Volume 16, Number 3
Making Headway: A Right Approach to a Wrong Tumor
What's that doing there?" neurosurgeon Ziya Gokaslan thought to himself (but didn't say to his patient). An amiable 47-year-old, Ronny Hardin had come to Hopkins from Texas knowing he had a rare tumor, a synovial chondromatosis. But he had little idea of the challenge it presented.
Synovial chondromatoses are benign growths of the cartilagenous tissue lining joints or tendon sheaths. The tumors have the odd habit of budding off and calcifying, causing no end of trouble. But the saving grace is that they typically grow in larger joints like the knee or elbow, where a quick surgical scrape clears them away. Not so in Hardin's case, however. His appeared at the junction of head and neck, just in front of the second cervical vertebra-a rare, awkward spot for any tumor, and a risky one.
The tumor had eroded part of the vertebra, making the spine less stable. And its burgeoning mass shifted the vertebra upward, threatening the brainstem above. Part of the second vertebra, the dens, juts upward like the horn on a saddle. Push the dens through the skull's large foramen, into the brainstem, and risk breathing and heartbeat.
Hardin was relieved to have found someone with a grip on his problem. The Texan had suffered punishing headaches; then a hard knot had appeared under his jaw. One doctor gave him muscle relaxants. Another diagnosed cancer and said a rib and neck artery would have to go. Still another said watching and waiting was the idea. Hardin did the latter until, a year later, he'd had trouble swallowing. Then he brought himself to Hopkins.
Gokaslan could tell traditional surgery might not solve Hardin's problem. The usual approach through the mouth and then past a small cut at the back of the throat is a cramped one at best, like putting a hand in an olive jar. So Gokaslan decided to adapt a technique skull-base surgeons use, this time for the craniocervical area.
On a spring day in 2002, Gokaslan stabilized Hardin's skull and spine with a plate and rod. Later, in a second operation, plastic surgeon Anthony Tufaro, M.D., split Hardin's lip and separated his jaw, giving Gokaslan clear access to the tumor from the front. Three weeks later, Hardin was back in Texas. Now the headaches are gone; he eats without trouble and the scar on his chin is barely noticeable.
The approach works so well that Gokaslan's started using it for degenerative problems in that area, like rheumatoid arthritis or congenital difficulties that arise in teenagers with Down syndrome. As for Hardin, he's passed his final test, he says: "I'm now bench pressing 350 pounds."
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