A surgery by Dr. Juan Carlos Fernández-Miranda
En SurgSchool, a leading platform for surgical education, we present a highly complex surgery performed by the prestigious neurosurgeon Dr. Juan Fernández-Miranda: the complete resection of a complex skull base chordoma through a combined approach in two surgical stagesThis case exemplifies how strategic planning and technical mastery can achieve complete resection with negative margins, even in highly invasive tumors.
What is a skull base chordoma?
El chordoma It is a rare, aggressive, and locally destructive bone tumor that usually originates in the clivus (base of the skull) and can extend to critical regions such as the brainstem, cavernous sinus, Meckel's cavity or petrous apex.
These tumors compromise vital neurovascular structures, so their treatment requires a complex surgical strategy, multidirectional access, and high-precision microsurgical techniques.
First stage: extended endonasal endoscopic approach
In a 35-year-old patient with left XNUMXth nerve palsy and diplopia, the Dr. Fernández-Miranda initially performs a extended endonasal endoscopic surgery transpterygoid approach to access the central component of the tumor.
In addition, a transcavernous approach bilateral with interdural transposition of the pituitary gland, allowing access to the upper poles of the tumor.
During resection, critical structures such as the basilar artery, perforating vessels, as well as the cranial nerve VI, infiltrated by the tumor and sacrificed due to previous dysfunction and absence of electrical response.
A wide resection with decompression of the brainstem is achieved, although tumor remnants persist in deep regions such as Meckel's, cavernous sinus and petrous apex.
Second stage: orbitozygomatic craniotomy with anterior petrosectomy
In a second surgery, a extended middle fossa approach anterior petrosectomy and access trans-Meckel through orbitozygomatic craniotomy.
Key structures such as the Gasserian ganglion, cranial nerves V, IV, and III, as well as the internal auditory canalThe chordoma is meticulously resected, even medial and caudal to the trigeminal nerve, until reaching the dura mater of the posterior fossa.
The surgery concludes with complete visualization of the brainstem and negative margins confirmed by pathological anatomy. The patient tolerates the procedure well and subsequently undergoes corrective strabismus surgery.
Case Highlights:
- Complete resection of complex chordoma in two stages
- Combined approach: endoscopic endonasal and transpetrous middle fossa
- Preservation and selective sacrifice of cranial nerves
- Negative surgical margins
- Multilayer skull base reconstruction
- Favorable postoperative functional outcome
Access the complete surgery in SurgSchool
This case is available in the app SurgSchool, featuring high-definition video, surgeon commentary, and a didactic approach to help neurosurgeons and residents learn the most advanced techniques in skull base surgery.
