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Butenschoen VM, Wostrack M, Meyer B, Gempt J. Endoscopic Transnasal Odontoidectomy for Ventral Decompression of the Craniovertebral Junction: Surgical Technique and Clinical Outcome in a Case Series of 19 Patients. Oper Neurosurg (Hagerstown) 2020; 20:24-31. [PMID: 33094804 DOI: 10.1093/ons/opaa331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/05/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Abnormalities and pathologies of the craniovertebral junction as well as space-occupying lesions of the odontoid process can result in myelopathy symptoms. A staged procedure with posterior stabilization and anterior transnasal endoscopic decompression is recently considered a less invasive alternative to the transoral approach. We present a considerably large case series focused on the operative technique and the long-term neurological clinical outcome. OBJECTIVE To determine the safety and efficacy of odontoidectomy performed via an endoscopic transnasal approach. METHODS We retrospectively reviewed all patients treated in our neurosurgical department from January 2009 to January 2020. Demographics, pre- and postoperative clinical status, and operative technique and complications were extracted and analyzed. RESULTS In total, 22 transnasal operations were performed in 19 patients from January 2009 to January 2020. All but one patient underwent posterior C1-C2 instrumentation prior to the anterior transnasal computed tomography (CT)-navigated full-endoscopic decompression. The median duration of symptoms before surgery was 3 mo. Complications occurred in 1 patient who died from septic organ failure because of his initial diagnosis of osteomyelitis. Postoperative CT imaging showed sufficient decompression in 16 patients, and 3 patients underwent a transnasal endoscopic re-decompression (16%). CONCLUSION Transnasal endoscopic odontoidectomy presents a safe procedure with a satisfying clinical and radiological postoperative outcome.
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Affiliation(s)
- Vicki M Butenschoen
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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Klepinowski T, Limanówka B, Sagan L. Management of post-traumatic craniovertebral junction dislocation: A PRISMA-compliant systematic review and meta-analysis of casereports. Neurosurg Rev 2020; 44:1391-1400. [PMID: 32797319 PMCID: PMC8121741 DOI: 10.1007/s10143-020-01366-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/23/2022]
Abstract
Although historically considered fatal, with the advent of improved pre-hospital care, traumatic dislocation of the craniovertebral junction (CVJ) has been increasing in prevalence in neurosurgical centers. As more survivors are reported each year, a timely review with meta-analysis of their management seems necessary. PRISMA checklist was followed step by step. PubMed and Web of Science databases were searched using words “craniovertebral junction dislocation” and their corresponding synonyms. Study eligibility criteria included research studies from 2015 onwards that delineated adult and pediatric patients with confirmed post-traumatic atlantooccipital dislocation (AOD) or atlantoaxial dislocation (AAD) who survived until proper treatment. Of 1475 initial records, 46 articles met eligibility criteria with a total of 141 patients with traumatic CVJ dislocation. Of the patients, 90 were male (63.8%). Mean age of the cohort was 33.3 years (range 1–99 years). Trauma that most often led to this injury was road traffic accident (70.9%) followed by falls (24.6%). The majority of authors support posterior instrumentation of C1-C2 (45.2%) especially by means of Goel-Harms method. At mean follow-up of 15.4 months (range 0.5–60 months), 27.2% of treated patients remained neurologically intact. Of initially symptomatic, 59% improved, 37% were stable, and 4% deteriorated. Instrumenting the occiput in cases of pure AAD was associated with lower chance of neurological improvement in chi-square test (p = 0.0013) as well as in multiple linear regression (β = − 0.3; p = 0.023). The Goel-Harms C1-C2 fusion is currently the most frequently employed treatment. Many survivors remain with no deficits or improve, rarely deteriorate. Involving the occiput in stabilization in cases of AAD without AOD might be related with worse neurological prognosis.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Bartosz Limanówka
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Rossini Z, Milani D, Nicolosi F, Costa F, Lasio GB, D'Angelo VA, Fornari M, Colombo G. Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid: Technical Note and Case Series. World Neurosurg 2017; 110:373-385. [PMID: 29203314 DOI: 10.1016/j.wneu.2017.11.153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure. METHODS On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated. RESULTS Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade (1, 8) was improved versus the average preoperative grade (3). The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P = 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm2. CONCLUSIONS Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma.
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Affiliation(s)
- Zefferino Rossini
- Division of Neurosurgery, Università degli Studi di Milano, Milan, Italy; Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Davide Milani
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy.
| | - Federico Nicolosi
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Francesco Costa
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | | | - Maurizio Fornari
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Giovanni Colombo
- Division of Otorhinolaryngology, Humanitas Clinical and Research Center, Rozzano, 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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Abstract
Transoral microscopic odontoidectomy followed by posterior fixation has been accepted as a standard procedure to treat nonreducible basilar invagination during the half past century. In recent years, the development of endoscopic techniques has raised challenges regarding the traditional treatment algorithm. The endoscopic transnasal odontoidectomy is a feasible and effective method in the treatment of irreducible ventral cervicomedullary junction compression, which has several advantages over the transoral approach. The endoscopic odontoidectomy includes transnasal, transoral, and transcervical approaches. The 3 different approaches for endoscopic odontoidectomy present complementary advantages and limitations. The necessity of posterior fixation after odontoidectomy should be considered in every single case on the basis of the peculiar anatomic and clinical conditions.
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Re M, Iacoangeli M, Di Somma L, Alvaro L, Nasi D, Magliulo G, Gioacchini FM, Fradeani D, Scerrati M. Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction. ACTA OTORHINOLARYNGOLOGICA ITALICA 2016; 36:107-18. [PMID: 27196075 PMCID: PMC4907157 DOI: 10.14639/0392-100x-647] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 10/19/2015] [Indexed: 12/02/2022]
Abstract
We report our experience with the endoscopic endonasal approaches (EEA) for different craniocervical junction (CCJ) disorders to analyse outcomes and demonstrate the importance and feasibility of anterior C1 arch preservation or its reconstruction. Between January 2009 and December 2013, 10 patients underwent an endoscopic endonasal approach for different CCJ pathologies at our Institution. In 8 patients we were able to preserve the anterior C1 arch, while in 2 post-traumatic cases we reconstructed it. The CCJ disorders included 4 cases of irreducible anterior bulbo-medullary compression secondary to rheumatoid arthritis or CCJ anomalies, 4 cases of inveterate fractures of C1 and/or C2 and 2 tumours. Pre- and postoperative neuroradiological evaluation was always obtained by magnetic resonance imaging (MRI), computed tomographic (CT) scanning and dynamic cranio-vertebral junction x-ray. Pre- and postoperative neurologic disability assessment was obtained by Ranawat classification for patients with rheumatoid arthritis and by Nurick classification for the others. At a mean follow-up of 31 months (range: 14-73 months), an improvement of at least one Ranawat or Nurick classification level was observed in 6 patients, while in another 4 patients neurological conditions were stable. Radiological follow-up revealed an adequate bulbo-medullary decompression in all patients and a regular bone fusion in cases of C1 and/or C2 fractures. In all patients spinal stability was preserved and none required subsequent posterior fixation. The endoscopic endonasal surgery provided adequate exposure and a low morbidity minimally invasive approach to the antero-medial located lesions of the CCJ, resulting in a safe, effective and well-tolerated procedure. This approach allowed preservation of the anterior C1 arch and the avoidance of a posterior fixation in all patients of this series, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
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Affiliation(s)
- M Re
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Iacoangeli
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Di Somma
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - L Alvaro
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Nasi
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - G Magliulo
- Organi di Senso Department, University ''la Sapienza'', Rome, Italy
| | - F M Gioacchini
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - D Fradeani
- Department of Otorhinolaryngology, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
| | - M Scerrati
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy
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7
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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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La Corte E, Aldana PR, Ferroli P, Greenfield JP, Härtl R, Anand VK, Schwartz TH. The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies. Neurosurg Focus 2015; 38:E16. [PMID: 25828492 DOI: 10.3171/2015.1.focus14777] [Citation(s) in RCA: 40] [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 endoscopic endonasal approach (EEA) provides a minimally invasive corridor through which the cervicomedullary junction can be decompressed with reduced morbidity rates compared to those with the classic transoral approaches. The limit of the EEA is its inferior extent, and preoperative estimation of its reach is vital for determining its suitability. The aim of this study was to evaluate the actual inferior limit of the EEA in a surgical series of patients and develop an accurate and reliable predictor that can be used in planning endonasal odontoidectomies. METHODS The actual inferior extent of surgery was determined in a series of 6 patients with adequate preoperative and postoperative imaging who underwent endoscopie endonasal odontoidectomy. The medians of the differences between several previously described predictive lines, namely the nasopalatine line (NPL) and nasoaxial line (NAxL), were compared with the actual surgical limit and the hard-palate line by using nonparametric statistics. A novel line, called the rhinopalatine line (RPL), was established and corresponded best with the actual limit of the surgery. RESULTS There were 4 adult and 2 pediatric patients included in this study. The NPL overestimated the inferior extent of the surgery by an average (± SD) of 21.9 ± 8.1 mm (range 14.7-32.5 mm). The NAxL and RPL overestimated the inferior limit of surgery by averages of 6.9 ± 3.8 mm (range 3.7-13.3 mm) and 1.7 ± 3.7 mm (range -2.8 to 8.3 mm), respectively. The medians of the differences between the NPL and NAxL and the actual surgery were statistically different (both p = 0.0313). In contrast, there was no statistically significant difference between the RPL and the inferior limit of surgery (p = 0.4375). CONCLUSIONS The RPL predicted the inferior limit of the EEA to the craniovertebral junction more accurately than previously described lines. The use of the RPL may help surgeons in choosing suitable candidates for the EEA and in selecting those for whom surgery through the oropharynx or the facial bones is the better approach.
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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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10
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Van Abel KM, Mallory GW, Kasperbauer JL, M D, Moore EJ, Price DL, O'Brien EK, Olsen KD, Krauss WE, Clarke MJ, Jentoft ME, Van Gompel JJ. Transnasal odontoid resection: is there an anatomic explanation for differing swallowing outcomes? Neurosurg Focus 2015; 37:E16. [PMID: 25270135 DOI: 10.3171/2014.7.focus14338] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Swallowing dysfunction is common following transoral (TO) odontoidectomy. Preliminary experience with newer endoscopic transnasal (TN) approaches suggests that dysphagia may be reduced with this alternative. However, the reasons for this are unclear. The authors hypothesized that the TN approach results in less disruption of the pharyngeal plexus and anatomical structures associated with swallowing. The authors investigate the histological and gross surgical anatomical relationship between pharyngeal plexus innervation of the upper aerodigestive tract and the surgical approaches used (TN and TO). They also review the TN literature to evaluate swallowing outcomes following this approach. METHODS Seven cadaveric specimens were used for histological (n = 3) and gross anatomical (n = 4) examination of the pharyngeal plexus with the TO and TN surgical approaches. Particular attention was given to identifying the location of cranial nerves (CNs) IX and X and the sympathetic chain and their contributions to the pharyngeal plexus. S100 staining was performed to assess for the presence of neural tissue in proximity to the midline, and fiber density counts were performed within 1 cm of midline. The relationship between the pharyngeal plexus, clivus, and upper cervical spine (C1-3) was defined. RESULTS Histological analysis revealed the presence of pharyngeal plexus fibers in the midline and a significant reduction in paramedian fiber density from C-2 to the lower clivus (p < 0.001). None of these paramedian fibers, however, could be visualized with gross inspection or layer-by-layer dissection. Laterally based primary pharyngeal plexus nerves were identified by tracing their origins from CNs IX and X and the sympathetic chain at the skull base and following them to the pharyngeal musculature. In addition, the authors found 15 studies presenting 52 patients undergoing TN odontoidectomy. Of these patients, only 48 had been swallowing preoperatively. When looking only at this population, 83% (40 of 48) were swallowing by Day 3 and 92% (44 of 48) were swallowing by Day 7. CONCLUSIONS Despite the midline approach, both TO and TN approaches may injure a portion of the pharyngeal plexus. By limiting the TN incision to above the palatal plane, the surgeon avoids the high-density neural plexus found in the oropharyngeal wall and limits injury to oropharyngeal musculature involved in swallowing. This may explain the decreased incidence of postoperative dysphagia seen in TN approaches. However, further clinical investigation is warranted.
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Affiliation(s)
- Kathryn M Van Abel
- Division of Otolaryngology Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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11
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Zoli M, Mazzatenta D, Valluzzi A, Mascari C, Pasquini E, Frank G. Endoscopic Endonasal Odontoidectomy. Neurosurg Clin N Am 2015; 26:427-36. [PMID: 26141361 DOI: 10.1016/j.nec.2015.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Odontoidectomy is the treatment of choice for irreducible ventral cervical-medullary compression. The endonasal endoscopic approach is an innovative approach for odontoidectomy. The aim of this article is to identify in which conditions this approach is indicated, discussing variants of the technique for selected cases of craniovertebral malformation with platybasia. We believe that the technical difficulties of this approach are balanced by the advantages for patients. Some conditions related to the patient and to the anatomy of the craniovertebral junction may favor adoption of the endoscopic endonasal approach, which should be considered complementary and not alternative to standard approaches.
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Affiliation(s)
- Matteo Zoli
- Department of Neurosurgery, Center of Pituitary Tumors and Endoscopic Skull Base Surgery, IRCCS Scienze Neurologiche, via Altura, 3, Bologna 40139, Italy.
| | - Diego Mazzatenta
- Department of Neurosurgery, Center of Pituitary Tumors and Endoscopic Skull Base Surgery, IRCCS Scienze Neurologiche, via Altura, 3, Bologna 40139, Italy
| | - Adelaide Valluzzi
- Department of Neurosurgery, Center of Pituitary Tumors and Endoscopic Skull Base Surgery, IRCCS Scienze Neurologiche, via Altura, 3, Bologna 40139, Italy
| | - Carmelo Mascari
- Department of Neurosurgery, Center of Pituitary Tumors and Endoscopic Skull Base Surgery, IRCCS Scienze Neurologiche, via Altura, 3, Bologna 40139, Italy
| | - Ernesto Pasquini
- ENT Department, Azienda USL, via Altura, 3, Bologna 40139, Italy
| | - Giorgio Frank
- Department of Neurosurgery, Center of Pituitary Tumors and Endoscopic Skull Base Surgery, IRCCS Scienze Neurologiche, via Altura, 3, Bologna 40139, Italy
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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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Endoscopic Approaches to the Craniovertebral Junction and Odontoid Process. World Neurosurg 2014; 82:S49-53. [DOI: 10.1016/j.wneu.2014.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 07/25/2014] [Indexed: 11/23/2022]
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Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases. Orthop Traumatol Surg Res 2014; 100:775-8. [PMID: 25281548 DOI: 10.1016/j.otsr.2014.07.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2013] [Revised: 05/11/2014] [Accepted: 07/10/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Transoral odontoidectomy is the treatment of choice in cases of anterior bulbo-medullary compression. The development of endoscopic procedures has made it possible to perform odontoidectomy via a minimally invasive endoscopic endonasal approach. We discuss the feasibility, advantages, and limitations of this surgical approach. MATERIALS AND METHODS We report a two-center retrospective series of patients who underwent endoscopic endonasal odontoidectomy between September 2011 and February 2013. Preoperative characteristics, intraoperative data, clinical course, and postoperative complications were studied. The patients were followed for a minimum of 6 months. Cervico-occipital posterior fusion was performed during the same hospital stay in cases of preoperative instability. RESULTS Nine patients underwent decompressive odontoidectomy, for rheumatoid pannus in five cases and basilar impression in four cases. All had progressive neurological symptoms. Seven patients also underwent posterior fusion. In six patients, the C1 anterior arch was preserved. Decompression was achieved satisfactorily in all nine cases. The patients were able to resume oral feeding the day after the intervention. No patient required tracheostomy. We observed no dural fistulae or infectious complications. One patient died 2 months after the intervention of a pulmonary embolism. All patients improved in terms of their preoperative neurological status. CONCLUSION This short series shows the feasibility of the endoscopic endonasal approach for resection of the dens. This approach allows optimal viewing when using angulated instrumentation and seems to result in low morbidity. In some cases, this approach makes it possible to preserve the C1 anterior arch, thus limiting the risk of cranial settling. LEVEL IV retrospective study.
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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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Abstract
STUDY DESIGN This study evaluates a series of consecutive endoscopic endonasal odontoidectomies performed since 2008 in our center. OBJECTIVE The aim of the study was to analyze the outcome and the surgical technique to enlighten advantages and limitations of this procedure. SUMMARY OF BACKGROUND DATA Odontoidectomy represents the treatment of choice in selected cases of basilar invagination. Transoral-transpharyngeal odontoidectomy is the "gold standard" and more experienced technique. Recently, the endoscopic endonasal approach has been proposed as an alternative route. METHODS All patients underwent a pre- and postoperative evaluation of neurological status using physical neurological examination, assessment of American Spinal Injury Association impairment scale score, and neurophysiological investigations. Pre- and postoperative neuroradiological examinations consisted of magnetic resonance imaging, computed tomography, and radiography in flexion and extension. Surgical complications, time of orotracheal extubation and of resumption of oral feeding after surgery were considered, basing on medical records. RESULTS The series is composed of 5 cases. All cases presented a progressive tetraparesis despite a posterior occipitocervical arthrodesis. Two patients presented with irreducible atlantoaxial subluxation in Down syndrome, whereas the others presented with an atlanto-occipital malformation with platybasia and basilar invagination. No complications were observed. In all except one case, orotracheal intubation was removed immediately at the end of surgery. Oral feeding was resumed 1 day after surgery in all but one case that initially required an orogastric tube. At follow-up (mean: 34.2 mo; range: 3-57 mo), neurological symptoms have been shown to improve in 2 cases and stabilization, arresting the neurological worsening, in 3 cases. CONCLUSION Endoscopic endonasal odontoidectomy resulted in a safe, effective, and well-tolerated procedure. From our experience, we conclude that the different approaches for odontoidectomy should be considered to be complementary rather than alternative: the endonasal endoscopic can be advantageous in selected cases presenting some anatomical conditions related (micrognathia and macroglossia) to the oral cavity and to high position of the odontoid.
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Choudhri O, Mindea SA, Feroze A, Soudry E, Chang SD, Nayak JV. Experience with intraoperative navigation and imaging during endoscopic transnasal spinal approaches to the foramen magnum and odontoid. Neurosurg Focus 2014; 36:E4. [DOI: 10.3171/2014.1.focus13533] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this study the authors share their experience using intraoperative spinal navigation and imaging for endoscopic transnasal approaches to the odontoid in 5 patients undergoing C1–2 surgery for basilar invagination at Stanford Hospital and Clinics from 2010 to 2013.
Methods
Of these 5 patients undergoing C1–2 surgery for basilar invagination, 4 underwent a 2-tiered anterior C1–2 resection with posterior occipitocervical fusion during a first stage surgery, followed by endoscopic endonasal odontoidectomy in a separate setting. Intraoperative stereotactic navigation was performed using a surgical navigation system in all cases. Navigation accuracy, characterized as target registration error, ranged between 0.8 mm and 2 mm, with an average of 1.2 mm. Intraoperative imaging using a CT scanner was also performed in 2 patients.
Results
Endoscopic decompression of the brainstem was achieved in all patients, and no intraoperative complications were encountered. All patients were extubated within 24 hours after surgery and were able to swallow within 48 hours. After appropriate initial reconstruction of the defect at the craniocervical junction, no postoperative CSF leakage, arterial injury, or need for reoperation was encountered; 1 patient developed mild postoperative velopharyngeal insufficiency that resolved by the 6-month follow-up evaluation. There were no deaths and no patients required tracheostomy placement. The average inpatient stay after surgery varied between 72 and 96 hours, without extended intensive care unit stays for any patient.
Conclusions
Technologies such as intraoperative CT scanning and merged MRI/CT can provide the surgeon with detailed, virtual real-time information about the extent of complex endoscopic vertebral segment resection and brainstem decompression and lessens the prospect of revision or secondary procedures in this challenging surgical corridor. Moreover, patients experience limited morbidity and can tolerate early oral intake after transnasal endoscopic odontoidectomy. Essential to the successful undertaking of these endoscopic adventures is 1) an understanding of the endoscopic nasal, skull base, and neurovascular anatomy; 2) advanced and extended-length instrumentation including navigation; and 3) a team approach between experienced rhinologists and spine surgeons comfortable with endoscopic skull base techniques
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Affiliation(s)
| | | | | | - Ethan Soudry
- 2Otolaryngology–Head & Neck Surgery, Stanford University Medical Center, Stanford, California
| | | | - Jayakar V. Nayak
- 2Otolaryngology–Head & Neck Surgery, Stanford University Medical Center, Stanford, California
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Pseudotumor retroodontoideo en un paciente con hiperostosis esquelética idiopática difusa. Neurocirugia (Astur) 2014; 25:25-8. [DOI: 10.1016/j.neucir.2013.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 11/19/2012] [Accepted: 01/08/2013] [Indexed: 02/04/2023]
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Yu Y, Hu F, Zhang X, Ge J, Sun C. Endoscopic transnasal odontoidectomy combined with posterior reduction to treat basilar invagination: technical note. J Neurosurg Spine 2013; 19:637-43. [PMID: 24053376 DOI: 10.3171/2013.8.spine13120] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Transoral microscopic odontoidectomy has been accepted as a standard procedure to treat basilar invagination over the past several decades. In recent years the emergence of new technologies, including endoscopic odontoidectomy and posterior reduction, has presented a challenge to the traditional treatment algorithm. In this article, the authors describe 1 patient with basilar invagination who was successfully treated with endoscopic transnasal odontoidectomy combined with posterior reduction. The purpose of this report is to validate the effectiveness of this treatment algorithm in selected cases and describe several operative nuances and pearls based on the authors' experience. METHODS One patient with basilar invagination caused by a congenital osseous malformation underwent endoscopic transnasal odontoidectomy combined with posterior reduction in a single operative setting. The purely endoscopic transnasal odontoidectomy was first conducted with the patient supine. The favorable anatomical reduction was then achieved through a posterior approach after the patient was moved prone. RESULTS The patient was extubated after recovery from anesthesia and allowed oral food intake the next day. No complications were noted, and the patient was discharged 4 days after the operation. Postoperative imaging demonstrated excellent decompression of the anterior cervicomedullary junction pathology. The patient was followed up for 12 months and remarkable neurological recovery was observed. CONCLUSIONS The endoscopic transnasal odontoidectomy is a better minimally invasive approach for anterior decompression and can make the posterior reduction easier because the anterior resistant force is eliminated. The subsequent posterior reduction can make decompression of the ventral side of the cervicomedullary junction more effective because the C-2 vertebral body is pushed forward. A combination of these 2 approaches has the advantages of minimally invasive access and a faster patient recovery, and thus is a valid alternative in selected cases.
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Affiliation(s)
- Yong Yu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Aldana PR, Naseri I, La Corte E. The naso-axial line: a new method of accurately predicting the inferior limit of the endoscopic endonasal approach to the craniovertebral junction. Neurosurgery 2013; 71:ons308-14; discussion ons314. [PMID: 22791031 DOI: 10.1227/neu.0b013e318266e488] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The endoscopic endonasal approach (EEA) has developed as an emerging surgical corridor to the craniovertebral junction (CVJ). In addition to understanding its indications and surgical anatomy, the ability to predict its inferior limit is vital for optimal surgical planning. OBJECTIVE To develop a method that accurately predicts the inferior limit of the EEA on the CVJ radiologically and to compare this with other currently used methods. METHODS Predissection computerized tomographic scans of 9 cadaver heads were used to delineate a novel line, the naso-axial line (NAxL), to predict the inferior EEA limit on the upper cervical spine. A previously described method with the use of the nasopalatine line (NPL or Kassam line) was also used. On computerized tomographic scans obtained following dissection of the EEA, the predicted inferior limits were compared with the actual extent of dissection. RESULTS The postdissection inferior EEA limit ranged from the dens tip to the upper half of the C2 body, which matched the limit predicted by NAxL, with no statistically significant difference between them. In contrast to the NAxL, the NPL predicted a significantly lower EEA limit (P < .001), ranging from the lower half of the C2 body to the superior end plate of C3. CONCLUSION The novel NAxL more accurately predicts the inferior limit of the EEA than the NPL. This method, which can be easily used on preoperative sagittal scans, accounts for variations in patients' anatomy and can aid surgeons in the assessment of the EEA to address caudal CVJ pathology.
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Affiliation(s)
- Philipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine Jacksonville/Wolfson Children's Hospital, Jacksonville, FL 32207, USA.
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Iacoangeli M, Gladi M, Alvaro L, Di Rienzo A, Specchia N, Scerrati M. Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis. Spine J 2013; 13:542-8. [PMID: 23453575 DOI: 10.1016/j.spinee.2013.01.043] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 09/27/2012] [Accepted: 01/25/2013] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). PURPOSE The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure. STUDY DESIGN Technical description and cohort report. METHODS We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach. RESULTS Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation. CONCLUSIONS Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.
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Affiliation(s)
- Maurizio Iacoangeli
- Department of Neurosurgery, Umberto I University General Hospital, Università Politecnica delle Marche, Ancona, Italy.
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Singh H, Grobelny BT, Harrop J, Rosen M, Lober RM, Evans J. Endonasal access to the upper cervical spine, part one: radiographic morphometric analysis. J Neurol Surg B Skull Base 2013; 74:176-84. [PMID: 24436909 DOI: 10.1055/s-0033-1342923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 01/22/2013] [Indexed: 01/31/2023] Open
Abstract
Objectives To determine the anatomical relationships that may influence endonasal access to the upper cervical spine. Setting We retrospectively analyzed computed tomography of 100 patients at a single institution. Participants Participants included adults with imaging of the hard palate, clivus, and cervical spine without evidence of fracture, severe spondylosis, or previous instrumentation. Main Outcome Measures Morphometric analyses of hard palate length and both distance and angle between the hard palate and odontoid process were based on radiographic measurements. Descriptive zones were assigned to cervical spine levels, and endoscopic visualization was simulated with projected lines at 0, 30, and 45 degrees from the hard palate to the cervical spine. Results We found an inverse relationship between hard palate length and the lowest zone of the cervical spine potentially visualized by nasal endoscopy. The distance between the posterior tip of the hard palate and the odontoid tip, and the angle formed between the two, directly influenced the lowest possible cervical exposure. Conclusions Radiographic relationships between hard palate length, distance to the odontoid, and the angle formed between the two predict the limits of endonasal access to the cervical spine. These results are supported by cadaveric data in Part Two of this study.
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Affiliation(s)
- Harminder Singh
- Department of Neurosurgery, Stanford Hospitals and Clinics, Stanford, California, USA
| | - Bartosz T Grobelny
- Department of Neurosurgery, New York University, New York, New York, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Marc Rosen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Lober
- Department of Neurosurgery, Stanford Hospitals and Clinics, Stanford, California, USA
| | - James Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Perez-Orribo L, Little AS, Lefevre RD, Reyes PR, Newcomb AG, Prevedello DM, Roldan H, Nakaji P, Dickman CA, Crawford NR. Biomechanical Evaluation of the Craniovertebral Junction After Anterior Unilateral Condylectomy: Implications for Endoscopic Endonasal Approaches to the Cranial Base. Neurosurgery 2013; 72:1021-29; discussion 1029-30. [DOI: 10.1227/neu.0b013e31828d6231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Endoscopic endonasal approaches to the craniovertebral junction and clivus, which are increasingly performed for ventral skull base pathology, may require disruption of the occipitocondylar joint.
OBJECTIVE:
To study the biomechanical implications at the craniovertebral junction of progressive unilateral condylectomy as would be performed through an endonasal exposure.
METHODS:
Seven upper cervical human cadaveric specimens (C0-C2) underwent nondestructive biomechanical flexibility testing during flexion-extension, axial rotation, and lateral bending at C0-C1 and C1-C2. Each specimen was tested intact, after an inferior one-third clivectomy, and after stepwise unilateral condylectomy with an anterior approach. Angular range of motion (ROM), lax zone, and stiff zone were determined and compared with the intact state.
RESULTS:
At C0-C1, mobility during flexion-extension and axial rotation increased significantly with progressive condylectomy. ROM increased from 14.3 ± 2.7° to 20.4 ± 5.2° during flexion and from 6.7 ± 3.5° to 10.8 ± 3.0° during right axial rotation after 75% condyle resection (P < .01). At C1-C2, condylectomy had less effect, with ROM increasing from 10.7 ± 2.0° to 11.7 ± 2.0° during flexion, 36.9 ± 4.8° to 37.1 ± 5.1° during right axial rotation, and 4.3 ± 1.9° to 4.8 ± 3.3° during right lateral bending (P = NS). Because of marked instability, the 100% condylectomy condition was untestable. Changes in ROM were a result of changes more in the lax zone than in the stiff zone.
CONCLUSION:
Lower-third clivectomy and unilateral anterior condylectomy as would be performed in an endonasal approach cause progressive hypermobility at the craniovertebral junction. On the basis of biomechanical criteria, craniocervical fusion is indicated for patients who undergo > 75% anterior condylectomy.
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Affiliation(s)
- Luis Perez-Orribo
- Spinal Biomechanics Research Laboratory
- Department of Neurosurgery, Hospital Universitario de Canarias, Canary Islands, Spain
| | - Andrew S. Little
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | | | | | | | | | - Hector Roldan
- Department of Neurosurgery, Hospital Universitario de Canarias, Canary Islands, Spain
| | - Peter Nakaji
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Curtis A. Dickman
- Barrow Pituitary and Cranial Base Center, Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations. 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 2012; 22:1127-36. [PMID: 23224062 DOI: 10.1007/s00586-012-2605-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 10/30/2012] [Accepted: 11/24/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Transoral resection of the odontoid has been accepted as a standard procedure to decompress the cervicomedullary junction during the past several decades. The endoscopic transnasal odontoidectomy is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we describe several operative nuances and pearls from our experience about this approach, which provided successful decompression. METHODS From September 2009 to April 2010, three consecutive patients with basilar invagination, of which the etiology was congenital osseous malformations, underwent endoscopic transnasal odontoidectomy. All patients presented with myelopathy. The last two cases also received occipitocervical fixation and bone fusion during the same surgical episode to ensure stability. RESULTS All the patients were extubated after recovery from anesthesia and allowed oral food intake the next day. Cerebrospinal fluid rhinorrhea was found in the second case and cured by continuous lumber drainage of cerebrospinal fluid. No infection was noted. The average follow-up time was more than 24 months. Remarkable neurological recovery was observed postoperative in all patients. CONCLUSION The endoscopic transnasal odontoidectomy is a feasible approach for anterior decompression of pathology at the cervicomedullary junction. The advantages over the standard transoral odontoidectomy include elimination of risk of tongue swelling and teeth damaging, improvement of visualization, alleviation of prolonged intubation, reduction of need for enteral tube feeding and less risk of affecting phonation. The minimally invasive access and faster recovery associated with this technique make it a valid alternative for decompression of the ventral side of the cervicomedullary junction.
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Beech TJ, McDermott AL, Kay AD, Ahmed SK. Endoscopic endonasal resection of the odontoid peg--case report and literature review. Childs Nerv Syst 2012; 28:1795-9. [PMID: 22585452 DOI: 10.1007/s00381-012-1791-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 04/26/2012] [Indexed: 11/27/2022]
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Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion. 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 2012; 21 Suppl 1:S55-60. [PMID: 22398642 DOI: 10.1007/s00586-012-2220-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 02/19/2012] [Indexed: 12/17/2022]
Abstract
PURPOSE Anterior decompression of the craniovertebral junction is reserved to patients with irreducible ventral bulbo-medullary lesions and rapidly deteriorating neurological functions. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA). METHODS Four patients with irreducible, anterior bulbo-medullary compression due to rheumatoid pannus and basilar invagination were enrolled. The imaged-guided EEA was used to resect the odontoid process, trying to preserve the C1 anterior arch. RESULTS Neurological improvement and adequate bulbo-medullary decompression were obtained in all patients. In two cases, anterior C1 ring was preserved. These patients did not required a posterior fusion. CONCLUSIONS Compared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.
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Wu JC, Mummaneni PV, El-Sayed IH. Diseases of the odontoid and craniovertebral junction with management by endoscopic approaches. Otolaryngol Clin North Am 2011; 44:1029-42. [PMID: 21978894 DOI: 10.1016/j.otc.2011.06.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Surgical approaches to the craniovertebral junction (CVJ) can result in dysfunction of the upper aerodigestive tract. However, few data are available regarding the incidence of complications after such surgery. Evaluation of a CVJ lesion for treatment must establish the biology, transverse and longitudinal extent of the lesion, and the preoperative and postoperative stability of the spine. Endoscopic approaches to the CVJ, which should reduce the expected morbidity of an open transoral approach, have been described recently. This article reviews common pathologies of the CVJ and surgical approaches, and provides an evidence-based analysis of whether endoscopic approaches reduce velopharyngeal insufficiency.
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Affiliation(s)
- Jau-Ching Wu
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, Room M779, San Francisco, CA 94143-0112, USA
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