Surgeons bid for medical first: Removing spinal tumor through patient's eye

Yahoo

05-05-2025

Just before the medical staff wheeled Karla Flores into the operating room so that surgeons could work inside her head for the third time in less than a month, the 19-year-old budding manicurist said goodbye to her mom and dad. She didn't know if she would see them again.
Her previous surgeries in the same building at the University of Maryland Medical Center had been hard enough: a pair of 14-hour procedures to rid Flores's brain of a rare bone tumor the size of a chicken's egg. This time, the surgeons faced a greater challenge. A second, smaller chordoma was strangling Flores's spinal cord near the base of the skull. After much discussion, the medical team had decided to try something that had never been done.
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They would remove the spinal tumor through her left eye socket.
If the surgical path was not precise to within a few millimeters, Flores could lose all movement below the neck or suffer a fatal brain-stem stroke. If the procedure was successful, however, it would open a new avenue for doctors around the world treating difficult-to-reach tumors.
One floor below the operating room entrance, Flores's lead surgeon, Mohamed A.M. Labib, sat in the hospital chapel. The 46-year-old neurosurgeon asked God to help Flores. In his preoperative ritual, prayer is the final act before he scrubs his hands for surgery.
'I am only a tool in the hands of God,' Labib tells patients, an idea that comforts him. Performing neurosurgery can feel like walking through a minefield, so it helps Labib to call on his belief as a Muslim that Allah is guiding him.
Born in Dubai, the son of a gynecologist, Labib was 17 when he flew to Canada by himself to pursue his medical education.
As a doctor, he has embraced the motto of pioneering neurosurgeon Robert Spetzler, who trained Labib at Barrow Neurological Institute in Phoenix. Accept challenges, Spetzler told him. Reject norms.
True to those watchwords, Labib began taking on unusual cases in 2021 soon after arriving in Baltimore, where he works for the medical center and is an assistant professor of neurosurgery at the University of Maryland School of Medicine. In two procedures totaling more than 21 hours, he rescued a woman with five brain aneurysms, potentially life-threatening bulges that appear in arteries and blood vessels.
As surgeons, Labib said, 'sometimes we are captives of our fear,' especially when another doctor has labeled a case inoperable. 'Fear should ignite in us the motivation to try and understand: Why are we not able to do these cases?' Just pondering the question, he said, can reveal a solution.
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The third nostril
Flores, a young woman with a fondness for horror movies and the Call of Duty video game series, had been healthy most of her life. While learning to drive in 2023, however, she encountered problems. When she peered through the windshield, she saw two stripes on the road where there was only one, two cars up ahead instead of one. Her primary-care doctor thought she might be experiencing double vision because she was forgetting to wear her glasses.
But to Flores's alarm, the scan that the eye doctor ordered revealed a large mass pressing against her left eye. It was a rare tumor called a chordoma, a malignant growth known for its diverse texture, including sections that are fluid, gelatinous and calcified; about 300 are diagnosed in the United States each year.
After receiving a referral, Flores sat in Labib's office last spring listening as the surgeon explained that it would take two operations to remove all of the brain tumor. He would perform the first himself and the second with his frequent partner, head and neck surgeon Andrea Hebert, who is an associate professor at the School of Medicine. As he talked, Labib was struck by the extraordinary calm of his young patient.
Flores showed poise explaining the surgery to her parents, who lacked her skill with English. If the teenager was afraid, she hid it well.
The first surgery, on April 16, 2024, involved removing a palm-size chunk of her skull, then gently pushing the brain aside to reach the tumor underneath. After removing a section of tumor ―it was too large to eliminate in a single procedure ― the surgeon reinstalled the piece of skull. Although the surgery went well, that was the day Labib realized he was dealing, not with one chordoma, but two.
The discovery of the second chordoma, a thumb-size mass in her cervical spinal cord, meant that after undergoing a second surgery to remove the remainder of the brain tumor, Flores would still face a third lengthy procedure. If not treated aggressively, the spinal chordoma could grow significantly, increasing pressure on the spinal cord and eventually paralyzing or killing her.
Removing the second tumor presented a dilemma. The medical team could blast it with radiation, but that option risked allowing the tumor to grow back more quickly.
Doctors could approach the tumor by going through the back of Flores's neck. But that would leave them with an obstructed view of the mass they were trying to remove, since most of it lay in the front of the spinal column.
They could enter from the front through her mouth. But mouths teem with germs, so Flores would be at risk of infection. They could enter through a nostril, but their path to the spine would be limited by sections of the palate and upper jaw.
One more option existed, a strategy Labib had laid out in a paper the previous year. They could proceed through the lower eye socket, an opening Labib had dubbed 'the third nostril.' Although surgery through the eye socket was not new, using that route to reach down to the spine was.
In his paper, Labib suggested the opening as a way to reach tumors below the inner ear in a region called the jugular foramen. He based his findings on work in cadaver heads.
He had never used the technique on a living patient.
To determine whether the route would work, Labib and Hebert described Flores's case to Kalpesh Vakharia, a 44-year-old facial, plastic and reconstructive surgeon at the hospital who was also an associate professor at the School of Medicine. They asked: Could you go through the eye socket to get us to the spine?
Vakharia knew the procedure would be novel and said it felt 'awesome' to be chosen for it. But his excitement was tempered with an awareness that 'on the other end of this is a human being.'
'Can I take the weekend and think how that would be possible?' Vakharia asked.
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Accept challenges, reject norms
The three surgeons met again the following week and discussed their two major concerns: the novelty of the procedure, and the risk that it might place pressure on the eyeball, damaging or even destroying Flores's vision. They all agreed the eye socket offered the best chance of success.
Labib then met with Flores and explained what the doctors were considering. He made sure she understood that the procedure had never been done. He told her the decision was hers.
Flores appreciated the surgeon's sense of urgency. She, too, wanted to be free of the tumor as soon as possible. But she did not feel ready for a third surgery, and it made her nervous that she would be the first person ever to undergo the procedure.
Still, she had come to trust Labib. She liked the calm, straightforward way he explained what would happen.
'He said it was in God's hands,' Flores recalled, 'and that's what gave me a lot of faith.' Like the doctor, she prayed before surgery.
She told Labib she would go forward with the procedure.
First, though, doctors removed the remainder of Flores's brain tumor eight days after the first surgery, proceeding through both nostrils to reach a portion in the nasal cavity. After the 14-hour surgery, Flores had a week before she was due back in the operating room.
In the days leading up to the third surgery, she tried not to imagine it, worried that she would be left with a giant scar near her eye. Her parents told her again and again that everything would be all right, that she didn't need to worry. But when Flores looked in their eyes, worry was what she saw.
She tried to focus on an image of life after surgery: the whole family laughing together in the living room of their Maryland home, her cat, Sushi, curled up beside her.
To prepare himself for Flores's surgery, Labib spent weekends and other free time reporting to his lab a short distance from the hospital in Baltimore. In a room a little smaller than a single-car garage, under fluorescent lights, he spent long days running through the full procedure again and again on cadaver heads to make sure it would work. Vakharia and Hebert each joined for one of the practice surgeries. Labib performed an additional seven or so by himself.
The practice runs helped Labib confirm that the procedure was possible and that it placed only minimal pressure on the eyeball. There would still be risks, especially damage to the spinal cord that could leave Flores paralyzed from the neck down.
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A delicate procedure
On May 1, 2024, the morning of the surgery, Labib woke feeling hyperalert, downed his customary three shots of espresso - no food - then left for the hospital. Excited and nervous, Hebert was reviewing Flores's scans and running through all the steps involved in the surgery. Vakharia, feeling the tension of attempting a medical first, tried imagining his calm place - an ocean washing over a sandy beach - a scene he'd grown up with during his childhood in California.
As Flores and her parents drove to the hospital that morning, they sat quietly, each alone with their thoughts. Just a week earlier, Flores had undergone the second long surgery. The family felt distraught to be facing the fear and stress one more time. Flores's younger sister had advised her to stay strong, so she tried.
Shortly after entering the operating room at 8 a.m., Flores went under anesthesia. With six doctors, nurses and residents looking on, Vakharia then made an incision in the upper gums, allowing him to separate soft tissue from bone in both the cheeks and lower eyelid.
Peering down at Flores's eye through a microscope, he made a few small incisions in the inner portion of the eyelid, releasing the eyeball and the surrounding muscle and fat, so they could be shifted a few millimeters back in the socket. That way, the surgeons would not put pressure on the eyeball or its delicate web of nerves.
To further protect the eye, Vakharia fitted over it a small plastic corneal shield.
'When you are in the orbit,' he explained, 'you have to be mindful that you have to just treat the eye like a newborn baby.'
Although some doctors like to have music playing in the operating suite, Labib prefers to have nothing that could muffle communication among the medical staff. The only other sounds in the operating room as the team worked on Flores were the gentle beeping of the anesthesia machine, the deep breaths of the suction machine and the whine of the drill.
Vakharia used a special drill to melt the fine cuts in bone that enabled him to remove sections from the upper jaw, the orbital floor, and the inner wall separating the eye socket from the sinus. He placed the sections of bone on the back table. Doctors also removed a 2-to-3-centimeter section of bone from Flores's hip, which would be used later when Vakharia reconstructed the areas of the face that had been altered.
When he finished creating the opening through the eye socket, Labib and Hebert took over, clearing and navigating their way behind the throat toward the tumor.
Through Flores's right nostril, Hebert wielded the endoscope, the combination light and camera that illuminated the passage to the spine so that Labib could see it clearly on the screen in front of him. Through the left nostril, Labib lowered the suction device used to pull out the sections of tumor that he cut away.
Down the third nostril, the opening below Flores's eyelid, Labib guided the drill. He drilled into the bone of the spine, reaching the tumor, then used dissectors to delicately separate and remove the tumor, piece by piece, from the protective tissue around the spinal cord.
Doctors also took fat from Flores's abdomen to pack around the spine and spinal cord to prevent fluid from leaking.
They worked through the afternoon and late into the evening, taking short breaks every few hours to eat and drink.
'Time seemed to pass unnoticed,' Labib said later. 'You train your body to handle the long hours. Most importantly, I enjoy operating.'
Finally, Vakharia returned, and using some of the bone from Flores's hip, he resculpted the sections of the upper jaw and eye socket that had been removed. He attached the resculpted sections, using titanium plates and tiny screws to keep them in place. He used titanium mesh to reconstruct the walls of the eye socket.
Like other plastic surgeons, Vakharia views the work as an art form. His goal was to make Flores's face look as if the surgeons had never been there. When he'd finished, he pulled back the cloth drape so that doctors could see her entire face.
Flores was then taken for a CT scan. The doctors checked the scan to ensure the tumor was completely gone. Her surgery ended at 2:50 a.m., almost 19 hours after it began.
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The view ahead
Two days later, Flores went through another, much briefer surgery to stabilize the junction between the bone at the base of the skull and the cervical spine, using screws, plates and rods.
Flores's first clear memory after the surgeries is lying in her hospital bed eating red Jell-O and seeing her family, everyone asking, 'Are you okay?'
The view from her left eye was foggy. She felt exhausted. She could barely walk. But she felt relieved to be done with the procedures.
Flores spent a month and a half recovering, first in a rehabilitation center, then at home.
Months later, she began proton therapy, a form of radiation treatment intended to kill any tiny fragments of tumor that remained.
Today, almost a year after the surgery, Flores said her neck still hurts. She wears a bone therapy collar to support her neck and limit movement. Her most recent scans in March showed no evidence that the cancer had returned, and Labib said her prognosis is 'excellent.'
Although her health insurance covered the first two procedures, Flores said, it has not covered the nearly $600,000 cost of the surgery that went through her eye socket and the stabilizing procedure two days later.
Flores is eager to resume her old job as a warehouse worker for Kohl's so that she can save up her money for nail school. She paints little gold bows on her own nails and often decorates her mother's as well.
She pictures herself working for an established nail salon, but one day, she hopes to create a shop of her own.
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