Complex Case

Skull Base Surgery for
 a Chordoma

A 23-year-old woman presented at another hospital complaining of a number of symptoms.

Several months prior, she noticed she was having trouble using her hands to write and to braid her hair; soon after, she began having tingling and numbness in her hands and arms. Eating made her cough, and her voice started to weaken. Eventually she came to have trouble walking. In the week before coming to the hospital her symptoms worsened markedly. She was given high doses of steroids, which helped with the symptoms. An MRI of the cervical spine and head revealed a large tumor rising from a damaged clivus and extending into the left petrous apex and posterior fossa, causing severe brainstem compression and displacement of the vertebral artery on both sides. The patient was referred to NYU Langone neurosurgeon Chandranath Sen, MD, director of NYU Langone’s Benign Brain Tumor and Cranial Nerve Disorders Programs, and a specialist in challenging skull base tumors.

Dr. Sen determined that the tumor was likely a clival chordoma, and planned a two-stage surgery to resect it. The first stage was an endonasal endoscopic procedure, performed in partnership with Richard Lebowitz, MD, a frequent collaborator of Dr. Sen. Dr. Lebowitz helped ensure proper surgical access through the nasal passages and on through the back of the throat. The procedure would provide an approach from the front that would allow access to the bulk of the tumor which was pushing into the brainstem, though it would also require great care to avoid brainstem, vascular, or cranial nerve injury, as well as cerebrospinal fluid leakage.

case2_5aLeft: Sagittal T1 — Preoperative. Right: Axial T2 — Preoperative.

At the start of the surgery, a face mask was applied to the patient’s stabilized head to calibrate image-guided navigation. Dr. Sen and Dr. Lebowitz went into the skull through both nostrils, proceeding past the soft palate and the back of the hard palate, from where Dr. Sen could see the lowest point of the tumor, near the C1 arch. After detaching the posterior pharyngeal mucosa and several muscles blocking access to the tumor, Dr. Sen was able to remove the tumor in pieces and use a diamond drill for the tumor’s irregular bony edges. Some of the tumor remained inaccessible behind the back of the clival bone, but enough of the tumor was removed to allow extensive decompression of the brainstem and clival dura. The patient was in stable condition immediately after the procedure, and recovery was good, including improvement of the patient’s gait.

The second stage of the operation, performed several weeks later, was a craniotomy to resect the rest of the tumor, located by the lower clivus. After entering the skull with a left-side, frontotemporal approach, Dr. Sen elevated the temporal lobe, providing access for an operating microscope. Dr. Sen drilled through the bony Eustachian tube, unroofed the carotid artery to move it aside, and drilled down into the bone until reaching the tumor. He removed the remaining tumor and all abnormal-looking bone, then reconstructed the area, enlisting abdominal fat grafts for packing.

case2_5bLeft: Sagittal T2 — Postoperative. Right: Axial T2 ­­— Postoperative.

The patient’s recovery was good. Aside from exhibiting some mild weakness of the upper left face, eyelid and forehead, she is now doing well, and has returned to her full-time job and active life.