old woman with no significant medical history presented with lower back and leg pain. Her sacral mass was diagnosed as chordoma, which was in an especially challenging location due to risks such as CSF leak, proximity to the bowel and pelvic organs, and high wound‑related complication rates.

Here, the necessity of a multidisciplinary surgical team became a central theme.

“A multidisciplinary team is a key here," says Dr. Gokaslan. Explaining why colorectal expertise matters intraoperatively, he adds, "Finding a leak later is really quite catastrophic for the patient.”

The panel discussed key decision points for the case:

• When to use a combined anterior–posterior approach versus a posterior‑only approach

• Counseling patients about complications specific to sacral surgery, including phantom pains, bowel and bladder dysfunction, and stress fractures

• The association between gabapentin and dementia risk, and why these medications should be used only temporarily

• Pain management options that carry less longterm risk, such as spinal cord stimulation

Case 3: When spine surgery is needed for a young person with benign disease

A 35‑year‑old woman with hand numbness and progressive weakness was found to have a right intradural extramedullary mass with ventral spinal cord compression. Given her age and the likely diagnosis of schwannoma, the group discussed the balance between complete resection and the risks of operating near critical neural structures.

These tumors can appear ominous on imaging, but may still be entirely extradural. The operative goal is to remove the tumor extradurally whenever possible. However, ultrasound may be needed mid‑procedure to determine whether dura must be opened to fully assess the tumor.

Key decision points for this case included:

• When to obtain CT angiography to evaluate the vertebral artery — particularly if the tumor encases the vessel

• Why image‑guided navigation is essential in modern spinal tumor surgery

• Methods for achieving a watertight dural closure

• Approaches to "dumbbell" tumors, when portions extend both anteriorly and posteriorly

Case 4: A rare diagnosis hiding in a familiar presentation

A 24‑year‑old man presented with three months of back and right‑buttock tightness. He was found to have an intradural lumbar tumor, which was removed en bloc. Although the differential diagnosis initially pointed toward schwannoma, intraoperative findings of the tumor told a different story.

"There was some clear fluid inside of it, which was kind of an interesting thing," adds Dr. Holman. "So this was the surprising finding of this case. This turned out to be a clear cell meningioma in the lumbar spine."

He notes the rarity of this diagnosis: only 200–300 cases of this specific meningioma type have been reported in the lumbar spine. They more commonly arise in the upper thoracic region, tending to be aggressive and show a higher recurrence rate.

(Related: Treating a Complex Meningioma: A Brain Tumor Case Not For the Timid)

Panel discussion for this case centered around:

• The importance — and challenges — of neuromonitoring

• How to respond intraoperatively when neuromonitoring indicates neurologic risk

• The value of monitoring D‑waves to assess spinal cord integrity in real time

What these cases teach us about spinal oncology today

Across four very different spinal tumor scenarios, the panel emphasized the importance of diagnostic precision, intraoperative technology, interdisciplinary collaboration and individualized surgical decision‑making.

The four cases illustrate not only the technical complexity of spinal oncology, but the steady, nuanced judgment required to safely navigate it — reinforcing why subspecialized expertise remains essential in the care of patients with spinal tumors.