Name: Revision Endoscopic Transforaminal Decompression for Recurrent Cervicothoracic Tumor
Uploaded: 2026-07-02T00:00:00Z
Channel: Arthrex
Description: Mark A. Mahan, MD (Salt Lake City, UT), presents a revision endoscopic transforaminal case in a young patient with acute spinal cord compression following rapid recurrence of an aggressive cervicothoracic tumor. Endoscopic debulking was performed to achieve urgent decompression while minimizing surgical morbidity and allowing timely initiation of adjuvant oncologic therapy.

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Mark A. Mahan, MD (Salt Lake City, UT), presents a revision endoscopic transforaminal case in a young patient with acute spinal cord compression following rapid recurrence of an aggressive cervicothoracic tumor. Endoscopic debulking was performed to achieve urgent decompression while minimizing surgical morbidity and allowing timely initiation of adjuvant oncologic therapy.

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VID1-009588-en-US | A | Revision Endoscopic Transforaminal Decompression for Recurrent Cervicothoracic Tumor

Mark Mahan, MD (Salt Lake City, UT)

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Revision Endoscopic Transforaminal Decompression for Recurrent Cervicothoracic Tumor

Speaker  I'm Doctor Mark Mahan, professor of neurosurgery from Salt Lake City, Utah. We'll be reviewing a relatively complex case of an aggressive tumor with compression of the spinal cord. In this case, I utilized endoscopic spinal techniques to allow for urgent decompression of the spinal cord and the setting where the patient needed concurrent emergent radiotherapy and chemotherapy. Fundamentally, only an endoscopic technique allows for revision surgical debulking of an intracanalicular tumor while simultaneously receiving radiation and chemotherapy. This may not be a typical case, however it demonstrates the substantial benefits of endoscopic surgery, the role of endoscopic techniques in oncologic surgeries, and confident that even in the most challenging situations than an endoscope is safe and effective for decompressing the spinal cord. This patient is a young man who presented to our emergency room with a one week history of an inability to walk. Over the preceding four months, he had noticed weakness of his left arm, particularly with hand movements. His prior medical and family history were largely non-contributory, with no evidence of tumor syndromes. He was essentially only weakly anti-gravity in his bilateral lower extremities and very weak in his left hand function. He described loss of sensation below the pectoralis muscle and described a C7 distribution of radicular pain traveling down the left arm. Pathology was first reported to be a rhabdoid tumor, which would require gross total resection. Speaker  Rhabdoid tumors are relatively rare sarcomas, known both as extrarenal malignant rhabdoid tumors, as well as atypical rhabdoid tumors. They are considered embryonal and exhibit rapid growth with a consequent short life expectancy despite maximal therapy. Preoperative MRI demonstrated a large left mass arising from the C8 nerve root with both Intradural and Extradural components, compressing the lower cervical cord. Because of his paraplegia, I recommended a two stage approach. First, a posterior tumor resection involving intradural tumor removal and a C8 root resection and C7 pedicle. Subtraction, osteotomy and instrumentation of C5 to T2, followed by a second stage supraclavicular tumor resection. This is an intraoperative image of the tumor arising from the C8 nerve root with extradural compression. The T1 and C7 nerve roots were not grossly involved. After resection of the C8 nerve root, the dura was opened in the intradural component of the tumor was visualized here and then subsequently resected. The tumor is seen here with deformation of the cord ventral to the dentate ligaments. I perform the second surgery achieving an R1 resection, meaning gross total resection with positive margins due to the involvement of the subclavian artery esophagus pleura ribs and remaining nerve roots to his left arm. The lower trunk of his brachial plexus was completely involved in tumor, which necessitated resection of the C8 and T1 nerve roots. Speaker  This is an image of the tumor. Prior to resection, the anterior scalene muscle has been removed. The esophagus at the top of the image, reflective of the most medial portion of the surgery, and the upper trunk of the brachial plexus, is the most lateral structure at the bottom of the image, with the subclavian artery caudally on the left side of the photo. This is a picture after gross total resection. The view is down the chest cavity with the dome of the pleura visualized below his rib two and three. The normal middle trunk of the brachial plexus is better visualized here. After the second surgery, the patient was able to regain independent walking. However, unfortunately, during his rehabilitation stay, the patient was not started on chemo radiation. On the first day of anticipated radiation therapy, the patient instead represented to the emergency room with new onset paraparesis and massive tumor recurrence. Mri demonstrated recurrence of the tumor in the supraclavicular fossa with extension inside the spinal canal, and severe compression of the cervical thoracic spinal cord. Although he needed emergent decompression of his spinal cord, oncology was eager to start chemotherapy and radiation. A revision of his midline open posterior surgery would be at high risk for either immediate wound breakdown from the concurrent chemotherapy and radiation, or continued disease progression from a delay in his adjuvant therapies. Speaker  The choice of chemo radiation alone would have left him paralyzed. The choice of an open revision surgery threatened his life expectancy. Therefore, I proposed an endoscopic transsphenoidal debulking of the Intracanalicular tumor with immediate start of chemo radiation. The day after surgery, to maximize his chances of regaining ambulation again. Endoscopic approaches to the spinal cord at the Cervicothoracic junction are both straightforward and fun in comparison to open procedures. Endoscopic transforaminal approaches at this location open up new opportunities for treatment of pathologies. That would be much more morbid and challenging, with open approaches such as anterior approaches at C7, T1, or T1 two. In this case, I used a single incision to approach both the c6-t1 levels. Remember that the seven pedicle had been removed and the T1 two level. Even though it was anticipated that the initial view from the endoscope would be deep in solid tumor. My plan was to approach the intact osseous landmarks and use them to guide me to the dura. Comfort with access at the Cervicothoracic junction is critical. Fortunately, the slope of the upper ribs is usually forgiving in comparison to the midthoracic ribs. The flatter ribs of the upper thoracic spine allows a flatter approach to the ventral spinal canal. Speaker  Typical needle localization was performed first using both AP and lateral imaging and subsequent dilation and tube placement. I then approached the C6 T1 space as the seven pedicle had been previously removed. Similarly, tumor was removed with identification of the ventral venous plexus and dura. The tumor displayed consistent appearance and was easily distinguished from the dura. The silk suture from the C8 root resection was visualized. Finally, the C7 nerve root was seen marking our cranial endpoint of resection. Our patient awoke with immediate modest improvement, largely in decrease of his clonus. Postoperative MRI demonstrated CSF around the cord at all levels with a small amount of residual blood from the resection. Impressively, he regained ambulation, although with a cane, and this time he completed chemo radiation. This case represents, in my humble opinion, some of the best assets of endoscopic surgery, including such a minimally invasive approach that chemotherapy and radiation could be safely started immediately after surgery. An ability to handle a vascular tumor with the benefit of irrigation and clear visualization of the tumor from dura. I have used endoscopic techniques in multiple other cases where the need for urgent surgical decompression and chemo radiation collide. Even in cases where the vascularity of the tumor, such as renal cell metastases, is concerning, irrigation has made the resection surprisingly straightforward.

Foraminotomía y descompresión cervical 

Revision Endoscopic Transforaminal Decompression for Recurrent Cervicothoracic Tumor

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