The new pathways to 'inoperable' tumors

Overview

A 19-year-old Maryland woman had a chordoma wrapped around her spine and spinal cord. Only 300 Americans get this diagnosis yearly. Approaching from the back risked paralyzing her. Instead, surgeons carved a pathway through the bottom of her eye socket—a first for spinal tumors—and extracted the cancer without disturbing her spinal cord, major blood vessels, or nerves controlling speech and swallowing.

In This Story

3 People

Transorbital Becomes Standard for Select Spinal Cases

3 Context

Harvey Cushing Pioneers Modern Neurosurgery (1900s-1930s)

Key Indicators

300

Annual U.S. chordoma cases

One of the rarest cancers, making surgical innovation critical

82%

5-year survival for cervical chordoma

Complete resection plus radiation therapy

13 months

Extended survival for inoperable brain tumors

Tumor-treating fields plus immunotherapy vs. traditional approach

3 hours

Duration of eye socket surgery

Compared to 8+ hours for traditional craniotomy approaches

Interactive

Exploring all sides of a story is often best achieved with Play.

Ever wondered what historical figures would say about today's headlines?

Debate Arena

Two rounds, two personas, one winner. You set the crossfire.

People Involved

Dr. Mohamed A.M. Labib

Assistant Professor of Neurosurgery, University of Maryland (Lead surgeon on first transorbital spinal tumor removal)

Karla Flores

Patient (Cancer-free, recovering from multiple surgeries)

Dr. Kalpesh T. Vakharia

Chief of Facial Plastic and Reconstructive Surgery, University of Maryland (Director of Facial Nerve Center)

Organizations Involved

University of Maryland Medical Center

Academic Medical Center

Status: Site of first transorbital spinal tumor removal

Maryland's first hospital and a flagship R. Adams Cowley Shock Trauma Center, home to the Skull Base 360° Laboratory.

Skull Base 360° Laboratory

Surgical Research and Training Facility

Status: Active surgical innovation center

Cadaver laboratory where surgeons test novel approaches before attempting them on patients.

Timeline

Second Annual Skull Base 360° Course
Medical Education

Four-day workshop in Columbia, Maryland trains surgeons on advanced minimally invasive techniques using cadaver specimens.
November 21st, 2025
First Transorbital Spinal Tumor Removal
Surgical Breakthrough

Maryland surgeons remove chordoma wrapped around 19-year-old's spine through eye socket in 3-hour procedure—world first for spinal tumors.
May 4th, 2025
UK Surgeons Remove Inoperable Brain Tumor
Surgical Innovation

Leeds Teaching Hospitals team uses transorbital keyhole surgery for previously inoperable cavernous sinus tumor—UK first.
May 2025
Tumor-Treating Fields Breakthrough
Treatment Advance

Electric field therapy plus immunotherapy extends inoperable glioblastoma survival by 13 months versus standard treatment.
2024
Karla Flores Diagnosed with Chordoma
Patient Case

Maryland teenager diagnosed with rare spinal cancer after experiencing double vision; second tumor discovered via MRI positioning error.
2024
Labib Publishes 'Third Nostril' Research
Academic Publication

Journal of Neurosurgery article coins term, describes combining transorbital with endonasal approaches for skull base tumors.
March 31st, 2023
First Transorbital Endoscopic Surgery
Surgical Innovation

Surgeons first use eye socket corridor for brain and sinus tumors, opening possibilities for new approaches.
2009
Minimally Invasive Neurosurgery Breakthrough
Medical Milestone

International meeting in Wiesbaden marks paradigm shift toward minimally invasive brain surgery techniques.
1993

Scenarios

Transorbital Becomes Standard for Select Spinal Cases

Discussed by: University of Maryland Medical Center researchers, neurosurgery publications covering the case

The Maryland success catalyzes adoption at major academic centers within 18-24 months. Surgeons identify specific chordoma presentations—cervical spine location, anterior tumor position, patients under 40—where transorbital access offers superior outcomes to traditional posterior approaches. Insurance coverage follows clinical guidelines by 2027. The technique remains specialized, performed at perhaps 20 U.S. centers, but transforms what 'operable' means for 50-100 patients annually. Key barrier: surgeon training requires cadaver lab access and mentorship from early adopters.

Complications Emerge, Technique Remains Experimental

Discussed by: Risk assessment implicit in neurosurgical literature, typical pattern for novel approaches

Follow-up studies on Flores and subsequent patients reveal higher-than-expected rates of eye movement disorders, infection, or CSF leaks. The three-hour surgery time proves unrealistic for average cases—most take six hours with comparable outcomes to traditional methods. The approach finds a narrow niche: second-line option when standard surgery fails or for specific anatomical scenarios. Most spinal chordomas continue via posterior or anterior cervical approaches. The Maryland case becomes a proof-of-concept cited in textbooks but rarely replicated, similar to other technically successful but clinically limited innovations.

Robotic Systems Accelerate Widespread Adoption

Discussed by: Surgical robotics companies, medical technology analysts

Within five years, robotic surgical platforms adapt the transorbital corridor for semi-automated navigation, reducing surgeon learning curves from years to months. Systems like da Vinci or Mazor integrate real-time MRI guidance with millimeter-precision instruments, making the approach safer and faster. This democratizes access beyond elite academic centers. By 2030, transorbital access extends to thoracic spine tumors and other hard-to-reach malignancies. The technique merges with AI tumor mapping and intraoperative molecular diagnostics, creating a new subspecialty: orbital corridor oncologic surgery.

Historical Context

Harvey Cushing Pioneers Modern Neurosurgery (1900s-1930s)

1900-1939

What Happened

Cushing systematically reduced brain surgery mortality from 90% to under 10% through meticulous technique, antiseptic protocols, and blood pressure monitoring. He performed over 2,000 brain tumor operations, establishing neurosurgery as a viable specialty. Before Cushing, opening the skull routinely killed patients from infection or hemorrhage; after Cushing, it became a calculated risk with improving odds.

Outcome

Short Term

Neurosurgery established as legitimate medical specialty; major medical centers built dedicated neurosurgical departments.

Long Term

Created framework for all subsequent neurosurgical innovation; techniques like bone flap preservation still used today.

Why It's Relevant Today

The transorbital spinal approach represents a similar inflection point—redefining what's surgically possible through technique refinement rather than dramatic technology, just as Cushing did with sterile procedure.

Endoscopic Endonasal Surgery Revolution (1990s-2000s)

1993-2010

What Happened

The 1993 Wiesbaden conference catalyzed shift from large craniotomies to accessing brain tumors through nostrils using endoscopes adapted from ENT sinus surgery. Hadad's 2006 nasoseptal flap technique drastically reduced CSF leaks and infections, making the approach safe enough for routine use. By 2010, skull base tumors once requiring weeks of recovery were being removed in outpatient procedures with patients home same-day.

Outcome

Short Term

Pituitary adenomas, craniopharyngiomas, and anterior skull base meningiomas shifted from open surgery to endoscopic within a decade.

Long Term

Established minimally invasive neurosurgery as preferable default; created demand for surgical corridors that avoid brain retraction.

Why It's Relevant Today

The eye socket represents the logical next corridor after the nose was proven viable—same principles of using natural pathways to avoid traumatizing healthy tissue, now applied to spinal tumors.

Robotic Surgery Adoption in Prostatectomy (2000s)

2000-2015

What Happened

Da Vinci surgical robot transformed prostate cancer treatment from open surgery with long recovery to keyhole procedure with faster healing and better outcomes. Initial skepticism—'Why do we need robots?'—gave way to widespread adoption as data showed reduced complications. By 2015, over 85% of U.S. prostatectomies used robotic assistance. Training programs emerged to scale surgeon expertise beyond early-adopter academic centers.

Outcome

Short Term

Prostate cancer surgery recovery time cut from 4-6 weeks to 1-2 weeks; continence outcomes improved.

Long Term

Established template for technology-enabled diffusion of complex surgical techniques; proved payers would cover premium pricing for better outcomes.

Why It's Relevant Today

If transorbital spinal surgery follows prostatectomy's path, adoption hinges on robotic or imaging systems that compress the learning curve—letting more surgeons master the technique safely.