Charles Lavender’s surgery in April 2023 to remove a cervical intradural traumatic neuroma from his neck lasted 11 hours. The tumor, pressing dangerously on his spinal cord, was exceedingly rare, based on its location, pathology, and the patient’s history.
This very unique and rare surgery was one of the most complex that Elias Elias, M.D., Assistant Professor of Neurological Surgery at UT Southwestern Medical Center, has performed during his career as a neurosurgeon.
Dr. Elias and Charles Lavender
Three days earlier, his resident physician had called him for consultation after viewing Mr. Lavender’s magnetic resonance imaging scan. The MRI showed a lesion at the C6-C7 level of the spine, not a herniated disk as the radiologist’s report from another facility had indicated. Dr. Elias only knew that intricate preparation to remove it safely was imperative.
Located inside the dura, the very thin membrane that covers and protects the brain and spinal cord, the tumor was compressing the cord and the nerve root, which extends out of the cord and provides sensation and motor power.
“If you can move your finger, it’s because of the nerve root. If you’re in pain, it’s because of the nerve root,” Dr. Elias said.
No history of trauma
Traumatic neuromas typically involve a reaction to an injured peripheral nerve, characterized by an excessive growth of axons, Schwann cells, and fibroblasts, and accompanied by neuropathic pain. While some have been reported in atypical locations such as the facial nerve and supraorbital nerve, there have been only six documented cases of traumatic neuroma in the cervical nerve root, according to a 2023 case study Dr. Elias and colleagues published in the Journal of Neurosurgery.
Most traumatic neuromas occur in patients with a clear history of trauma. But as Dr. Elias and colleagues wrote in the study, Mr. Lavender had no self-reported history of trauma that would have caused development of a neuroma in the nerve root.
“A literature review provided some explanation for the formation of a traumatic neuroma,” the study reported. “This includes minor brachial plexus injury, a forceful pull on a baby’s head during birth, or a forgotten traction injury to the upper extremity during childhood.”
Benefits far outweigh risks
As with any surgery in or near the spinal cord, the risks in Mr. Lavender’s case were great. Using his experience and knowledge, Dr. Elias formulated a meticulous plan, then met with Mr. Lavender, a U.S. Navy veteran who is now 56, and his family at the Dallas VA Medical Center. Dr. Elias is Chief of Neurosurgery at the center, where a number of UT Southwestern clinicians treat patients.
Dr. Elias brought along the MRI and X-ray, a neck model to demonstrate which parts the surgery would affect, and a forthrightness that left nothing to chance.
“I went through the risks, the benefits, and exactly what I would do,” Dr. Elias said. “I told them how I’d remove the tumor and how I would then put in screws to stabilize his neck.”
Dr. Elias told the family that, because of an unexpected opening in his schedule, the surgery could take place the following Monday.
“He woke up and had sensation in his hands. He could use his shoulder. He felt immediately better.”
Elias Elias, M.D., Assistant Professor, Department of Neurological Surgery
Mr. Lavender, who owns a Dallas tax consulting firm and lives in Midlothian southwest of Dallas, agreed almost immediately. He wanted to get back to the optimal physical shape he’d been in before balance issues and numbness – primarily on his right side and mostly in his leg, foot, and hand – developed over about six weeks. Due to the weakness, he was unable to walk in a straight line and work out as he had during his 30 years in the Navy. He wanted to feel his toes again.
Primarily, he said yes because he trusted Dr. Elias and UTSW from the onset.
“What he told me was very logical,” said Mr. Lavender, whose primary care physician initially suspected his symptoms might indicate amyotrophic lateral sclerosis (ALS), or Lou Gehrig’s disease. “Dr. Elias was so confident. Never once did I have any doubt in what he told me he would do.”
Nor did Dr. Elias. Again and again before surgery, he went over in his head each detailed step he would take. He was extremely prepared; you cannot go into such surgeries otherwise, he said.
“If we didn’t remove the tumor,” Dr. Elias said, “it would compress more of his spinal cord and nerve roots, and he could have become paralyzed.”
‘He felt immediately better’
On the day of the surgery, in the operating room with Dr. Elias were a chief resident, an anesthesiologist, a scrub technician, and an OR nurse to hand him eight screws to go into Mr. Lavender’s neck. Neuromonitoring kept track of activity in the patient’s brain and spine.
During the surgery, Mr. Lavender was in a prone position. Dr. Elias made the incision on the back of his neck, then dissected all the muscles until he saw the spine. He removed the lamina and lateral facets to expose the spinal cord and from there, made a midline incision in the dura to visualize the spinal cord and the tumor.
After meticulously dissecting the cord and the nerve roots from the tumor, Dr. Elias carried out dissection to contour the tumor and take it out as one piece, from origin to end. Additionally, because he had to remove some bone to reach the tumor, he put eight screws on each side of the C5-C6-C7 vertebrae to stabilize Mr. Lavender’s neck.
Dr. Elias then reversed his steps, closing the dura and reconstructing it around the spinal cord so cerebrospinal fluid would not leak out.
“I felt really good after it was over,” he said. “I knew Charles would be OK because of the neuromonitoring, which would tell if he lost motor power or sensation. He woke up and had sensation in his hands. He could use his shoulder. He felt immediately better.”
When an aide came to give Mr. Lavender a sponge bath in the intensive care unit later, he was ecstatic that he could feel his foot when she touched it. Building further on his best possible outcome, testing by UTSW Pathology staff confirmed the neuroma was benign, which is generally true of this type of tumor.
‘Every day is a blessing’
Mr. Lavender is fond of saying he’s more focused on the windshield of life than the rearview mirror, so what caused the neuroma isn’t important to him. What is, instead, is the vast future that awaits – all because Dr. Elias removed the threatening neuroma and gave him back his life.
“I remember being in the hospital and telling myself I would never miss another sunrise and sunset,” he said recently. “I wake up and count down the time till the sun rises and then watch it again at the end of the day. Every day is a blessing, and important from beginning to end.”
Following the surgery, Mr. Lavender had to wear a neck brace around the clock for 90 days. He experienced one setback: a stroke in summer 2024 – unrelated to the surgery, Dr. Elias told him – that put his physical therapy on hold temporarily. Mr. Lavender said he was probably working out harder than necessary and that might have been a factor. But because he was in such good shape, he said, he’s had no repercussions from the stroke.
He’s looking forward to 2025, when he plans to take his wife on an extended trip to Italy. Until then and far beyond, he plans to keep doing what he has been – living every day, grateful to Dr. Elias and to UT Southwestern, and to be alive.
“Miracles and God and Elias,” Mr. Lavender said, “all of those combined to create the success of my surgery, I truly believe.
“Dr. Elias saved my life.”