A behind-the-scenes look at how surgical planning, advanced imaging and real-time decision-making come together to navigate one of the most challenging spine tumors.
Video Highlights
In this cervical chordoma, a two-stage approach allowed for tumor debulking and stabilization posteriorly before definitive anterior resection, balancing surgical access with risk mitigation to critical neurovascular structures.
Although en bloc resection is preferred when feasible, this case required a gross total piecemeal resection, emphasizing the need to tailor surgical strategy based on anatomy, tumor involvement and patient safety considerations.
A patient-specific titanium implant, created from preoperative imaging, provided structural support in an area not amenable to standard implants, highlighting the role of personalized reconstruction in oncologic spine surgery.
ENT surgeons played a critical role in achieving adequate exposure via mandibulotomy when less invasive approaches were insufficient, demonstrating how cross-specialty collaboration expands surgical options.
Given the high likelihood of microscopic residual disease, postoperative radiotherapy was incorporated into the treatment plan, reinforcing the importance of coordinated care across neurosurgery, radiation oncology and medical oncology.
Chordoma is a rare primary spine tumor characterized by locally aggressive behavior and complex surgical management challenges. In the video above, Dr. Sean Baber, neurosurgeon at Houston Methodist, presents a case of a cervical chordoma with compressive symptoms that required a staged approach to achieve maximal resection while minimizing neurologic and vascular risk. The surgical plan combined posterior stabilization using a custom titanium implant with a subsequent anterior resection in collaboration with ENT surgeons. This case illustrates the importance of individualized surgical strategy, multidisciplinary coordination and adjunctive therapy in optimizing outcomes for patients with complex spine tumors.
Article Transcript
00:00–00:30 Chordoma is a unique tumor in that it's histologically benign, but it's very malignant in its behavior, and it's very rare. It's one in a million people. It can occur in so many different locations, skull base, mobile spine, sacrum. When you're trying to remove them in an en bloc fashion, the structures they're touching, the vascular structures, other neural structures, nerve roots, spinal cord. every single case is unique. I'm Sean Barber. I'm a neurosurgeon here at Houston Methodist Hospital. Clinically, my kind of passion has always been spine tumors.
00:30–01:00 Chordoma is a primary spine tumor, which means it grows from the spine. The average lifespan for someone with chordoma is something like five years, unfortunately, but treatment, surgery specifically does have a big impact on that, and the way in which the tumor is removed can greatly affect a patient's prognosis if the tumor is removed in an appropriate manner. Sometimes very aggressive techniques are used in an attempt to get all of the tumor out.
01:00–01:30 It can vastly improve a patient's prognosis and likelihood of recurrence. Presentation of a chordoma can vary depending on its location. It can be axial pain. So if someone has a chordoma in the mobile spine, for instance, it can be neck pain or lower back pain. Sometimes they can grow to enormous size before diagnosis, in which case they can push on other structures, like even the abdominal viscera, so it can cause constipation. But in this case, the patient's chordoma was in the prevertebral space right in front of the cervical spine.
01:30–02:00 It was pushing on the esophagus and the pharynx, so his initial presentation was actually voice changes, couldn't swallow very well, also shortness of breath. So he initially thought it was his tonsils and saw an ENT specialist who did a scope and kind of saw that it wasn't his tonsils, there was kind of a mass behind the pharynx there. Today, we're taking out tumor from the back and stabilizing the spine with instrumentation.
02:00–02:30 Part of the tumor was coming into some bony elements in the spine called the pedicles, so we wanted to remove that. And there's not really an implant designed to fit to replace that, so we got a custom implant from a company. We used his CAT scan to create a custom implant out of titanium for him. So we removed the tumor that we could from the back and put this custom titanium implant in. Also, screw fixation kind of from the lower part of the skull to the mid part of his neck just to provide stability around that implant. And then in two days, we're going to come back from the front with our ENT colleagues.
02:30–03:00 and take out most of the tumor, which is actually in the front of the spine. So this is just half of a kind of staged operation to take out as much of this tumor as we can. Typically, we'd like to have an en bloc or sort of a wider marginal resection, but in this case was not possible, so we opted for an attempted gross total, a piecemeal resection. We're trying to sort of balance the morbidity of the procedure with outcome, so we of course want him to live as long as he possibly can, the highest quality of life he possibly can, but we don't want to exchange too high of a risk, for instance, of him dying from bilateral vertebral artery injuries, spinal cord injury, being paralyzed.
03:00–03:30 Quantity of life is important, but quality, also important. And so we have to kind of balance all these things and I think it's good for us to have mentors and other sort of spine tumor surgeons in the community. We can get our heads together. For this stage, in preparation for the mandibulotomy, a company, made kind of a custom implant to plate back his mandible together in the best opposition and sort of the best cosmetic way.
03:30–04:00 And then also had another company helping us with VR imagery, creating models of the tumor, which I've never used that much before, but is useful, I think, to sort of get in your mind's eye exactly how the tumor relates to the surrounding anatomy before you go in there. So, I just tried that out today. I thought it was very interesting. Might use that in the future. Everything went great with the second half of the surgery. Our ENT colleagues helped us out greatly with the approach. We initially hoped to do partial transoral approach and partial kind of submandibular approach to save him the morbidity
04:00–04:30 of a mandibulotomy, but his mouth opening was just too small really to get good access. It did end up splitting the mandible, which our ENT colleagues helped with and got good exposure, able to get all of the tumor out. Seemed to have gotten a gross total resection and the ENT surgeons are closing right now. So overall, very happy with the outcome. He's doing fine neurologically. So it was a challenging case, but you know, we all kind of put our expertise together, I think able to achieve a good outcome.
04:30–05:00 It's certainly possible and actually highly likely that at least one cell or maybe many cells are left. And so we use radiotherapy post-operatively to treat the surgical bed and try to prevent recurrence. So our colleagues here at Methodist radiation oncologists are seeing him and going to start radiotherapy soon. Clinically, he's doing very well. He's in good spirits, walking, talking, and I think hopefully start eating soon.
05:00–05:30 Treating spine tumors in general requires a multidisciplinary team and we need medical oncology, radiation oncology, surgery, all kind of play different roles depending on the tumor histology. Here at Methodist, I think we have a great team of medical oncologists, radiation oncologists, and other surgeons like our ENT colleagues who helped us in this case to all kind of achieve the best outcome we can for our spine tumor patients.