Surgery performed by Dr. Juan Casado
La sphenorbital metastasis It is an uncommon entity within the oncological pathology of the skull base, but with a significant clinical impact due to its visual and orbital repercussions. In the online surgery platform SurgSchool This case, which has recently been incorporated into the investigation, has been handled by the Dr. Juan Casado (Miguel Servet University Hospital in Zaragoza, Spain), which illustrates in a very didactic way the surgical decision-making in this complex scenario.
These lesions can mimic primary tumors such as spheno-orbital meningioma, especially when they present with dural infiltration, bone involvement, and orbital compromise. However, rapid growth, a known oncological context—in this case, prostate adenocarcinoma—and the progressive onset of proptosis should raise suspicion of a metastatic etiology. Surgical intervention is usually functional and palliative, aimed at orbital decompression, local disease control, and diagnostic confirmation.
Preoperative planning
Preoperative planning is crucial in this type of surgery. Dr. Juan Casado part of a detailed radiological evaluation using contrast-enhanced magnetic resonance imagingwhich allows defining the dural, muscular, and intraorbital extent, and CT scan to assess bone involvement.
Bone destruction with an irregular or "moth-eaten" appearance, especially of the sphenoid wing and orbital roof, suggests a secondary lesion in contrast to the hyperostosis typical of meningioma. It is essential to analyze the relationship with the optical channelThe anterior clinoid process and the periorbital area should be examined, and infiltration of the brain parenchyma should be ruled out. Patient selection should consider systemic status, life expectancy, and the actual functional benefit of surgery.
Description of the surgical approach
The approach chosen by the Dr. Casado For this resection of spheno-orbital metastasis, it is a extended minipterional craniotomy up to the superior temporal line. This approach provides adequate exposure of the sphenoid wing, the infiltrated dura mater, and the lateral orbit, allowing sequential and controlled work on bone, dura, and orbital components.
The main advantage of this approach is that it offers an optimal balance between visibility and minimal trauma, allowing for wide resection without the need for more extensive skull base incisions. However, it requires precise anatomical orientation to avoid unnecessary opening of the orbital compartment.
Key surgical steps
Resection of spheno-orbital metastases begins with the extensive bone resection of the sphenoid wing, the lateral wall of the orbit, and the orbital roof. The goal is to reach macroscopically healthy bone, which facilitates both local control and subsequent reconstruction.
Once the metastatic nature was confirmed intraoperatively, the Dr. Casado It adopts a more aggressive approach to the infiltrated structures, including the temporalis muscle and dura mater. Dural excision is performed systematically, seeking healthy margins and avoiding leaving any remnants that could lead to early recurrence.
La orbital decompression This is performed by carefully separating the periorbita from the intraorbital tumor, prioritizing the identification of planes and avoiding unnecessary fat herniation. Partial resection of the anterior clinoid process is justified when there is adjacent bone involvement, provided that optic nerve function is not compromised.
The surgery culminates in a dural plastic in inlay technique, sutured over healthy dura mater, a key step to minimize the risk of CSF fistula in this type of extensive resections.
Critical points and risks
The structures at greatest risk during this surgery are the optic nervethe orbital fat and extraocular muscles. Excessive manipulation of the orbital contents can result in persistent diplopia or visual impairment.
Indiscriminate opening of the periorbital area hinders anatomical orientation and increases morbidity. Similarly, incomplete dural resection increases the risk of local progression. Careful control of the bone and dural margins is essential.
Surgical tips & pearls
El Dr. Casado Prioritize completing the bone and dural phase first before extensively addressing the intraorbital component. Always working with clear anatomical landmarks and progressing toward healthy planes reduces complications. Meticulous dural reconstruction is as important as tumor excision for a good postoperative outcome.
Common mistakes / pitfalls
One of the most common errors is underestimating dural infiltration, leaving microscopic remnants that lead to early recurrence. Another frequent mistake is attempting excessive orbital excision without a defined plane, which increases morbidity without providing any real oncological benefit.
Results and postoperative considerations
The expected functional result is the immediate improvement of proptosis and diplopia, as can be seen in this intervened case uploaded to the surgical training app SurgSchoolPostoperative evolution is usually favorable, with early discharge if there are no complications.
Follow-up should be multidisciplinary, with radiological monitoring and coordination with oncology to assess systemic treatment or adjuvant radiotherapy. Reintervention is only considered in cases of symptomatic progression or local complications.
For whom is this surgery especially useful?
This type of spheno-orbital metastasis surgery is especially formative for advanced residents that begin in skull base pathology, young assistants who seek realistic indication criteria in neuro-oncology and expert surgeons interested in technical nuances of complex palliative resection.
