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Yakdan SM, Greenberg JK, Krishnaney AA, Mroz TE, Spiessberger A. Transcervical, retropharyngeal odontoidectomy - Anatomical considerations. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:393-398. [PMID: 38268697 PMCID: PMC10805156 DOI: 10.4103/jcvjs.jcvjs_112_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/19/2023] [Indexed: 01/26/2024] Open
Abstract
Context Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications. Aims This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process. Methods and Surgical Technique To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach. Results The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas. Conclusions For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.
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Affiliation(s)
- Salim M. Yakdan
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Ajit A. Krishnaney
- Center for Spine Health, Cleveland Clinic, Neurologic Institute, Cleveland, OH, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Neurologic Institute, Cleveland, OH, USA
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Shkarubo AN, Chernov IV, Andreev DN, Konovalov NA, Sinelnikov ME. [Minimally invasive surgery for invaginated CII odontoid process]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:5-12. [PMID: 37325821 DOI: 10.17116/neiro2023870315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Odontoidectomy is indicated for anterior compression of the brainstem by invaginated odontoid process. This procedure can currently be performed via transoral microsurgical and transnasal endoscopic access. OBJECTIVE To analyze the results of endoscopic transnasal odontoidectomy. MATERIAL AND METHODS We assessed treatment outcomes in 10 patients with anterior compression of the brainstem by invaginated odontoid process. All patients underwent endoscopic transnasal odontoidectomy. RESULTS Brainstem decompression was achieved in all cases. CONCLUSION Currently, endoscopic transnasal approach is gradually replacing the transoral one in some patients requiring anterior odontoidectomy. Analysis of literature data reflects the development of this technique taking into account various features of surgical treatment including optimization of dimensions of surgical field, attempts to perform C1-sparing surgeries and analysis of sufficient size of trepanation. Nasopalatine and nasoclival lines are used to select optimal access. Nevertheless, the choice of access depends on equipment of the hospital and surgical experience in most cases.
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Affiliation(s)
| | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - M E Sinelnikov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Kim JY, Cho JH, Yoon SH, Cho SM, Lim YC. New Simple 3-Dimensional Computed Tomogram Classification Leading to Successful Conservative Treatment in 51 Atlanto-Axial Rotatory Fixation Children. Pediatr Neurosurg 2021; 56:125-132. [PMID: 33611332 DOI: 10.1159/000512368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE to present a new and easy classification of atlanto-axial rotatory fixation (AARF) and to investigate the efficiency of conservative treatment of AARF. BACKGROUND Although there is a precise definition and diagnostic classification of AARF, there is still significant difficulty in measuring the atlas and axis angles because all of the atlas or axis cannot be seen in a certain 2-dimensional computed tomogram image. In addition, some recent case reports showed that long-term conservative treatment can reduce pediatric AARFs, even that are severe or chronic. METHODS Fifty-one children with AARF were analyzed retrospectively with new 3-dimensional computed tomogram (3DCT)-based AARF classification; the mean age was 72.7 ± 35.2 months (19-139 months). In the new AARF classification, type 1 was defined as that when the C1C2 angle is not 0° on midline and type 2 as that when the C1C2 angle is 0° on the midline. RESULTS All 7 children with AARF type 1 were treated successfully only with Halter tractions. Twenty among 44 children with type 2 did not show any difference in improvement compared with not-treated 24 children with type 2. CONCLUSION The first new AARF classification based on 3DCT appears to be easy to use and even the most severe children with AARF may be managed only with conservative treatment such as long-term Halter traction.
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Affiliation(s)
- Jong Yeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Ho Cho
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Soo Han Yoon
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Republic of Korea,
| | - Sung Min Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Yong Cheol Lim
- Department of Neurosurgery, Ajou University School of Medicine, Suwon, Republic of Korea
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Shkarubo AN, Nikolenko VN, Chernov IV, Andreev DN, Shkarubo MA, Chmutin KG. [Anatomy of anterior craniovertebral junction in endoscopic transnasal approach]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2020; 84:46-53. [PMID: 32759926 DOI: 10.17116/neiro20208404146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Modern achievements in endoscopic technologies ensure extending the indications for endoscopic transnasal approach in skull base surgery. Knowledge on topographic anatomy of craniovertebral junction is a prerequisite for surgical interventions in this area. Transnasal endoscopic surgery of craniovertebral junction is a relatively new field. Therefore, this manuscript and similar anatomical studies are extremely important for neurosurgeons.
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Affiliation(s)
| | - V N Nikolenko
- Sechenov First Moscow State Medical University, Moscow, Russia.,Lomonosov Moscow State University, Moscow, Russia
| | - I V Chernov
- Burdenko Neurosurgical Center, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | - K G Chmutin
- People's Friendship University of Russia, Moscow, Russia
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Kobets A, Ammar A, Dowling K, Cohen A, Goodrich J. The limits of endoscopic endonasal approaches in young children: a review. Childs Nerv Syst 2020; 36:263-271. [PMID: 31845030 DOI: 10.1007/s00381-019-04455-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The endoscopic endonasal approach (EEA) provides visualization of four deep surgical corridors (transcribiform, transtubercular, transsellar, and transclival) with superior illumination and specialized deep-reaching instruments, as compared to microscopic techniques. Several studies have evaluated EEAs in children but do not stratify for the very young of age, whose particularly small nares and developmental anatomy may limit endonasal instrumentation. METHODOLOGY A comprehensive review of EEAs in infants and children to age 4 was performed to determine the limitations in this age group. RESULTS Eighteen studies were identified describing this approach for pediatric patients and the surgical caveats and limitations were reviewed. In very small children, CSF leaks, meningioencephaloceles, tumors of the anterior skull base, and lesions at the rostral cervical spine have been successfully treated endonasally. While newer studies advocate using 2.7-mm diameter (18-cm length) lenses, 4-mm diameter rigid lenses have been used without technical difficulty. The youngest patient in whom an EEA was used was a 6-week-old for a dermoid resection. Some have advocated that due to the small nares, approaches via bilateral entry are optimal for multiple instruments, however, others, including authors of a series of 28 repaired CSF leaks demonstrate successful single nare access. DISCUSSION EEAs are associated with less blood loss, are less likely to hinder normal growth of the skull and midface, and allow for the resection of even malignant lesions. Despite the limitations of the frontal, ethmoid, and sphenoid sinuses before age 3, reports have not documented insurmountable difficulty with EEAs even in infants. 2.7-mm diameter endoscopes are favored unilaterally or bilaterally to treat both benign and malignant lesions and preserve the young patient's facial anatomy better than older methods. Ever improving technology has facilitated the use of this approach in patients it would otherwise be infeasible for in the past, but it still cannot overcome the anatomical constraints of certain young patients in which this approach remains unindicated. Patient selection is therefore of utmost importance and the risks and benefits of more extensive approaches in these cases must be considered.
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Affiliation(s)
- Andrew Kobets
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe St, 5th Floor, Baltimore, MD, 21287, USA.
| | - Adam Ammar
- Leo Davidoff Department of Neurological Surgery, Division of Pediatric Neurosurgery, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave, The Bronx, NY, 10467, USA
| | - Kamilah Dowling
- Leo Davidoff Department of Neurological Surgery, Division of Pediatric Neurosurgery, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave, The Bronx, NY, 10467, USA
| | - Alan Cohen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe St, 5th Floor, Baltimore, MD, 21287, USA
| | - James Goodrich
- Leo Davidoff Department of Neurological Surgery, Division of Pediatric Neurosurgery, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave, The Bronx, NY, 10467, USA
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Deopujari CE, Shah NJ, Shaikh ST, Karmarkar VS, Mohanty CB. Endonasal endoscopic skullbase surgery in children. Childs Nerv Syst 2019; 35:2091-2098. [PMID: 31079184 DOI: 10.1007/s00381-019-04167-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/17/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The role of endonasal endoscopic approach for pathologies in the paediatric population is evolving and has still not been accepted as standard of care in neurosurgery. It represents a challenge in terms of narrow access, instrument manipulation and adequate reconstruction of defects. We have described our experience in 49 cases from a single neurosurgical unit in paediatric skull base surgeries through this approach over the last 12 years. MATERIAL AND METHODS A case series of 59 paediatric skull base surgeries in 49 children through endoscopic endonasal route over the last 12 years is presented. The age ranges from 4 months to 18 years. Out of 49 cases, 22 cases were of craniopharyngiomas, 8 cases of pituitary adenomas, 5 cases with CSF rhinorrhea, 5 cases with meningoencephalocele, 3 cases of Rathke's cleft cysts, 2 cases of odontoidectomy and 4 miscellaneous cases viz. mucocele, hypothalamic glioma, esthesioneuroblastoma and epidermoid. CSF leaks were repaired with free graft in the initial years and by vascularized flap more recently. RESULTS The goal of surgery was achieved in all but two cases in whom the tumour excision was unsatisfactory due to failure of the cyst wall to collapse after decompression. Extent of tumour excision was not compromised by the choice of this approach. Revision surgery for CSF leak was required in three patients. Local vascularized nasoseptal flap has been possible even in very young patients and has now become the standard for reconstruction. CONCLUSION In spite of the challenges posed by small nostrils and ill-developed sinuses in the paediatric age group, surgery from endoscopic endonasal corridor is possible to be carried out successfully in selected cases.
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Affiliation(s)
| | - Nishit J Shah
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Salman T Shaikh
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Vikram S Karmarkar
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Chandan B Mohanty
- Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, Mumbai, India
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Archer J, Thatikunta M, Jea A. Posterior transdural approach for odontoidectomy in a child: case report. J Neurosurg Pediatr 2019; 25:8-12. [PMID: 31604321 DOI: 10.3171/2019.7.peds19337] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
The transoral transpharyngeal approach is the standard approach to resect the odontoid process and decompress the cervicomedullary spinal cord. There are some significant risks associated with this approach, however, including infection, CSF leak, prolonged intubation or tracheostomy, need for nasogastric tube feeding, extended hospitalization, and possible effects of phonation. Other ventral approaches, such as transmandibular and circumglossal, endoscopic transcervical, and endoscopic transnasal, are also viable alternatives but are technically challenging or may still traverse the nasopharyngeal cavity. Far-lateral and posterior extradural approaches to the craniocervical junction require extensive soft-tissue dissection. Recently, a posterior transdural approach was used to resect retro-odontoid cysts in 3 adult patients. The authors present the case of a 12-year-old girl with Down syndrome and significant spinal cord compression due to basilar invagination and a retro-flexed odontoid process. A posterior transdural odontoidectomy prior to occiptocervical fusion was performed. At 12 months after surgery, the authors report satisfactory clinical and radiographic outcomes with this approach.
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Affiliation(s)
- Jacob Archer
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Meena Thatikunta
- 2Department of Neurological Surgery, University of Louisville Hospital School of Medicine, Louisville, Kentucky
| | - Andrew Jea
- 1Section of Pediatric Neurosurgery, Riley Hospital for Children, Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
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Shkarubo AN, Nikolenko VN, Chernov IV, Andreev DN, Shkarubo MA, Chmutin KG, Sinelnikov MY. Anatomical Aspects of the Transnasal Endoscopic Access to the Craniovertebral Junction. World Neurosurg 2019; 133:e293-e302. [PMID: 31520764 DOI: 10.1016/j.wneu.2019.09.011] [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: 07/17/2019] [Revised: 09/02/2019] [Accepted: 09/03/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Interest in endoscopic transnasal access has increased with continued technological advances in endoscopic technology. The goals of this study were to review the normal anatomy in transnasal endoscopic neurosurgery and outline the anatomical basis for an expanded surgical approach. Defining anatomical aspects of surgical endoscopy helps guide the surgeon by defining normal anatomy of the access vector. METHODS This anatomic study was conducted on 15 adult male cadaver specimens using various microsurgical tools and endoscopic instruments and 1 intraoperative case. The vasculature was injected with colored silicone to aid visualization. Different transnasal approach techniques were used, with angles of endoscope access at 0°, 30°, 45°, and 70° accordingly for extensive anatomical mapping. RESULTS The proximity of critical structures is different in each approach degree. A full understanding of the possible structures to be met during transnasal access is described. As a result of the study, anatomical aspects and important structures were outlined, and a surgical protocol was defined for minimal risk access in respect to normal anatomy of the area. CONCLUSIONS Thorough knowledge of topographic anatomy of the craniovertebral junction is required for performing minimal-risk surgical intervention in this region. It is important to know all anatomical aspects of the transnasal approach in order to reduce the risk of damage to vital structures. Transnasal endoscopic surgery of the craniovertebral junction is a relatively new direction in neurosurgery; therefore, anatomical studies such as the one described in this article are extremely important for the development of this access method.
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Affiliation(s)
- Alexey Nikolaevich Shkarubo
- Department of Neurosurgery, N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation; Department of Neurosurgery, RUDN University, Moscow, Russian Federation; Department of Neurosurgery, N.N. Priorov Central Institute of Traumatology and Orthopedics, Moscow, Russian Federation.
| | - Vladimir Nikolaevich Nikolenko
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation; Department of Anatomy, Lomonosov Moscow State University, Moscow, Russian Federation
| | - Ilia Valerievich Chernov
- Department of Neurosurgery, N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Dmitry Nikolaevich Andreev
- Department of Neurosurgery, N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | - Mikhail Alekseevich Shkarubo
- Department of Neurosurgery, N.N. Burdenko National Medical Research Center of Neurosurgery, Moscow, Russian Federation
| | | | - Mikhail Yegorovich Sinelnikov
- I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University), Moscow, Russian Federation
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Alalade AF, Ogando-Rivas E, Forbes J, Ottenhausen M, Uribe-Cardenas R, Hussain I, Nair P, Lehner K, Singh H, Kacker A, Anand VK, Hartl R, Baaj A, Schwartz TH, Greenfield JP. A Dual Approach for the Management of Complex Craniovertebral Junction Abnormalities: Endoscopic Endonasal Odontoidectomy and Posterior Decompression with Fusion. World Neurosurg X 2019; 2:100010. [PMID: 31218285 PMCID: PMC6580888 DOI: 10.1016/j.wnsx.2019.100010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction. METHODS Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery. RESULTS A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0. CONCLUSIONS The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.
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Affiliation(s)
- Andrew F. Alalade
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Elizabeth Ogando-Rivas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jonathan Forbes
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Malte Ottenhausen
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Rafael Uribe-Cardenas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Prakash Nair
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Kurt Lehner
- Zucker School of Medicine, Hofstra-Northwell Health School of Medicine, New York, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Vijay K. Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ali Baaj
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Theodore H. Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Visocchi M, Iacopino DG, Signorelli F, Olivi A, Maugeri R. Walk the Line. The Surgical Highways to the Craniovertebral Junction in Endoscopic Approaches: A Historical Perspective. World Neurosurg 2018; 110:544-557. [PMID: 29433179 DOI: 10.1016/j.wneu.2017.06.125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/17/2017] [Accepted: 06/19/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND We compiled a comprehensive literature review on the anatomic and clinical results of endoscopic approaches to the craniocervical junction (CVJ) to better contribute to identify the best strategy. METHODS An updated literature review was performed in the PubMed, OVID, and Google Scholar medical databases, using the terms "Craniovertebral junction," "Transoral approach," "Transnasal approach," "Transcervical approach," "Endoscopic endonasal approach," "Endoscopic transoral approach," "Endoscopic transcervical approach." Clinical series, anatomic studies, and comparative studies were reviewed. RESULTS Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the deeper surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging option to standard microsurgical techniques for transoral approaches to the anterior CVJ. This approach should be considered as complementary rather than an alternative to the traditional microsurgical transoral-transpharyngeal approach. CONCLUSIONS The transoral approach with sparing of the soft palate still remains the gold standard compared with the pure transnasal and transcervical approaches because of the wider working channel provided by the former technique. The transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus.
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Affiliation(s)
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | | | - Alessandro Olivi
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy.
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Aldahak N, Richter B, Bemora JS, Keller JT, Froelich S, Abdel Aziz KM. The endoscopic endonasal approach to cranio-cervical junction: the complete panel. Pan Afr Med J 2017; 27:277. [PMID: 29187946 PMCID: PMC5660904 DOI: 10.11604/pamj.2017.27.277.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022] Open
Abstract
We aim to establish a complete summary on the Endoscopic Endonasal Approach (EEA) to Cranio Cervical Junction (CCJ): evolution since first description, criteria to predict the feasibility and limitations, anatomical landmarks, indications and biomechanical evaluation after performing the approach. A comprehensive literature search to identify all available literature published between March 2002 and June 2015, the articles were divided into four categories according to their main purpose: 1- surgical technique, 2- anatomical landmarks and limitations, 3- literature reviews to identify main indications, 4- biomechanical studies. Thereafter, we demonstrate the approach step-by-step, using 1 fresh and 3 silicon injected embalmed cadaveric specimen heads. 61 articles and one poster were identified. The approach was first described on cadaveric study in 2002, and firstly used to perform odontoidectomy in 2005. The main indication is odontoid rheumatoid pannus and basilar invagination. The nasopalatine line (NPL), the superior nostril-hard palate Line (SN-HP), the naso-axial line (NAxL), the rhinopalatine Line (RPL) and other methods were described to predict the anatomical feasibility of the approach. The craniocervical fusion is potentially unnecessary after removal of < 75% of one occipital condyle. A recent cadaveric study stated the possibility of C1-C2 fusion via EEA. This paper reviews all available clinical and anatomical studies on the EEA to CCJ. The approach marked a significant evolution since its first description in 2002. Because of its lesser complications compared to the transoral approach, the EEA became when feasible, the approach of choice to the ventral CCJ.
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Affiliation(s)
- Nouman Aldahak
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA.,Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Bertram Richter
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
| | - Joseph Synèse Bemora
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Jeffery Thomas Keller
- Departments of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, P.O Box 670515 Cincinnati, Ohio 45267-0515, USA
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Khaled Mohamed Abdel Aziz
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
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Chibbaro S, Cebula H, Aldea S, Baussart B, Tigan L, Todeschi J, Romano A, Ganau M, Debry C, Servadei F, Proust F, Gaillard S. Endonasal Endoscopic Odontoidectomy in Ventral Diseases of the Craniocervical Junction: Results of a Multicenter Experience. World Neurosurg 2017; 106:382-393. [PMID: 28676464 DOI: 10.1016/j.wneu.2017.06.148] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/20/2017] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Over the past decades, supported by preliminary anatomic and clinical studies exploring its feasibility and safety, experience has increased of the use of the endoscopic endonasal approach (EEA) to ventral diseases at the craniocervical junction (CCJ). METHODS A multicenter study was carried out over a 4-year period of 14 patients managed by EEA odontoidectomy for CCJ diseases causing irreducible atlantoaxial dislocation. The surgical setup included an IGS system based on computed tomography and magnetic resonance images fusion, and 0° and 30° angled endoscopes with dedicated endoscopic tools. RESULTS Nine men and 5 women, with a mean age of 60.7 years, were included. The mean follow-up was 28.5 months; 9 patients had basilar impression, whereas 5 had a degenerative pannus. The quality of anterior decompression was excellent in all cases; nonetheless, a posterior stabilization was deemed necessary in 13 patients, and no external orthosis was used during the postoperative course. No tracheostomy or gastrostomy was required after surgery; no deaths, no new neurologic deficits/complications, and no postoperative cerebrospinal fluid leak were recorded. At follow-up, the neurologic status assessed with Frankel grade did not deteriorate in any of the patients but improved in 13 of them; and no new listhesis was shown on neuroradiologic follow-up. CONCLUSIONS The results show that EEA provides a direct surgical corridor to the CCJ, allowing an adequate decompression as with the more invasive transoral route. Morbidity is less than with a transoral approach, resulting in higher patient comfort and faster recovery.
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Affiliation(s)
- Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France.
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Sorin Aldea
- Department of Neurosurgery, Foch Hospital, Suresnes (Paris), France
| | | | - Leonardo Tigan
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Romano
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Christian Debry
- Department of ENT, Strasbourg University Hospital, Strasbourg, France
| | - Franco Servadei
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | - Francois Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
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Karsy M, Moores N, Siddiqi F, Brockmeyer DL, Bollo RJ. Bilateral sagittal split mandibular osteotomies for enhanced exposure of the anterior cervical spine in children: technical note. J Neurosurg Pediatr 2017; 19:464-471. [PMID: 28186477 DOI: 10.3171/2016.11.peds16530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The bilateral sagittal split mandibular osteotomy (BSSMO), a common maxillofacial technique for expanding the oropharynx during treatment of micrognathia, is a rarely employed but useful adjunct to improve surgical access to the ventral cervical spine in children. Specifically, it provides enhanced exposure of the craniocervical junction in the context of midface hypoplasia, and of the subaxial cervical spine in children with severe kyphosis. The authors describe their technique for BSSMO and evaluate long-term outcomes in patients. The pediatric neurosurgical database at a single center was queried to identify children who underwent BSSMO as an adjunct to cervical spine surgery over a 22-year study period (1993-2015). The authors retrospectively reviewed clinical and radiographic data in all patients. The authors identified 5 children (mean age 5.3 ± 3.1 years, range 2.1-10.0 years) who underwent BSSMO during cervical spine surgery. The mean clinical follow-up was 3.0 ± 1.9 years. In 4 children, BSSMO was used to increase the size of the oropharynx and facilitate transoral resection of the odontoid and anterior decompression of the craniocervical junction. In 1 patient with subaxial kyphosis and chin-on-chest deformity, BSSMO was used to elevate the chin, improve anterior exposure of the subaxial cervical spine, and facilitate cervical corpectomy. Careful attention to neurovascular structures, including the inferior alveolar nerve, lingual nerve, and mental branch of the inferior alveolar artery, as well as minimizing tongue manipulation and compression, are critical to complication avoidance. The BSSMO is a rarely used but extremely versatile technique that significantly enhances anterior exposure of the craniocervical junction and subaxial cervical spine in children in whom adequate visualization of critical structures is not otherwise possible.
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Affiliation(s)
- Michael Karsy
- Department of Neurosurgery, Division of Pediatric Neurosurgery, and
| | - Neal Moores
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Faizi Siddiqi
- Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | | | - Robert J. Bollo
- Department of Neurosurgery, Division of Pediatric Neurosurgery, and
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Endoscopic Endonasal Approach for Craniovertebral Junction Pathologic Conditions: Myth and Truth in Clinical Series and Personal Experience. World Neurosurg 2017; 101:122-129. [PMID: 28179170 DOI: 10.1016/j.wneu.2017.01.099] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 01/25/2017] [Accepted: 01/26/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE For many years, the microsurgical transoral approach has been accepted as the gold standard for anterior decompressions of the craniovertebral junction (CVJ). The introduction of the endoscopic endonasal approach (EEA) has gained wide recognition and overwhelming support in recent years, including for diseases of the CVJ. The aim of this study was to critically analyze and discuss all cases of CVJ diseases approached by means of an EEA so far reported in the literature, including our institutional experience consisting of 6 consecutive patients. METHODS Six consecutive patients affected by CVJ disease underwent an EEA. Three patients had a tumor (2 chordomas and 1 myeloma) and 3 had impressio basilaris. RESULTS Five patients had an uncomplicated postoperative course and 1 developed an intraoperative cerebrospinal fluid leak and subsequent meningitis and died 5 weeks after surgery. A total of 107 patients (including our 6) affected by CVJ disease and treated with EEA have been reported so far. Among these patients, cerebrospinal fluid leak was reported in 13 (12.4%), transient velopharyngeal incompetence in 6 (5.6%), postoperative epistaxis in 2 (1.86%), and respiratory dysfunction requiring a tracheostomy in 2 (1.86%). In our extended institutional series of more than 20 consecutive anterior decompressions for CVJ diseases (including transoral and transnasal microsurgical approaches), the only fatal complication was associated with EEA. CONCLUSIONS On the basis of the reviewed literature and our personal experience, the reported increased safety of the EEA needs to be reassessed and discussed.
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Abstract
STUDY DESIGN Retrospective case series of atlantoaxial rotatory fixed dislocation (AARFD). OBJECTIVE To describe clinical features and the surgical treatment of AARFD. SUMMARY OF BACKGROUND DATA The classification and treatment strategy for atlantoaxial rotatory fixation (AARF) were previously described and remained controversial. AARF concomitant with atlantoaxial dislocation has different clinical features and treatment strategy with the most AARF. Due to deficiency of the transverse ligament or odontoid, the atlantoaxial remains unstable even after the torticollis relieved or cured. Because of the rarity, treatment strategy for this special condition has not been specialized and fully explored in the literatures. METHODS Thirty-two children with AARFD (sustained torticollis more than 6 weeks and atlanto-dental internal more than 5 mm) were retrospectively reviewed. Treatment methodology, pearls, and pitfalls of the treatment were discussed. RESULTS Thirty-two cases had sustained torticollis for an average of 5.7 months. ADI of them ranged from 8 to 22 mm, with a mean of 11.3 mm. Eight cases presented with signs and symptoms of spinal cord dysfunction. All 32 cases underwent surgery and had no spinal cord or vertebral artery injury. The surgery included posterior reduction and fusion (reducible dislocation and torticollis, 16 cases), and transoral release followed by posterior reduction and fusion (irreducible dislocation and torticollis, 16 cases). The average follow-up time was 42 months. Solid fusion and torticollis healing were achieved in 31 patients (96.9%) as detected radiologically. Two cases (6.3%, 2/32) suffered complications (cerebrospinal fluid leakage and recurred torticollis followed by revision). CONCLUSION AARFD had distinct clinical features relative to common presentations of AARF. Because of deficiency of the transverse ligament or odontoid and subsequent atlantoaxial dislocation, surgical treatments are applied for this condition, including transoral release and posterior C1-2 reduction and fusion. AARFD cases were successfully managed surgically without preoperative traction, with few complications seen. LEVEL OF EVIDENCE 4.
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Chan AK, Benet A, Ohya J, Zhang X, Vogel TD, Flis DW, El-Sayed IH, Mummaneni PV. The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example. Neurosurg Focus 2016; 40:E11. [DOI: 10.3171/2015.11.focus15498] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption.
METHODS
A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video.
RESULTS
The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1–27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6–23.7 mm) and 16.70 mm on the left side (range 8.1–26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2–41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range −4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range −1.5 to 7.3 mm); and palatal line relative to the C-1 arch, −2.75 mm (range −5.8 to 0 mm).
CONCLUSIONS
The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.
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Affiliation(s)
| | - Arnau Benet
- Departments of 1Neurological Surgery and
- 2Otolaryngology, University of California, San Francisco, California
| | | | - Xin Zhang
- Departments of 1Neurological Surgery and
| | | | - Daniel W. Flis
- 2Otolaryngology, University of California, San Francisco, California
| | - Ivan H. El-Sayed
- 2Otolaryngology, University of California, San Francisco, California
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Chang PY, Yen YS, Wu JC, Chang HK, Fay LY, Tu TH, Wu CL, Huang WC, Cheng H. The importance of atlantoaxial fixation after odontoidectomy. J Neurosurg Spine 2016; 24:300-308. [DOI: 10.3171/2015.5.spine141249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Although anterior odontoidectomy has been widely accepted as a procedure for decompression of the craniovertebral junction (CVJ), postoperative biomechanical instability has not been well addressed. There is a paucity of data on the necessity for and choice of fixation.
METHODS
The authors conducted a retrospective review of consecutively treated patients with basilar invagination who underwent anterior odontoidectomy and various types of posterior fixation. Posterior fixation included 1 of 3 kinds of constructs: occipitocervical (OC) fusion with atlantoaxial (AA) fixation, OC fusion without AA fixation, or AA-only (without OC) fixation. On the basis of the use or nonuse of AA fixation, these patients were assigned to either the AA group, in which the posterior fixation surgery involved both the atlas and axis simultaneously, regardless of whether the patient underwent OC fusion, or the non-AA group, in which the OC fusion construct spared the atlas, axis, or both. Clinical outcomes and neurological function were compared. Radiological results at each time point (i.e., before and after odontoidectomy and after fixation) were assessed by calculating the triangular area causing ventral indentation of the brainstem in the CVJ.
RESULTS
Data obtained in 14 consecutively treated patients with basilar invagination were analyzed in this series; the mean follow-up time was 5.75 years. The mean age was 53.58 years; there were 7 males and 7 females. The AA and non-AA groups consisted of 7 patients each. The demographic data of both groups were similar. Overall, there was significant improvement in neurological function after the operation (p = 0.03), and there were no differences in the postoperative Nurick grades between the 2 groups (p = 1.00). According to radiological measurements, significant decompression of the ventral brainstem was achieved stepwise in both groups by anterior odontoidectomy and posterior fixation; the mean ventral triangular area improved from 3.00 ± 0.86 cm2 to 2.08 ± 0.51 cm2 to 1.68 ± 0.59 cm2 (before and after odontoidectomy and after fixation, respectively; p < 0.05). The decompression gained by odontoidectomy (i.e., reduction of the ventral triangular area) was similar in the AA and non-AA groups (0.66 ± 0.42 cm2 vs 1.17 ± 1.42 cm2, respectively; p = 0.38). However, the decompression achieved by posterior fixation was significantly greater in the AA group than in the non-AA group (0.64 ± 0.39 cm2 vs 0.17 ± 0.16 cm2, respectively; p = 0.01).
CONCLUSIONS
Anterior odontoidectomy alone provides significant decompression at the CVJ. Adjuvant posterior fixation further enhances the extent of decompression after the odontoidectomy. Moreover, posterior fixation that involves AA fixation yields significantly more decompression of the ventral brainstem than OC fusion that spares AA fixation.
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Affiliation(s)
- Peng-Yuan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Yu-Shu Yen
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Jau-Ching Wu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Hsuan-Kan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Li-Yu Fay
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 4Institute of Pharmacology, National Yang-Ming University; and
| | - Tsung-Hsi Tu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 5Molecular Medicine Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan
| | - Ching-Lan Wu
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
| | - Wen-Cheng Huang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Henrich Cheng
- 1Department of Neurosurgery, Neurological Institute, and
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
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Shkarubo AN, Konovalov NA, Zelenkov PV, Mazaev VA, Andreev DN, Chernov IV. [Endoscopic endonasal removal of the invaginated odontoid process of the C2 vertebra]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 79:82-90. [PMID: 26528618 DOI: 10.17116/neiro201579582-90] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
UNLABELLED Pathological processes in the craniovertebral region (clivus, C1 anterior arch, odontoid process and body of the C2 vertebra, i.e. C0-C1-C2 segments) are very difficult to diagnose and treat. The craniovertebral junction instability may develop in the case of a significant lesion of C1-C2 segments. Among diseases causing destruction of the clivus structures and C1-C2 vertebrae and compression of the spinal cord, the following ones are most common: chordoma, giant cell tumor, osteoblastoma, rheumatoid lesion, metastases, platybasia, and basilar impression. These diseases can cause the initial instability of the craniovertebral junction and be accompanied by gross neurological disorders, which complicates the diagnosis and surgical treatment of these patients. MATERIAL AND METHODS We operated on two patients diagnosed with invagination of the odontoid process of the C2 vertebra. In both cases, one-stage operation was performed that included occipitospondylodesis and endoscopic endonasal removal of the C2 odontoid process. RESULTS In the postoperative period, partial regression of the neurological symptoms was observed that included an increase in the strength and range of motions in the arms and distal legs, regressed spasticity in the arms and significantly reduced spasticity in the legs, and a significant improvement in all kinds of sensitivity in the arms, legs, and torso. Postoperative liquorrhea was observed in 1 case (patient 2); re-operation to close a CSF fistula was conducted. Later, no signs of liquorrhea were noted. In both cases, control MRI and spiral CT revealed a postoperative bone defect of the C2 odontoid process and clivus, complete decompression of the medulla oblongata and upper cervical spine segments, and no evidence of spinal canal stenosis; the stabilizing system was competent and properly placed. CONCLUSION The endoscopic endonasal approach, compared to the standard transoral approach, has significant advantages in that the soft palate remains intact, the oropharynx area is less damaged, and the hospitalization and rehabilitation duration is reduced. Also, there are no problems and complications such as possible failure of sutures in the oral cavity and a large wound surface in the oropharynx area. The patient can eat on his own immediately after the operation without the use of a stomach tube (it does not cause any inflammatory complications of the oral cavity). However, the surgical technique of the endoscopic endonasal approach to the C1-C2 segment is more complex than that of transoral surgery and requires the surgeon to be skilled and experienced.
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Affiliation(s)
- A N Shkarubo
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - P V Zelenkov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V A Mazaev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Andreev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I V Chernov
- Sechenov First Moscow State Medical University, Moscow, Russia
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Tubbs RS, Demerdash A, Rizk E, Chapman JR, Oskouian RJ. Complications of transoral and transnasal odontoidectomy: a comprehensive review. Childs Nerv Syst 2016; 32:55-9. [PMID: 26248673 DOI: 10.1007/s00381-015-2864-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 07/28/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Odontoidectomy has been considered an effective way to treat anterior cervicomedullary compression in patients presenting with craniocervical joint anomalies. The transoral and transnasal routes have been described for anterior decompression surgery. However, to date, a comprehensive review of the complications from this procedure is lacking in the extant medical literature. Therefore, herein, we review this specific literature as a resource for surgeons. METHODS A comprehensive review of the literature via online search engines was performed. CONCLUSION The most reported complications for odontoidectomy are CSF leakage, postoperative craniocervical instability, velopharyngeal insufficiency, wound dehiscence, pulmonary issues, meningitis, and death. To our knowledge, this is the first comprehensive review of complications of odontoidectomy. Increased awareness of the more common complications associated with this procedure may help in the care of patients in the future.
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Affiliation(s)
| | | | - Elias Rizk
- Neurological Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
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Liu JK, Patel J, Goldstein IM, Eloy JA. Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances. Neurosurg Focus 2015; 38:E17. [PMID: 25828493 DOI: 10.3171/2015.1.focus14813] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The transoral approach is considered the gold-standard surgical route for performing anterior odontoidectomy and ventral decompression of the craniovertebral junction for pathological conditions that result in symptomatic cervicomedullary compression, including basilar invagination, rheumatoid pannus, platybasia with retroflexed odontoid processes, and neoplasms. Extended modifications to increase the operative corridor and exposure include the transmaxillary, extended "open-door" maxillotomy, transpalatal, and transmandibular approaches. With the advent of extended endoscopic endonasal skull base techniques, there has been increased interest in the last decade in the endoscopic endonasal transclival transodontoid approach to the craniovertebral junction. The endonasal route represents an attractive minimally invasive surgical alternative, especially in cases of irreducible basilar invagination in which the pathology is situated well above the palatine line. Angled endoscopes and instrumentation can also be used for lower-lying pathology. By avoiding the oral cavity and subsequently using a transoral retractor, the endonasal route has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia. Postoperative recovery is quicker, and hospital stays are shorter. In this report, the authors describe and illustrate their method of purely endoscopic endonasal transclival odonotoidectomy for anterior decompression of the craniovertebral junction and describe various operative pearls and nuances of the technique for avoiding complications.
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Visocchi M, Di Martino A, Maugeri R, González Valcárcel I, Grasso V, Paludetti G. Videoassisted anterior surgical approaches to the craniocervical junction: rationale and clinical results. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:2713-23. [PMID: 25801742 DOI: 10.1007/s00586-015-3873-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 03/08/2015] [Indexed: 01/31/2023]
Abstract
PURPOSE In this narrative review, we aim to give an update on the anatomic fundamentals of endoscopic assisted surgery to the craniocervical junction (transnasal, transoral and transcervical), and to report on the available clinical results. METHODS A non-systematic review and reporting on the anatomical and clinical results of endoscopic assisted approaches to the craniocervical junction (CVJ) is performed. RESULTS Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the lack of 3-dimensional perception of the surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior CVJ. Used in conjunction with traditional microsurgery and intraoperative fluoroscopy, it provides a safe and improved method for anterior decompression with or without a reduced need for extensive soft palate splitting, hard palate resection, or extended maxillotomy. CONCLUSIONS Transoral (microsurgical or video-assisted) approach with sparing of the soft palate still remains the gold standard compared to the "pure" transnasal and transcervical approaches due to the wider working channel provided by the former technique. Transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus. Combined transnasal and transoral procedures can be tailored according to the specific pathological and radiological findings.
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Affiliation(s)
| | - Alberto Di Martino
- Department of Orthopaedics and Trauma Surgery, University Campus Bio-medico of Rome, Rome, Italy.
| | - Rosario Maugeri
- Neurosurgery Clinic, Department of Experimental Medicine and Clinical Neurosciences, University of Palermo, Palermo, Italy
| | | | - Vincenzo Grasso
- Surgical Department, Neurosurgical Unit, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Gaetano Paludetti
- Institute of Otorhinolaringology, Catholic University of Rome, Rome, Italy
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Fujii T, Platt A, Zada G. Endoscopic Endonasal Approaches to the Craniovertebral Junction: A Systematic Review of the Literature. J Neurol Surg B Skull Base 2015; 76:480-8. [PMID: 26682128 DOI: 10.1055/s-0035-1554904] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/11/2015] [Indexed: 02/07/2023] Open
Abstract
Background We reviewed the current literature pertaining to extended endoscopic endonasal approaches to the craniovertebral junction. Methods A systematic literature review was utilized to identify published surgical cases of endoscopic endonasal approaches to the craniovertebral junction. Full-text manuscripts were examined for various measures of surgical indications, patient characteristics, operative technique, and surgical outcomes. Results We identified 71 cases involving endoscopic endonasal approaches for surgical management of a variety of pathologies located within the craniovertebral junction. Patient ages ranged from 3 to 87 years, with 40 females and 31 males. Five patients required tracheostomy, two were reintubated, and all others experienced an average intubation duration of 0.54 days following surgery. Fifty-eight patients (81.7%) underwent an additional posterior decompression or fusion either before or after the endonasal procedure. A complete resection of the pathologic lesion was reported in 57 cases (83.8%), another five were successful biopsies, and four resulted in partial resection. The follow-up time ranged from 0.5 to 57 months. Conclusion Although the transoral approach has been the standard for anterior surgical management for the past several decades, our systematic review illustrates that the extended endoscopic endonasal approach is a safe and effective alternative for most pathologies affecting the craniovertebral junction.
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Affiliation(s)
- Tatsuhiro Fujii
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Andrew Platt
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
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Ponce-Gómez JA, Ortega-Porcayo LA, Soriano-Barón HE, Sotomayor-González A, Arriada-Mendicoa N, Gómez-Amador JL, Palma-Díaz M, Barges-Coll J. Evolution from microscopic transoral to endoscopic endonasal odontoidectomy. Neurosurg Focus 2015; 37:E15. [PMID: 25270134 DOI: 10.3171/2014.7.focus14301] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to compare the indications, benefits, and complications between the endoscopic endonasal approach (EEA) and the microscopic transoral approach to perform an odontoidectomy. Transoral approaches have been standard for odontoidectomy procedures; however, the potential benefits of the EEA might be demonstrated to be a more innocuous technique. The authors present their experience with 12 consecutive cases that required odontoidectomy and posterior instrumentation. METHODS Twelve consecutive cases of craniovertebral junction instability with or without basilar invagination were diagnosed at the National Institute of Neurology and Neurosurgery in Mexico City, Mexico, between January 2009 and January 2013. The EEA was used for 5 cases in which the odontoid process was above the nasopalatine line, and was compared with 7 cases in which the odontoid process was beneath the nasopalatine line; these were treated using the transoral microscopic approach (TMA). Odontoidectomy was performed after occipital-cervical or cervical posterior augmentation with lateral mass and translaminar screws. One case was previously fused (Oc-C4 fusion). The senior author performed all surgeries. American Spinal Injury Association scores were documented before surgical treatment and after at least 6 months of follow-up. RESULTS Neurological improvement after odontoidectomy was similar for both groups. From the transoral group, 2 patients had postoperative dysphonia, 1 patient presented with dysphagia, and 1 patient had intraoperative CSF leakage. The endoscopic procedure required longer surgical time, less time to extubation and oral feeding, a shorter hospital stay, and no complications in this series. CONCLUSIONS Endoscopic endonasal odontoidectomy is a feasible, safe, and well-tolerated procedure. In this small series there was no difference in the outcome between the EEA and the TMA; however, fewer complications were documented with the endonasal technique.
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Affiliation(s)
- Juan Antonio Ponce-Gómez
- Departments of Neurological Surgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suarez," Mexico City, Mexico
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Fang CH, Friedman R, Schild SD, Goldstein IM, Baredes S, Liu JK, Eloy JA. Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review. Int Forum Allergy Rhinol 2015; 5:754-60. [PMID: 25946171 DOI: 10.1002/alr.21537] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/18/2015] [Accepted: 03/03/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ. METHODS A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed. RESULTS Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months. CONCLUSION Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power.
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Affiliation(s)
- Christina H Fang
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Remy Friedman
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Sam D Schild
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Ira M Goldstein
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
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Burns TC, Mindea SA, Pendharkar AV, Lapustea NB, Irime I, Nayak JV. Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis. J Neurol Surg Rep 2015; 76:e37-42. [PMID: 26251807 PMCID: PMC4520966 DOI: 10.1055/s-0034-1395492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/14/2014] [Indexed: 01/29/2023] Open
Abstract
Ventral epidural abscess with osteomyelitis at the craniocervical junction is a rare occurrence that typically mandates spinal cord decompression via a transoral approach. However, given the potential for morbidity with transoral surgery, especially in the setting of immunosuppression, together with the advent of extended endonasal techniques, the transnasal approach could be attractive for selected patients. We present two cases of ventral epidural abscess and osteomyelitis at the craniocervical junction involving C1/C2 that were successfully treated via the endoscopic transnasal approach. Both were treated in staged procedures involving posterior cervical fusion followed by endoscopic transnasal resection of the ventral C1 arch and odontoid process for decompression of the ventral spinal cord and medulla. Dural repairs were successfully performed using multilayered, onlay techniques where required. Both patients tolerated surgery exceedingly well, had brief postoperative hospital stays, and recovered uneventfully to their neurologic baselines. Postoperative magnetic resonance imaging confirmed complete decompression of the foramen magnum and upper C-spine. These cases illustrate the advantages and low morbidity of the endonasal endoscopic approach to the craniocervical junction in the setting of frank skull base infection and immunosuppression, representing to our knowledge a unique application of this technique to osteomyelitis and epidural abscess at the craniocervical junction.
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Affiliation(s)
- Terry C Burns
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Stefan A Mindea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Nicolae B Lapustea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Ioana Irime
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
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Visocchi M, Trevisi G, Iacopino DG, Tamburrini G, Caldarelli M, Barbagallo GMV. Odontoid process and clival regeneration with Chiari malformation worsening after transoral decompression: an unexpected and previously unreported cause of "accordion phenomenon". EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24 Suppl 4:S564-8. [PMID: 25519842 DOI: 10.1007/s00586-014-3720-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 12/04/2014] [Accepted: 12/05/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Transoral odontoidectomy followed by occipito-cervical fixation is a widely used approach to relieve ventral compressions at the craniovertebral junction (CVJ). Despite the large amount of literature on this approach and its complications, no previous reports of odontoid process and clival regeneration following transoral odontoidectomy are present in the English literature. METHODS We report the case of odontoid process and clival regeneration following transoral odontoidectomy. RESULTS A 7-year-old boy presented with symptoms of brainstem and upper cervical spinal cord compression due to a complex malformation at the CVJ including a basilar invagination with Chiari malformation. A successful transoral microsurgical endoscopic-assisted odontoidectomy extended to the clivus was performed along with occipito cervical instrumentation and fusion. Clinical and radiological resolution of the CVJ compression was evident up to 2 years post-op, when the child had a relapse of some of the presenting symptoms and the follow-up CT and MRI scans showed a quite complete regrowth of the odontoid process, clival partial regeneration and recurrence of preoperative Chiari malformation. CONCLUSIONS Besides the need of an accurate complete resection of the periosteum, which apparently was incompletely performed in our case, our experience suggests the need of resection of the odontoid down to the dentocentral synchondrosis and an accurate lateral removal of the bone surrounding the anterior tubercle of the Clivus is advised when an anterior CVJ decompression is required in children presenting a still evident synchondrosis at neuroradiological investigation.
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Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Policlinico Gemelli, Catholic University School of Medicine, Largo A. Gemelli 8, 00168, Rome, Italy,
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Lam SK, Sayama C, Harris DA, Briceño V, Luerssen TG, Jea A. Nationwide practice patterns in the use of recombinant human bone morphogenetic protein-2 in pediatric spine surgery as a function of patient-, hospital-, and procedure-related factors. J Neurosurg Pediatr 2014; 14:476-85. [PMID: 25171721 DOI: 10.3171/2014.7.peds1499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Current national patterns as a function of patient-, hospital-, and procedure-related factors, and complication rates in the use of recombinant human bone morphogenetic protein-2 (rhBMP-2) as an adjunct to the practice of pediatric spine surgery have scarcely been investigated. METHODS The authors conducted a cross-sectional study using data from the Healthcare Cost and Utilization Project Kids' Inpatient Database. Univariate and multivariate logistic regression were used to calculate unadjusted and adjusted odds ratios and 95% confidence intervals, and p values < 0.05 were considered to be statistically significant. RESULTS The authors identified 9538 hospitalizations in pediatric patients 20 years old or younger who had undergone spinal fusion in the US in 2009; 1541 of these admissions were associated with rhBMP-2 use. By multivariate logistic regression, the following factors were associated with rhBMP-2 use: patient age 15-20 years; length of hospital stay (adjusted odds ratio [aOR] 1.01, p = 0.017); insurance status (private [aOR 1.49, p < 0.001] compared with Medicaid); hospital type (nonchildren's hospital); region (Midwest [aOR 2.49, p = 0.008] compared with Northeast); spinal refusion (aOR 2.20, p < 0.001); spinal fusion approach/segment (anterior lumbar [aOR 1.73, p < 0.001] and occipitocervical [aOR 1.86, p = 0.013] compared with posterior lumbar); short segment length (aOR 1.42, p = 0.016) and midlength (aOR 1.44, p = 0.005) compared with long; and preoperative diagnosis (Scheuermann kyphosis [aOR 1.56, p < 0.017] and spondylolisthesis [aOR 1.93, p < 0.001]). CONCLUSIONS Use of BMP in pediatric spine procedures now comprises more than 10% of pediatric spinal fusion. Patient-related (age, insurance type, diagnosis); hospital-related (children's hospital vs general hospital, region in the US); and procedure-related (redo fusion, anterior vs posterior approach, spinal levels, number of levels fused) factors are associated with the variation in BMP use in the US.
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Affiliation(s)
- Sandi K Lam
- Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Goldschlager T, Härtl R, Greenfield JP, Anand VK, Schwartz TH. The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding. J Neurosurg 2014; 122:511-8. [PMID: 25361480 DOI: 10.3171/2014.9.jns14733] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid. METHODS The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments. RESULTS There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency. CONCLUSIONS This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.
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Yen YS, Chang PY, Huang WC, Wu JC, Liang ML, Tu TH, Cheng H. Endoscopic transnasal odontoidectomy without resection of nasal turbinates: clinical outcomes of 13 patients. J Neurosurg Spine 2014; 21:929-37. [PMID: 25279654 DOI: 10.3171/2014.8.spine13504] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object The goal of the study was to report a series of consecutive patients who underwent endoscopic transnasal odontoidectomy (ETO) without resection of nasal turbinates. The techniques for this minimally invasive approach are described in detail. Methods The authors conducted a retrospective review of consecutive patients who underwent ETO for basilar invagination. All the patients had myelopathy caused by compression at the cervicomedullary junction, which required surgical decompression. Preoperative and postoperative data, including those from radiographic and clinical evaluations, were compared. Morbidity and mortality rates for the procedure are also reported in detail. Results Thirteen patients (6 men and 7 women) with a mean age of 52.7 years (range 24-72 years) were enrolled. The basilar invagination etiologies were rheumatoid arthritis (n = 5), trauma (n = 4), os odontoideum (n = 2), ankylosing spondylitis (n = 1), and postinfectious deformity (n = 1). The average follow-up duration was 51.2 months (range 0.3-105 months). One patient died 10 days after the operation as a result of meningitis caused by CSF leakage. Among the other 12 patients, the average postoperative Nurick grade (3.2) was significantly improved over that before the operation (4.1, p = 0.004). The mean (± SD) duration of postoperative intubation was 1.5 ± 2.1 days, and there was no need for perioperative tracheostomy or nasogastric tube feeding. There also was no postoperative velopharyngeal insufficiency. There were 6 (46%) intraoperative and 2 (15%) postoperative CSF leaks in the 13 patients in this series. Conclusions ETO is a viable and effective option for decompression at the ventral cervicomedullary junction. This approach is minimally invasive and causes little velopharyngeal insufficiency. The pitfall of this approach is the difficulty in repairing dural defects and subsequent CSF leakage.
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Affiliation(s)
- Yu-Shu Yen
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and
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30
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Tan SH, Ganesan D, Prepageran N, Waran V. A minimally invasive endoscopic transnasal approach to the craniovertebral junction in the paediatric population. Eur Arch Otorhinolaryngol 2014; 271:3101-5. [PMID: 24986428 DOI: 10.1007/s00405-014-3149-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Sien Hui Tan
- Department of Otolaryngology, Faculty of Medicine, University Malaya, Lembah Pantai, 50603, Kuala Lumpur, Malaysia,
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McDowell MM, Hanft SJ, Greenberg SA, Rahmati R, Carrao V, Eisig S, Anderson RCE. Resection of an upper cervical aneurysmal bone cyst and spinal reconstruction using a midline mandibular osteotomy in a pediatric patient. J Neurosurg Pediatr 2014; 13:622-5. [PMID: 24702619 DOI: 10.3171/2014.3.peds13511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors report on the surgical management of an extensive lesion of the upper cervical spine that required an uncommon transmandibular approach to facilitate exposure, resection, and stabilization in a pediatric patient. A 6-year-old boy with a large aneurysmal bone cyst of the C-2 vertebra presented with progressive weakness and right-sided neck pain. The lesion extended laterally into the soft tissue of the neck, inferiorly to C-4, and posteriorly around the spinal cord. A transmandibular osteotomy was performed to provide adequate exposure for complete resection of the mass and anterior C1-3 instrumentation and fusion. Subsequently, the patient underwent occiput to C-4 posterior instrumentation and fusion. The patient tolerated the operation well and had regained all function at 3 and 11 months' follow-up. No neurological complications or problems of speech, swallowing, or respiration occurred. Even in pediatric patients, the transmandibular approach for the treatment of upper cervical spine lesions is an effective method of maximizing exposure for complex lesions requiring resection and stabilization.
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Hickman ZL, McDowell MM, Barton SM, Sussman ES, Grunstein E, Anderson RCE. Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review. Neurosurg Focus 2014; 35:E14. [PMID: 23905952 DOI: 10.3171/2013.5.focus13147] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The endoscopic transnasal approach to the rostral pediatric spine and craniovertebral junction is a relatively new technique that provides an alternative to the traditional transoral approach to the anterior pediatric spine. In this case series, the authors provide 2 additional examples of patients undergoing endoscopic transnasal odontoidectomies for ventral decompression of the spinal cord. Both patients would have required transection of the palate to undergo an effective transoral operation, which can be a cause of significant morbidity. In one case, transnasal decompression was initially incomplete, and decompression was successfully achieved via a second endoscopic transnasal operation. Both cases resulted in significant neurological recovery and stable long-term spinal alignment. The transnasal approach benefits from entering into the posterior pharynx at an angle that often reduces the length of postoperative intubation and may speed a patient's return to oral intake. Higher reoperation rates are a concern for many endoscopic approaches, but there are insufficient data to conclude if this is the case for this procedure. Further experience with this technique will provide a better understanding of the indications for which it is most effective. Transcervical and transoral endoscopic approaches have also been reported and provide additional options for pediatric anterior cervical spine surgery.
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Affiliation(s)
- Zachary L Hickman
- Departments of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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Occipitocervical fusion with relief of odontoid invagination: atlantoaxial distraction method using cylindrical titanium cage for basilar invagination—case report. Neurosurg Rev 2014; 37:519-24; discussion 524-5. [DOI: 10.1007/s10143-014-0531-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 12/10/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
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