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Kale SS, Mishra S, Garg K, Singh PK, Borkar S, Agrawal D, Kumar R, Singh M, Suri A, Chandra PS. Surgical Management of Extradural Tumors at the Craniovertebral Junction - Insights from a Tertiary Care Center. World Neurosurg 2024:S1878-8750(24)01099-4. [PMID: 38945207 DOI: 10.1016/j.wneu.2024.06.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Craniovertebral junction (CVJ) tumors are challenging due to their unique anatomical location. This study aimed to evaluate the complexities in dealing with such precarious CVJ extradural lesions over the decade. METHODS Twenty-seven patients of extradural CVJ tumors operated between 2009 and 2018 were included. The demographic details, neurological status, surgical approach, extent of resection, type of fixation, complications, and outcome at final follow-up were recorded for each patient. RESULTS The mean age of the patients was 39.5 ± 20 years. Most (17/27) of the patients had involvement of a single level. Clivus was the most common (9/17) involved region followed by atlas (7/17) vertebrae. Majority of the patients (13/27) were operated through the posterior-only approach. About 15 patients (55.5%) had instability or extensive lesions that necessitated posterior fixation. None of the patients underwent anterior fixation. Gross and near total excision were achieved in 10 patients (37%) and 3 patients (11%) respectively while 14 patients underwent subtotal excision of tumor. On histopathological analysis, clival chordoma (8/27) was found to be the most common pathology followed by giant cell tumor (6/27), plasmacytoma (4/27), and multiple myeloma (2/27). Most patients (13 out of 27) had the same neurological status after the surgery. Six patients (22%) improved post-operatively with decreased weakness and spasticity. Thirteen (48%) patients underwent adjuvant radiotherapy. CONCLUSIONS This retrospective study provides valuable insights into managing extradural CVJ tumors and highlights the importance of individualized approaches for optimal outcome.
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Affiliation(s)
- Shashank Sharad Kale
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sandeep Mishra
- Department of Neurosurgery, Neo Hospital, Noida, Uttar Pradesh, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India.
| | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Sachin Borkar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rajender Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - P S Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Tomasi SO, Winkler PA. Letter to the Editor Regarding "Lumbar Interbody Fusion: Techniques, Pearls and Pitfalls". Asian J Neurosurg 2021; 16:665-666. [PMID: 34660393 PMCID: PMC8477847 DOI: 10.4103/ajns.ajns_82_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/10/2021] [Accepted: 04/10/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Santino Ottavio Tomasi
- Department of Neurological Surgery, Christian Doppler Klinik Paracelsus Medical University, Salzburg, Austria.,Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, Salzburg, Austria
| | - Peter A Winkler
- Department of Neurological Surgery, Christian Doppler Klinik Paracelsus Medical University, Salzburg, Austria.,Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, Salzburg, Austria
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Letter to the Editor Regarding "Decreasing Radiation Emission in Minimally Invasive Spine Surgery Using Ultra-Low-Radiation Imaging with Image Enhancement: A Prospective Cohort Study". World Neurosurg 2021; 151:320-321. [PMID: 34243655 DOI: 10.1016/j.wneu.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/21/2022]
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Capone C. Letter to the Editor Regarding "Evolution of Minimally Invasive Lumbar Spine Surgery". World Neurosurg 2021; 150:214-215. [PMID: 34098635 DOI: 10.1016/j.wneu.2021.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Crescenzo Capone
- Neurocritical Care Unit, Department of Neurosurgery and Institute of Intensive Care Medicine, University Hospital and University of Zürich, Zürich, Switzerland.
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Tomasi SO, Winkler PA. Letter to the Editor Regarding "Learning Curve and Minimally Invasive Spine Surgery". World Neurosurg 2021; 145:530-531. [PMID: 33348503 DOI: 10.1016/j.wneu.2020.07.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- S Ottavio Tomasi
- Department of Neurological Surgery and Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, Salzburg, Austria.
| | - Peter A Winkler
- Department of Neurological Surgery and Laboratory for Microsurgical Neuroanatomy, Christian Doppler Klinik, Salzburg, Austria
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Maiuri F, Cavallo LM, Corvino S, Teodonno G, Mariniello G. Anterior cervical osteophytes causing dysphagia: Choice of the approach and surgical problems. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 11:300-309. [PMID: 33824560 PMCID: PMC8019107 DOI: 10.4103/jcvjs.jcvjs_147_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background Anterior cervical osteophytes (ACOs) may rarely cause dysphagia, dysphonia, and dyspnea. Symptomatic ACOs are most commonly located between C3 and C7, whereas those at higher cervical (C1-C2) levels are rarer. We report a case series of 4 patients and discuss the best surgical approach according to the ostheophyte location and size, mainly for those located at C1-C2, and the related surgical problems. Materials and Methods Four patients (two males and two females) aged from 57 to 72 years were operated on for ACOs, causing variable dysphagia (and dyspnea with respiratory arrest in one). Three patients with osteophytes between C3 and C5 were approached through antero-lateral cervical approach, and one with a large osteophyte between C1 and C3-C4 level underwent a two-stage transcervical and transoral approach. All had significant postoperative improvement of dysphagia. Results The patient operated on though the transoral approach experienced postoperative flogosis of the prevertebral tissues and occipital muscles and thrombosis of the right jugular vein and transverse-sigmoid sinuses (Lemierre syndrome). Conclusion The transoral approach is the best surgical route to resect C1 and C2 ACOs, whereas the endoscopic endonasal approach is not indicated. The anterior transcervical approach is easier to resect osteophytes at C3, as well as those located below C3. A combined transoral and anterior cervical approach may be necessary for multilevel osteophytes.
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Affiliation(s)
- Francesco Maiuri
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University "Federico II", Naples, Italy
| | - Luigi Maria Cavallo
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University "Federico II", Naples, Italy
| | - Sergio Corvino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University "Federico II", Naples, Italy
| | - Giuseppe Teodonno
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University "Federico II", Naples, Italy
| | - Giuseppe Mariniello
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Neurosurgical Clinic, School of Medicine, University "Federico II", Naples, Italy
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Letter to the Editor Regarding “Radiolucent Carbon Fiber-Reinforced Pedicle Screws for the Treatment of Spinal Tumors: Advantages for Radiation Planning and Follow-Up Imaging”. World Neurosurg 2020; 139:674-675. [DOI: 10.1016/j.wneu.2020.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022]
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Umana GE, Passanisi M, Fricia M, Cicero S, Narducci A, Nicoletti GF, Scalia G. Letter to the Editor Regarding “Minimally Invasive Thoracolumbar Corpectomy and Stabilization for Unstable Burst Fractures Using Intraoperative Computed Tomography and Computer-Assisted Spinal Navigation”. World Neurosurg 2020; 139:692-693. [DOI: 10.1016/j.wneu.2020.04.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 02/06/2023]
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Letter to the Editor Regarding “Accuracy of Pedicle Screw Insertion Among 3 Image-Guided Navigation Systems: A Systematic Review and Meta-Analysis”. World Neurosurg 2020; 138:595-597. [DOI: 10.1016/j.wneu.2020.03.164] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 11/21/2022]
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Endonasal and Transoral Approaches to the Craniovertebral Junction: A Quantitative Anatomical Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:37-44. [PMID: 30610300 DOI: 10.1007/978-3-319-62515-7_6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The endoscopic endonasal approach has recently been added to the surgical armamentarium to access the anterior craniovertebral junction (CVJ). Comparative analyses with the transoral approach are scarce. The aim of this study was to provide a quantitative anatomical analysis of both approaches. METHODS In four specimens the endoscopic endonasal approach (before and after sphenoidectomy) and the transoral approach (without and with a soft palate split) were performed. ApproachViewer-part of GTx-UHN (Guided Therapeutics software, developed at University Health Network, Toronto, ON, Canada)-was used to quantify and visualize the working volume, as well as the exposed area, of each surgical approach. Different modalities (crossing and non-crossing) were used to quantify the exposure of the deep surface, providing an indirect quantitative value of the 'surgical freedom'. The lowest point exposed by the endonasal approaches was compared with that predicted by preoperative radiological lines. Non-parametric Welch analysis of variance (ANOVA) was used for statistical analyses. RESULTS The working volume was significantly larger and the distance to the target was shorter with the transoral approaches than with the endonasal approaches. Clival exposure was better with the endonasal approaches than with the non-crossing transoral approach without a soft palate split; areas below C1 were better exposed with the transoral routes. The nasoaxial line best predicted surgical exposure with the endonasal approaches. CONCLUSION Endoscopic endonasal and transoral approaches to the anterior CVJ provide optimal exposure of different areas that overlap at the level of C1 when no anatomical anomalies are present. A split of the soft palate is not necessary during the transoral approach if it is combined with an endoscopic endonasal approach.
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Visocchi M, Signorelli F, Liao C, Rigante M, Ciappetta P, Barbagallo G, Olivi A. Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Which Route Is Better? ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:181-186. [PMID: 30610321 DOI: 10.1007/978-3-319-62515-7_27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several pathologies that affect the craniovertebral junction (CVJ) can be treated by means of a microsurgical transoral approach (TOA) or, alternatively, with an endoscopic endonasal approach (EEA), which is potentially able to overcome some complications associated with the former approach. In this paper, after discussing updates in the recent literature, to which we add our own surgical experience, we critically analyse these procedures with the aim of demonstrating that the TOA still deserves to be considered a viable alternative and that, in selected cases, it can even be considered superior to the EEA. METHODS Our experience involves 25 anterior procedures in 24 paediatric and adult patients (18 TOA and seven EEA). The TOA group (13 male and five female patients) encompassed three tumours, three rheumatoid arthritis cases, one condylus tertius, three basilar invaginations, four impressio basilaris cases, one developmental anomaly of C0-C1, one os odontoideum, one posttraumatic C1-C2 compression and one C2 fracture. The EEA group (three male and four female patients, median age 39 years, operated on over a 7-year period) comprised four tumours, two impressio basilaris cases and one case of impressio basilaris with platybasia. RESULTS In the TOA group, all but one patient were discharged after posterior procedures within 2 weeks and improved or remained unchanged after surgery and during the follow-up period. No major complications occurred in the TOA group. In the EEA group, two patients who developed a cerebrospinal fluid (CSF) infection died, one from disease progression and the other from myocardial infarction. CONCLUSION Our data, in agreement with those from previous reports on other series, suggest that no clear superiority of the EEA over the endoscopic TOA can be postulated so far; in fact, the EEA can produce complications similar to those observed with the TOA in CVJ surgery.
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Affiliation(s)
| | | | - Chenlong Liao
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mario Rigante
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Pasquale Ciappetta
- Section of Neurological Surgery, University of Bari Medical School, Bari, Italy
| | - Giuseppe Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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Visocchi M, Signorelli F, Liao C, Rigante M, Paludetti G, Barbagallo G, Olivi A. Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Never Say Never. World Neurosurg 2018; 110:592-603. [PMID: 29433184 DOI: 10.1016/j.wneu.2017.05.125] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE For many years, the microsurgical transoral approach (TOA) has been accepted as the "gold standard" for the surgical treatment of a variety of congenital, developmental, and acquired pathologies affecting the craniovertebral junction. In the present study, we try to investigate both experimental and clinical fronts of such a challenging surgery, starting from the updated literature experience. TOA is actually presented as an "old-fashioned" surgical technique dealing with possible bacterial contamination, the need of postoperative nose gastric tube feeding for a week, the possible nasopharyngeal incompetence, and the postoperative tongue swelling. Otherwise, the endoscopic endonasal approach (EEA) appears strongly supported by the modern literature as the true "minimally invasive" procedure. METHODS Our clinical experience deals with 23 anterior procedures in paediatric and adult patients (17 TOA and 6 EEA). We further report on our experimental cadaver laboratory study of 12 subjects. RESULTS All the patients of TOA group but one were discharged after posterior procedures within two weeks and improved or remained unchanged after surgery and during the follow-up. No mayor complications occurred in TOA group. In EEA group two patients died for cerebrospinal fluid infection, for disease progression and for heart attack. CONCLUSION Our and other available data suggest that no clear superiority of EEA over endoscopic TOA can be assessed so far; on the other hand, EEA can produce complications similar to TOA in craniovertebral junction surgery.
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Affiliation(s)
| | | | - Chenlong Liao
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mario Rigante
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Gaetano Paludetti
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Giuseppe Barbagallo
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G.Rodolico" University Hospital, Catania, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery Catholic University of Rome, Rome, Italy
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