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Zhang B, Du Y, Zhang C, Qi M, Meng H, Jin T, Cui G, Guan J, Duan W, Chen Z. Analysis of Failed Atlantoaxial Reduction: Causes of Failure and Strategies for Revision. Orthop Surg 2024. [PMID: 39187976 DOI: 10.1111/os.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/24/2024] [Accepted: 07/24/2024] [Indexed: 08/28/2024] Open
Abstract
OBJECTIVE The craniovertebral junction (CVJ) presents intricate anatomical challenges. In severe or irreducible malformations, complications such as reduction loss and fixation failure may occur, necessitating revision surgery. The posterior facet joint distraction and fusion (PFDF) technique, offers a solely posterior approach for revisions. Hence, we delineate varied revision scenarios, proposing surgical strategies and technical details to enhance outcomes and mitigate risks, thereby enriching the neurosurgical community's repertoire. METHODS This was a retrospective cohort study, analyzed patient data from Xuanwu Hospital, between 2017 to 2023. All patients had a history of surgical treatment for CVJ malformations, and experienced failure or loss of reduction. The distance from the odontoid process tip to the Chamberlain's line (DCL), the atlantodental interval (ADI), clivus-canal angle, cervicomedullary angle, width of subarachnoid space, CVJ area, and width of syrinx were used for radiographic assessment. Japanese Orthopaedic Association (JOA) scores and SF-12 scores were used for clinical assessment. Independent sample t-tests were employed. A significance level of p < 0.05 indicates statistically significant differences. RESULTS We analyzed data from 35 patients. For patients who underwent PFDF, the postoperative DCL, ADI, and clivus-canal angle significantly improved. For all patients, the postoperative cervicomedullary angle, width of subarachnoid space, CVJ area, and width of syrinx all demonstrated significant improvement, indicating the relief of neural compression. All patients showed significant improvement in both symptoms and clinical assessments. CONCLUSION Severe atlantoaxial joint locking or ligament contracting are the fundamental cause of reduction and fixation failure. Anterior odontoidectomy is indicated for patients with robust bony fusion of the atlantoaxial joint in an unreduced position. The PFDF technique is safe and effective for patients with incomplete atlantoaxial bony fusion. Preoperative assessment of surgical feasibility and vertebral artery status ensures surgical safety and efficacy.
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Affiliation(s)
- Boyan Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Can Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Maoyang Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Hongfeng Meng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Tianyu Jin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Guoqing Cui
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Lab of Spinal Cord Injury and Functional Reconstruction, China International Neuroscience Institute (CHINA-INI), Beijing, China
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Song Z, Zhang K, Li G, Zhang Z, Zheng J, Ran M, Luo J, Wang Z, Chen W. Clinical effect and prognosis of transoral or endoscope-assisted transoral release for irreducible atlantoaxial dislocation: A retrospective cohort study. Heliyon 2024; 10:e35298. [PMID: 39170415 PMCID: PMC11336608 DOI: 10.1016/j.heliyon.2024.e35298] [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: 04/24/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/23/2024] Open
Abstract
Background The clinical applications of endoscope-assisted transoral release for irreducible atlantoaxial dislocations are limited. This study aimed to investigate the clinical effect and prognostic factors of traditional and endoscope-assisted transoral release, as well as posterior reduction and fixation, in treating irreducible atlantoaxial dislocations. Materials and methods We conducted a retrospective study on 59 patients with irreducible atlantoaxial dislocation who underwent either traditional or endoscope-assisted transoral release, posterior fixation, and fusion between January 2018 and January 2023. Various data, including surgical time, blood loss, drainage volume, oral intake, hospital stay, complications, and neurological status (assessed by the Japanese Orthopedic Association [JOA] score and Oswestry Disability Index [ODI]), were recorded. Imaging parameters such as the atlantodontoid interval (ADI), space available for the cord (SAC), and cervicomedullary angle (CMA) were analyzed and compared. In addition, the correlation between ODI, JOA and patient age, course of disease, preoperative ADI, SAC and CMA were analyzed. Results No significant differences were observed in age, sex, BMI, preoperative ADI, preoperative SAC, or preoperative CMA. All patients achieved excellent reduction with no significant differences between the two groups. Patients in the endoscopic group experienced significantly reduced blood loss, earlier oral intake, and shorter hospital stays compared to those in the open group (P < 0.05). The ODI and JOA scores improved significantly in both groups at 1, 6, 12, 18, and 24 months postoperatively (P < 0.05). Postoperative ADI, SAC, and CMA values in both groups were significantly better than preoperative values (P < 0.001). The patient age, course of disease and the preoperative ADI were negatively correlated with the postoperative ODI and the JOA improvement ratio (P < 0.01), and the preoperative SAC and preoperative CMA had positive correlations with the postoperative ODI and the JOA improvement ratio (P < 0.01) at 6, 12 and 24 months postoperatively. Conclusion Patient age, course of disease, preoperative ADI, SAC and CMA are correlated with the operative prognosis of irreducible atlantoaxial dislocation. The endoscope-assisted transoral approach, compared to the traditional transoral approach, is minimally invasive, resulting in less operative blood loss, earlier oral intake and a shorter length of hospital stay, which could be offered as an alternative for irreducible atlantoaxial dislocation.
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Affiliation(s)
- Zhaojun Song
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
- College of Biomedical Engineering, Chongqing Medical University, Chongqing, People's Republic of China
| | - Kai Zhang
- Operation Room of Suining Central Hospital, Sichuan, People's Republic of China
| | - Guangzhou Li
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Zhi Zhang
- Spine Surgery Department of Chengdu Fifth People's Hospital, Sichuan, People's Republic of China
| | - Jiazhuang Zheng
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Maobo Ran
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Juan Luo
- Medical Record Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Zhiqiang Wang
- Spine Surgery Department of Suining Central Hospital, Sichuan, People's Republic of China
| | - Wenzhi Chen
- College of Biomedical Engineering, Chongqing Medical University, Chongqing, People's Republic of China
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Zhou M, Sun P, Du Y, Zeng G, Chen Z, Duan W. Posterior intra-articular distraction technique to treat pediatric atlantoaxial instability. Childs Nerv Syst 2024; 40:2153-2160. [PMID: 38498172 DOI: 10.1007/s00381-024-06358-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/03/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Surgical treatment for atlantoaxial instability in pediatric patients is challenging. We report our experience with posterior intra-articular distraction technique in treating this disorder. METHODS This is a retrospective descriptive study which included 15 patients of atlantoaxial instability whose age was less than 16 years at the time of clinical presentation. All patients underwent anterior soft tissue released through a posterior-only approach, followed by intra-facet cage implantation, cantilever correction, and instrumentation. Clinical results were measured using the Japanese Orthopedic Association (JOA) scale and radiographic measurements including the atlantodental interval (ADI), posterior atlantodental interval (pADI), the distance of odontoid tip above Chamberlain's line, clivuscanal angle (CCA), and triangular area (TA) of craniovertebral junction. RESULTS The follow-up period ranged from 18 to 72 months, with an average of 41.2 ± 15.2 months. The JOA score increased from 13.6 ± 2.3 to 16.6 ± 0.8. ADI decreased from 4.31 ± 2.37 to 1.85 ± 1.09 mm, and TA decreased from 261.96 ± 107.99 to 197.12 ± 72.37 mm2. pADI increased from 12.89 ± 3.52 to 18.25 ± 3.89 mm, and CCA improved from 132.19 ± 16.34 to 144.35 ± 13.91°. All changes in measurements showed statistically significant. There were no evidence of surgery-related complications or iatrogenic secondary cervical deformity during follow-up. Radiological evaluation showed satisfactory corrections and bony fusions of C1-2 facet joint in all cases. CONCLUSION Posterior intra-articular distraction followed by cage implantation and cantilever correction can be one of the safe and effective ways to solve atlantoaxial instability in pediatric patients.
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Affiliation(s)
- Mading Zhou
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Peng Sun
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Yueqi Du
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Gao Zeng
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China
- Di Rocco Center of Pediatric Neurosurgery, China International Neuroscience Institute (CHINA-INI), Beijing, China
| | - Zan Chen
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China.
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China.
| | - Wanru Duan
- Departments of Neurosurgery, Xuanwu Hospital, Capital Medical University, No.45 Changchun St., Xicheng Distr., Beijing, China.
- Neurospine Center, China International Neuroscience Institute (CHINA-INI), Beijing, China.
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Tonomura H, Nagae M, Ishibashi H, Hosoi K, Ikeda T, Mikami Y, Takahashi K. Posterior Occipitocervical Fixation and Intrathecal Baclofen Therapy for the Treatment of Basilar Invagination with Klippel-Feil Syndrome: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:755. [PMID: 38792938 PMCID: PMC11122823 DOI: 10.3390/medicina60050755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 04/27/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024]
Abstract
Klippel-Feil syndrome (KFS) is characterized by the congenital fusion of the cervical vertebrae and is sometimes accompanied by anomalies in the craniocervical junction. In basilar invagination (BI), which is a dislocation of the dens in an upper direction, compression of the brainstem and cervical cord results in neurological defects and surgery is required. A 16-year-old boy diagnosed with KFS and severe BI presented with spastic tetraplegia, opisthotonus and dyspnea. CT scans showed basilar impression, occipitalization of C1 and fusion of C2/C3. MRI showed ventral compression of the medullocervical junction. Posterior occipitocervical reduction and fusion along with decompression were performed. Paralysis gradually improved postoperatively over 3 weeks. However, severe spasticity and opisthotonus persisted and intrathecal baclofen (ITB) therapy was initiated. Following this, opisthotonus disappeared and spasticity of the extremities improved. Rehabilitation therapy continued by controlling the dose of ITB. Five years after the surgery, self-propelled wheelchair driving was achieved and activities of daily life improved. The treatment strategy for patients with BI and congenital anomalies remains controversial. Posterior reduction and internal fixation using instrumentation were effective techniques in this case. Spasticity control achieved through a combination of surgery and ITB treatment enabled the amelioration of therapeutic efficacy of rehabilitation and the improvement of ADL.
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Affiliation(s)
- Hitoshi Tonomura
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Masateru Nagae
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Hidenobu Ishibashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kunihiko Hosoi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Takumi Ikeda
- Department of Rehabilitation Medicine, Japanese Red Cross Kyoto Daiichi Hospital, 15-749 Honmachi, Higashiyama-ku, Kyoto 605-0981, Japan
| | - Yasuo Mikami
- Department of Rehabilitation Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan
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Papalexis N, Ponti F, Masi PD, Peta G, Savarese LG, Miceli M, Facchini G, Spinnato P. Transpedicular Contrast-enhanced CT-guided biopsy of the body and dens of the axis avoiding the trans-oral approach: Technical report and literature review. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:118-122. [PMID: 38644913 PMCID: PMC11029103 DOI: 10.4103/jcvjs.jcvjs_183_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: 12/22/2023] [Accepted: 01/21/2024] [Indexed: 04/23/2024] Open
Abstract
This technical report illustrates the technique to perform computed tomography (CT)-guided bone biopsies in the body and dens of the axis (C2 vertebra) through a posterior transpedicular approach with the use of preoperative contrast-enhanced scans to highlight the course of the vertebral artery. The technique is presented through two exemplification cases: a pediatric patient with osteoblastoma and secondary aneurysmal bone cyst and one adult patient with melanoma metastasis. This case highlights the potential of the CT-guided posterolateral/transpedicular approach for performing safe and effective biopsies in the body and dens of C2, even in pediatric patients.
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Affiliation(s)
- Nicolas Papalexis
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Federico Ponti
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paola Di Masi
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuliano Peta
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Leonor Garbin Savarese
- Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirao Preto Medical School, University of Sao Paulo, Ribeirão Preto, Brazil
| | - Marco Miceli
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giancarlo Facchini
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Paolo Spinnato
- Department of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Kumar C, Kaye J, Phillips K, Forbes JA. Case report of bilateral middle ear effusion requiring myringotomy and tube placement following inferior U-shaped nasopharyngeal flap elevation for endonasal odontoidectomy: investigation of causality. Acta Neurochir (Wien) 2023; 165:2979-2983. [PMID: 37468660 DOI: 10.1007/s00701-023-05708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/24/2023] [Indexed: 07/21/2023]
Abstract
We describe a patient with symptomatic os odontoideum and a previous history of C1-2 wiring who underwent successful treatment with a staged endonasal odontoidectomy and C1-2 revision of instrumentation. Access to the odontoid process was gained through the endonasal corridor using an inverted U-shaped nasopharyngeal flap (IUNF). Post-operatively, the patient experienced resolution of her presenting neurologic symptoms but developed conductive hearing loss secondary to bilateral middle ear effusion, requiring bilateral myringotomy and tube placement 3 months post-operatively. We hypothesize this dysfunction may have resulted from surgical edema, packing buttressing the IUNF, or some combination thereof. In this manuscript, we review the evolution of the nasopharyngeal exposure for odontoidectomy and whether an IUNF may predispose to this complication.
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Affiliation(s)
- Chitra Kumar
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joel Kaye
- Department of Neurological Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Katie Phillips
- Department of Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan A Forbes
- Department of Neurological Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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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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Alijani B, Namin AK, Emamhadi M, Chabok SY, Behzadnia H, Haghani Dogahe M. Endoscopic Endonasal Approach to the Craniovertebral Junction Lesions: A Case Series of 18 Patients. J Neurol Surg B Skull Base 2023; 84:499-506. [PMID: 37671292 PMCID: PMC10477016 DOI: 10.1055/a-1924-8268] [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: 05/27/2022] [Accepted: 08/04/2022] [Indexed: 10/15/2022] Open
Abstract
Introduction Odontoid pathologies constitute a special category because they may lead to instability. Instability is defined by abnormal spinal alignment under physiologic conditions (loads) such as standing, walking, bending, or lifting. Since instability poses a risk of cord damage, surgical interventions may be required for durable long-term stabilization. This study demonstrates operative technique and results of endoscopic endonasal approach to the odontoid pathologies. Methods We conducted a retrospective study involving 18 patients who underwent endoscopic endonasal odontoidectomy (EEO) due to craniovertebral pathologies. Demographic data, clinical features of the patients, risk factors, and intraoperative and postoperative complications were reported in this series. Results Satisfactory outcomes achieved in 16 patients based on comparing the modified Rankin scale before and after the surgery ( p = 0.0001). The mean duration for EEO was 232.6 ± 18.8 minutes. The mean blood loss during surgery was 386.67 ± 153.04 mL. The mean duration of hospital stay was 7 days. All patients were extubated within a few hours after surgery. Despite of successful anterior decompression in the aforementioned cases, intraoperative cerebrospinal fluid (CSF) leakage, postoperative meningitis, and pulmonary thromboembolism occurred as complications. However, two intraoperative CSF leakages were managed by direct dural repair and fat graft; two patients died due to postoperative meningitis and pulmonary thromboembolism at 7 and 4 days after the second surgery. Conclusion In conclusion, EEO can be effectively used for anterior decompression of the odontoid pathologies, despite the risk of complications.
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Affiliation(s)
- Babak Alijani
- Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Guilan, Iran
| | - Ahmad K. Namin
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
| | - Mohammadreza Emamhadi
- Department of Neurosurgery, Guilan University of Medical Sciences, Rasht, Guilan, Iran
| | - Shahrokh Y. Chabok
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
| | - Hamid Behzadnia
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
| | - Mohammad Haghani Dogahe
- Guilan Road Trauma Research Center, Guilan University of Medical Sciences, Rasht, Guilan, Iran
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Corecha Santos R, Santiago RB, Gupta B, Dabecco R, Kaye B, Obrzut M, Adada B, Velasquez N, Borghei-Razavi H. Anatomical Description and Literature Review of the Endoscopic Endonasal Transclival Transodontoid Approach Combined with Endoscopic Transoral Decompression to the Anterior Craniovertebral Junction: A New Strategy. World Neurosurg 2023; 175:e151-e158. [PMID: 36931342 DOI: 10.1016/j.wneu.2023.03.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To describe and evaluate the steps required to perform a combined endoscopic endonasal/transoral transclival transodontoid approach for anterior decompression of the craniovertebral junction. METHODS The endoscopic endonasal transclival transodontoid approach combined with endoscopic transoral decompression was performed on 4 cadaveric specimens. Evaluation of this combined technique; a review of the literature; and the nuances, advantages, and pitfalls are reported. RESULTS Adequate wide anterior decompression was achieved in all specimens. This combined approach allowed the preservation of the anterior arch of C1 without injuring the eustachian tube anatomy and avoiding internal carotid artery manipulation. CONCLUSIONS Mastery of both techniques allows for a safe and comfortable surgical corridor. The transoral and transnasal approaches should not be considered as either/or techniques, but rather as a complement to each other. However, as with all new or developing techniques, there is a steep learning curve, which requires ample training in the skull base laboratory.
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Affiliation(s)
| | | | - Bhavika Gupta
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Rocco Dabecco
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Brandon Kaye
- Department of Neuroscience, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida, USA
| | - Michal Obrzut
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Badih Adada
- Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nathalia Velasquez
- Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic Florida, Weston, Florida, USA
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Ye J, Liu B, Li J, Zheng G, Duan K, Gao L, Zhang C, Huang J, Tang Y. Full-endoscopic uniportal retropharyngeal odontoidectomy: A preliminary case report. Front Surg 2023; 9:973064. [PMID: 36684289 PMCID: PMC9852495 DOI: 10.3389/fsurg.2022.973064] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 10/20/2022] [Indexed: 01/08/2023] Open
Abstract
Summary of background data Odontoidectomy aims to decompress the medulla oblongata and is usually performed through the classical transoral approach, which affects oropharynx and accompanied with high rate of complications comprising swallowing and respiratory tract. We have developed a minimal invasive method via a standard cervical anterior approach: full-endoscopic trans-cervical odontoidectomy, which provides an alternative access for the resection of odontoid process and medulla oblongata decompression without traversing potentially contaminated cavities. Methods From 2018 to 2020, three patients with either odontoid process lesion or basilar invagination underwent full-endoscopic uniportal trans-cervical odontoidectomy with/without combining the posterior instrumentation. With fluoroscopic guidance, a uniportal endoscope sleeve was placed inside of the odontoid process; then odontoid process was gradually resected from the inside to outside under endoscopic monitoring. Postoperative images and clinical data were collected during post-op follow-up. Result Patients were soon extubated after surgery when patients wake up from general anesthesia. There were no severely perioperative complications, especially dysphagia and airway obstruction, and the symptoms and neurological function was improved immediately after surgery. The final pathology of one patient with odontoid osteolytic lesion was confirmed as plasmacytoma. The postoperative CT scans proved that the range of odontoid process resection was consistent with the preoperative expectation. Conclusion In summary, our proposed endoscopic trans-cervical odontoidectomy provides a valid choice for non-oral approach, which would reduce postoperative approach related complications and accelerate postoperative recovery.
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Affiliation(s)
- Jichao Ye
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Bin Liu
- Department of Orthopedics, Lishui People's Hospital, Li Shui, China
| | - Jinteng Li
- Department of Orthopedics, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Guan Zheng
- Department of Orthopedics, The Eighth Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Kaidi Duan
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liangbin Gao
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chunyan Zhang
- Department of Surgery Center, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingwen Huang
- Department of Orthopedics, The Second Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Yong Tang
- Department of Orthopedics, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China,Correspondence: Yong Tang
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11
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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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12
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Combined transnasal/transoral endoscopic odontoid resection in pediatric patients: Otolaryngologic considerations to airway management, endoscopic exposure, and complication management. Int J Pediatr Otorhinolaryngol 2023; 164:111372. [PMID: 36402000 DOI: 10.1016/j.ijporl.2022.111372] [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] [Received: 08/16/2022] [Revised: 10/10/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Anterior brainstem compression from odontoid pathology can occur in patients with craniocervical disorders. Occasionally, odontoid resection is required. In adults, odontoid resection has evolved toward transnasal-only endoscopic techniques. Pediatric patients, however, pose special challenges due to abnormal anatomy and smaller working spaces. A combined transnasal/transoral endoscopic odontoid resection (TN/TO EOR) can overcome this limitation. We present a case series with emphasis on otolaryngologic considerations to airway management, endoscopic approach, and management of complications. METHODS A single center, retrospective review of patients aged ≤18 undergoing combined transnasal/transoral endoscopic odontoid resection between 2011 and 2022 is presented. Clinical and surgical variables consisting of diagnosis, intubation approach, other airway procedures performed, symptoms, complications, blood loss, and time to extubation, return to oral feeding, and discharge were recorded. RESULTS 19 patients aged 10.7 ± 4.3 (range: 3-18) were included. Diagnoses included congenital syndrome (n = 6), complex Chiari malformation (n = 11), and congenital syndrome with Chiari (n = 2). Patients commonly required indirect videolaryngoscopy for intubation, with or without fiberoptic endoscopic assistance. Seven underwent adenoidectomy, two underwent adenotonsillectomy, and one required adenoidectomy with midline palatal split and inferior turbinate outfracture. Four patients had undergone prior adenotonsillectomy. Presenting symptoms included extremity weakness (n = 9), dysphagia (n = 8), velopharyngeal insufficiency (n = 4), sleep disturbance (n = 5), and headaches (n = 8). Four patients had complications, including one re-operation for residual odontoid, one flap dehiscence, one cerebrospinal fluid (CSF) leak repaired primarily, and one complicated course including temporary spinal cord injury. Blood loss was 50 ± 43 cc (median 30). Time to extubation was 1.1 ± 2.1 days (median 0; one patient underwent tracheotomy for respiratory failure), time to oral intake was 2.9 ± 3.7 days (median 1), and time to discharge was 7.1 ± 7.5 days (median 4). CONCLUSIONS A combined transnasal/transoral approach can be successfully used in pediatric patients to overcome difficult endoscopic access. Although complications exist, early extubation and return to oral intake occurs in the vast majority of cases. For pediatric TN/TO EOR, the otolaryngologist plays a key role in preoperative assessment, airway management, endoscopic exposure, and complication management.
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13
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Hou Z, Fan T, Fan W, Jian Q, Wang Y. Basilar invagination without atlantoaxial dislocation: treatment by correction of clivus canal angle with interfacet distraction and fixation. BMC Musculoskelet Disord 2022; 23:1138. [PMID: 36581884 PMCID: PMC9798678 DOI: 10.1186/s12891-022-06102-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND This study reports on the surgical technique used and clinical outcomes obtained during the treatment of basilar invagination (BI) without atlantoaxial dislocation (AAD) through the correction of the clivus canal angle (CCA) using interfacet distraction and fixation. METHODS Nineteen cases with BI without AAD treated by the correction of the clivus canal angle were retrospectively analyzed. Pre- and postoperative computed tomography scans and three-dimensional reconstruction views were obtained to measure the size of the CCA, pB-C2 distance, and degree of BI. Chiari malformation and syringomyelia were evaluated by magnetic resonance imaging (MRI). The clinical outcomes for all patients were measured using the Japanese Orthopedic Association (JOA) scale. The CCA was corrected by using interfacet distraction and fixation techniques. The Wilcoxon test was used to compare pre- and postoperative measurements. RESULTS All the patients were followed up for 24.95 ± 5.22 months (range 12-36 months); no patient suffered intraoperative nerve or vascular injury. Clinical symptoms improved in 17 patients (89.5%). The mean JOA score increased from 12.32 ± 1.89 to 14.37 ± 1.30 (Z = -3.655, P < 0.001). The mean CCA improved from 129.34 ± 8.52° preoperatively to 139.75 ± 8.86° postoperatively (Z = -3.824, P < 0.001). The mean pB-C2 decreased from 7.47 ± 2.21 to 5.68 ± 3.13 (Z = -3.060, P = 0.002). Syringomyelia was significantly reduced in 10 out of 13 patients by the first follow-up year. All patients achieved bony fusion. CONCLUSION Posterior interfacet distraction and fixation to correct the CCA is a feasible and effective method for treating BI without AAD.
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Affiliation(s)
- Zhe Hou
- grid.478016.c0000 0004 7664 6350Department of Neurosurgery, Beijing Luhe Hospital, Capital Medica University, Beijing, People’s Republic of China ,grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tao Fan
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wayne Fan
- grid.17091.3e0000 0001 2288 9830Faculty of Science, The University of British Columbia, Vancouver, BC Canada
| | - Qiang Jian
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yinqian Wang
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
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14
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Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci 2022; 12:brainsci12121685. [PMID: 36552145 PMCID: PMC9776068 DOI: 10.3390/brainsci12121685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/03/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
The endoscopic endonasal approach (EEA) provides a direct trajectory to ventral skull base lesions, avoidance of brain retraction, and clear visualization of cranial nerves as they exit skull base foramina. Despite these benefits, the EEA is not without complications. Here, we review published literature highlighting complications associated with the EEA including cerebrospinal fluid (CSF) leak, cranial nerve (CN) dysfunction, pituitary gland dysfunction, internal carotid artery (ICA) injury, infection, and others; we place special emphasis on discussing the prevention of these complications. As widespread adoption of the EEA continues, it becomes critical to educate surgeons regarding potential complications and their prevention while identifying gaps in the current literature to guide future research and advances in clinical care.
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15
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Palmisciano P, Al Fawares Y, Woodhouse C, Yang G, Xu A, d'Herbemont S, Hoang S, McGuire JL, Phillips KM, Cheng J, Forbes JA. The Impact of C1 Anterior Arch Preservation on Spine Stability After Odontoidectomy: Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:165-175.e2. [PMID: 36049722 DOI: 10.1016/j.wneu.2022.08.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent instrumentation. There is no consensus on the importance of C1 anterior arch preservation in prevention of iatrogenic instability. We conducted a systematic review of the impact of C1 anterior arch preservation on postodontoidectomy spine stability. METHODS PubMed, Embase, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients undergoing odontoidectomy. Random-effect model meta-analyses were performed to compare spine stability between C1 anterior arch preservation versus removal and posttreatment outcomes between transoral approaches (TOAs) versus endoscopic endonasal approaches (EEAs). RESULTS We included 27 studies comprising 462 patients. The most common lesions were basilar invagination (73.3%) and degenerative arthritis (12.6%). Symptoms included myelopathy (72%) and neck pain (43.9%). Odontoidectomy was performed through TOA (56.1%) and EEA corridors (34.4%). The C1 anterior arch was preserved in 16.7% of cases. Postodontoidectomy stabilization was performed in 83.3% patients. Median follow-up was 27 months (range, 0.1-145). Rates of spine instability were significantly lower (P = 0.004) when the C1 anterior arch was preserved. Postoperative clinical improvement and pooled complications were reported in 78.8% and 12.6% of patients, respectively, with no significant differences between TOA and EEA (P = 0.892; P = 0.346). Patients undergoing EEA had significantly higher rates of intraoperative cerebrospinal fluid leaks (P = 0.002). CONCLUSIONS Odontoidectomy is safe and effective for treating craniovertebral junction lesions. Preservation of the C1 anterior arch seems to improve maintenance of spine stability. TOA and EEA show comparable outcomes and complication rates.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yara Al Fawares
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Cody Woodhouse
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, USA
| | - George Yang
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alice Xu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sophie d'Herbemont
- Department of Neurological Surgery, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Stanley Hoang
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Jennifer L McGuire
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katie M Phillips
- Department of Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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16
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Penner F, De Marco R, Di Perna G, Portonero I, Baldassarre B, Garbossa D, Zenga F. Endoscopic endonasal odontoidectomy: a long-term follow-up results for a cohort of 21 patients. 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 2022; 31:2693-2703. [PMID: 35859067 DOI: 10.1007/s00586-022-07308-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/29/2022] [Accepted: 06/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic endonasal odontoidectomy (EEO) has been described as a potential approach for craniovertebral junction (CVJ) disease which could cause anterior bulbomedullary compression and encroaching. Due to the atlantoaxial junction's uniqueness and complex biomechanics, treating CVJ pathologies uncovers the challenge of preventing C1-C2 instability. A large series of patients treated with endonasal odontoidectomy is reported, analyzing the feasibility and necessity of whether or not to perform posterior stabilization. Furthermore, the focus is on the long-term follow-up, especially those whom only underwent partial C1 arch preservation without posterior fixation. METHODS This study is a retrospective analysis of patients with ventral spinal cord compression for non-reducible CVJ malformation, consecutively treated with EEO from July 2011 to March 2019. Postoperative dynamic X-ray and CT scans were obtained in each case in order to document CVJ decompression as well as to exclude instability. The anterior atlas-dens interval, posterior atlas-dens interval and C1-C2 total lateral overhang were measured as a morphological criteria to determine upper cervical spine stability. RESULTS Twenty-one patients (11:10 F:M) with a mean age of 60.6 years old at the time of surgery (range 34-84 years) encountered the inclusion criteria. For all 21 patients, a successful decompression was achieved at the first surgery. In 11 patients, the partial C1 arch integrity did not require a posterior cervical instrumentation on the bases of postoperative and constant follow-up radiological examination. In 13 cases, an improvement of motor function was recorded at the time of discharge. Only one patient had further motor function improvement at follow-up. Among the patients that did not show any significant motor change at discharge, 4 patients showed an improvement at the last follow-up. CONCLUSIONS The outcomes, even in C1 arch preservation without posterior fixation, are promising, and it could be said that the endonasal route potentially represents a valid option to treat lesions above the nasopalatine line.
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Affiliation(s)
- Federica Penner
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Raffaele De Marco
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Giuseppe Di Perna
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
| | - Irene Portonero
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Bianca Baldassarre
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Diego Garbossa
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
| | - Francesco Zenga
- Section of Neurosurgery, Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy
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17
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Akins PT, Ledgerwood LG, Duong HT. Early and late complications after open and endoscopic neurosurgery for complex skull base and craniofacial pathology: Case series, illustrative cases, and review. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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18
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Chatain GP, Chee K, Finn M. Review of transoral odontoidectomy. Where do we stand? Technical note and a single-center experience. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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19
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Dabboucy B, Lahiani W, Bresson D, Aldahak N. The endoscopic transnasal approach to the lesions of the craniocervical junction: two case reports. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2022; 40:96-101. [PMID: 35855592 PMCID: PMC9946913 DOI: 10.12701/jyms.2022.00234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/22/2022] [Indexed: 11/04/2022]
Abstract
The endoscopic endonasal approach (EEA) to the craniovertebral junction (CVJ) has recently been considered a safer alternative and less invasive approach than the traditional transoral approach because the complications associated with the latter are avoided or minimized. Here, we present two challenging cases of CVJ pathologies. The first case involved os odontoideum associated with anterior displacement of the occipitocervical junction where the EEA was used, followed by C0-C1-C2 fusion using a posterior approach to decompress the CVJ, and was complicated by rhinorrhea and Candida albicans meningitis. The second case involved basilar invagination with syringomyelia previously treated using a posterior approach, where aggravation of neuropathic symptoms required combined treatment with EEA and occipitocervical fusion of C0-C2-C3-C4, with the postoperative course challenged by operative site infection requiring drainage with debridement and antibiotic therapy. The EEA is an alternative approach for accessing the CVJ in well-selected patients. Knowledge of EEA complications is crucial for the optimal care of patients.
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Affiliation(s)
- Baraa Dabboucy
- Department of Neurosurgery, Faculty of Medicine, Lebanese University, Beirut, Lebanon,Corresponding author: Baraa Dabboucy, MD Department of Neurosurgery, Faculty of Medicine, Lebanese University, Rafic Hariri University Campus, Hadath, Lebanon Tel: +961-71661019 • E-mail:
| | - Wissem Lahiani
- Department of Neurosurgery, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Damien Bresson
- Department of Neurosurgery, AP-HP, Henri Mondor Hospital, Créteil, France
| | - Nouman Aldahak
- Department of Neurosurgery, AP-HP, Henri Mondor Hospital, Créteil, France
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20
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Giammalva GR, Dell’Aglio L, Guarrera B, Baro V, Calvanese L, Schiavo G, Mantovani G, Rinaldi V, Iacopino DG, Causin F, Nicolai P, Ferrari M, Denaro L. Transnasal Endoscopic Approach for Osteoid Osteoma of the Odontoid Process in a Child: Technical Note and Systematic Review of the Literature. Brain Sci 2022; 12:brainsci12070916. [PMID: 35884723 PMCID: PMC9316770 DOI: 10.3390/brainsci12070916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/05/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
Osteoid osteoma (OO) is a primary benign tumor that accounts for up to 3% of all bone tumors. The cervical spine is less affected by OOs, and very few cases of C2 OOs have been reported in the literature, both in adults and children. Surgery may be required in case of functional torticollis, stiffness, and reduced range of motion (ROM) due to cervical OOs refractory to medical therapy. Several posterior and anterior surgical techniques have been described to remove C2 OOs. In particular, anterior approaches to the cervical spine represent the most used surgical route for treating C2 OOs. We describe the first case of OO of the odontoid process removed through a transnasal endoscopic approach with the aid of neuronavigation in a 6-year-old child. No intraoperative complications occurred, and the post-operative course was uneventful. The patient had immediate relief of neck pain and remained pain-free throughout the follow-up period, with complete functional recovery of the neck range of motion (ROM). In this case, based on the favorable anatomy, the transnasal endoscopic approach represented a valuable strategy for the complete removal of an anterior C2 OO without the need for further vertebral fixation since the preservation of ligaments and paravertebral soft tissue.
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Affiliation(s)
- Giuseppe Roberto Giammalva
- Unit of Neurosurgery, Post Graduate Residency Program in Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy;
- Correspondence:
| | - Letizia Dell’Aglio
- Academic Neurosurgery, Department of Neurosciences DNS, University of Padua, 35128 Padua, Italy; (L.D.); (B.G.); (V.B.); (L.D.)
| | - Brando Guarrera
- Academic Neurosurgery, Department of Neurosciences DNS, University of Padua, 35128 Padua, Italy; (L.D.); (B.G.); (V.B.); (L.D.)
| | - Valentina Baro
- Academic Neurosurgery, Department of Neurosciences DNS, University of Padua, 35128 Padua, Italy; (L.D.); (B.G.); (V.B.); (L.D.)
| | - Leonardo Calvanese
- Unit of Otorhinolaryngology—Head and Neck Surgery, Department of Neurosciences DNS, “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (L.C.); (G.S.); (P.N.); (M.F.)
| | - Gloria Schiavo
- Unit of Otorhinolaryngology—Head and Neck Surgery, Department of Neurosciences DNS, “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (L.C.); (G.S.); (P.N.); (M.F.)
| | - Giulia Mantovani
- Unit of Anesthesia and Intensive Care, Integrated Didactic-Scientific Healtcare Department of Surgery (DIDAS Chirurgia), “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (G.M.); (V.R.)
| | - Valentina Rinaldi
- Unit of Anesthesia and Intensive Care, Integrated Didactic-Scientific Healtcare Department of Surgery (DIDAS Chirurgia), “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (G.M.); (V.R.)
| | - Domenico Gerardo Iacopino
- Unit of Neurosurgery, Post Graduate Residency Program in Neurosurgery, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy;
| | - Francesco Causin
- Unit of Neuroradiology, Department of Neurosciences DNS, University of Padua, 35128 Padua, Italy;
| | - Piero Nicolai
- Unit of Otorhinolaryngology—Head and Neck Surgery, Department of Neurosciences DNS, “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (L.C.); (G.S.); (P.N.); (M.F.)
| | - Marco Ferrari
- Unit of Otorhinolaryngology—Head and Neck Surgery, Department of Neurosciences DNS, “Azienda Ospedale Università di Padova”, University of Padua, 35128 Padua, Italy; (L.C.); (G.S.); (P.N.); (M.F.)
- Guided Therapeutics (GTx) Program International Scholarship, University Health Network (UHN), Toronto, ON M5G 2C4, Canada
- Technology for Health (Ph.D. Program), Department of Information Engineering, University of Brescia, 25123 Brescia, Italy
| | - Luca Denaro
- Academic Neurosurgery, Department of Neurosciences DNS, University of Padua, 35128 Padua, Italy; (L.D.); (B.G.); (V.B.); (L.D.)
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Rehman RU, Akhtar MS, Bibi A, Shah SM, Khan S, Kashif M. Transoral Odontoidectomy - Our Experience in A Limited-Resource Setup. World Neurosurg 2022; 165:27-44. [PMID: 35700863 DOI: 10.1016/j.wneu.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although posterior procedures are used for most cases of basilar invagination, transoral decompression is an important tool in complex deformities with severe degeneration and neural compression. METHODS Consecutive patients who underwent transoral odontoidectomy for basilar invagination and atlantoaxial dislocation at the neurosurgical unit of Lady Reading Hospital Peshawar between June 2016 and January 2022 were retrospectively included. Preoperative and postoperative neurological, clinical, and radiological parameters were recorded and compared. RESULTS Of the 33 patients included in this study, 22 were men and 11 were women. The mean age was 23.4 years ±8.4 years (mean ± standard deviation). The most common presenting symptoms were gait abnormalities and neck pain. A total of 28 patients were treated for the first time, while 5 patients had prior posterior fusion. The mean distance of the tip of the dens above the chamberlain line was 8.9 ± 4.2 mm, while the mean anterior atlantodental interval was 6.5 ± 2.1 mm. Seven patients had an anomalous course of vertebral artery on at least one side. A total of 28 patients improved significantly, while 5 patients did not improve at the follow-up. The mean follow-up was 8.5 months ±6.3 (mean ± standard deviation). The mean Nurick and Modified Japanese Orthopedic Association scores improved postoperatively (P < 0.05). Three patients underwent reoperation including one with vertebral artery injury. Three patients underwent tracheostomy. CONCLUSIONS With proper patient selection, transoral odontoidectomy can be safely performed in a limited-resource setting.
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Affiliation(s)
- Riaz Ur Rehman
- Department of Neurosurgery, Lady Reading Hospital, Peshawar, Pakistan
| | | | - Amna Bibi
- Department of General Surgery, Hayatabad Medical Complex, Peshawar, Pakistan
| | | | - Sohrab Khan
- Muhammad Teaching Hospital, Peshawar, Pakistan
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Pongmanee S, Sarasombath P, Rojdumrongrattana B, Liawrungrueang W. An Unusual Chordoma of the Odontoid Process: A Case Report and Literature Review. J Am Acad Orthop Surg Glob Res Rev 2022; 6:e22.00018. [PMID: 35584249 PMCID: PMC10566828 DOI: 10.5435/jaaosglobal-d-22-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/24/2022] [Indexed: 06/15/2023]
Abstract
The aim of this study is to present a rare case of chordoma in the odontoid process in which the tumor involved the odontoid process and compressed the spinal cord at the craniocervical junction. We report on the effectiveness and successful outcome of anterior microscopic tumor resection combined with posterior occipitocervical fixation and review the current standard treatment. A 39-year-old man presented with sudden dyspnea and quadriparesis caused by an unknown tumor compression at C2. Radiographic examination revealed a large destructive mass at C2 and heterogeneous enhancement. The patient received urgent surgical intervention by microscopic-assisted anterior tumor resection and posterior spinal fixation from the occiput to the C5 level. The pathohistologic reports for cytokeratins, epithelial membrane antigen, and S-100 protein were positive. The final diagnosis was chordoma of the odontoid process. At the 2-year follow-up, the patient's condition had improved, and a postoperative MRI showed no indication of tumor regrowth. Chordoma of the odontoid process or C2 body is very rare. The current standard management is wide tumor resection to prevent recurrence. The combined approach of anterior tumor resection with microscopic assistance and posterior stabilization of the occiput to C5 is the optimal treatment for this condition.
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Affiliation(s)
- Suthipas Pongmanee
- From the Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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23
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Halderman AA, Barnett SL. Endoscopic endonasal approach to the craniovertebral junction. World J Otorhinolaryngol Head Neck Surg 2022; 8:16-24. [PMID: 35619929 PMCID: PMC9126158 DOI: 10.1002/wjo2.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/17/2021] [Indexed: 12/03/2022] Open
Abstract
The surgical approach to lesions of the ventral craniovertebral junction (CVJ) has evolved significantly in the last several years with the advent of endoscopic skull base surgery. Differing pathologies of the CVJ can result in irreducible compression of the cervicomedullary region. The endoscopic endonasal approach lends itself well to this region due to the ventral location, and while there is a steep learning curve, is a safe and effective way to perform decompression of the cervicomedullary region. Herein, we discuss the anatomy of the CVJ, preoperative evaluation and surgical considerations, our surgical approach, complications, and outcomes.
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Affiliation(s)
- Ashleigh A. Halderman
- Department of Otolaryngology Head and Neck Surgery University of Texas Southwestern Medical Center Dallas Texas USA
| | - Samuel L. Barnett
- Department of Neurological Surgery University of Texas Southwestern Medical Center Dallas Texas USA
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24
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Soni P, Loss JG, Gillespie CM, Colbrunn RW, Schlenk R, Steinmetz MP, Recinos PF, Benzel EC, Kshettry VR. Evaluating stability of the craniovertebral junction after unilateral C1 lateral mass resection: implications for the direct lateral approach. J Neurosurg Spine 2022; 36:269-275. [PMID: 34598153 DOI: 10.3171/2021.4.spine21226] [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: 02/07/2021] [Accepted: 04/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The direct lateral approach is an alternative to the transoral or endonasal approaches to ventral epidural lesions at the lower craniocervical junction. In this study, the authors performed, to their knowledge, the first in vitro biomechanical evaluation of the craniovertebral junction after sequential unilateral C1 lateral mass resection. The authors hypothesized that partial resection of the lateral mass would not result in a significant increase in range of motion (ROM) and may not require internal stabilization. METHODS The authors performed multidirectional in vitro ROM testing using a robotic spine testing system on 8 fresh cadaveric specimens. We evaluated ROM in 3 primary movements (axial rotation [AR], flexion/extension [FE], and lateral bending [LB]) and 4 coupled movements (AR+E, AR+F, LB + left AR, and LB + right AR). Testing was performed in the intact state, after C1 hemilaminectomy, and after sequential 25%, 50%, 75%, and 100% C1 lateral mass resection. RESULTS There were no significant increases in occipital bone (Oc)-C1, C1-2, or Oc-C2 ROM after C1 hemilaminectomy and 25% lateral mass resection. After 50% resection, Oc-C1 AR ROM increased by 54.4% (p = 0.002), Oc LB ROM increased by 47.8% (p = 0.010), and Oc-C1 AR+E ROM increased by 65.8% (p < 0.001). Oc-C2 FE ROM increased by 7.2% (p = 0.016) after 50% resection; 75% and 100% lateral mass resection resulted in further increases in ROM. CONCLUSIONS In this cadaveric biomechanical study, the authors found that unilateral C1 hemilaminectomy and 25% resection of the C1 lateral mass did not result in significant biomechanical instability at the occipitocervical junction, and 50% resection led to significant increases in Oc-C2 ROM. This is the first biomechanical study of lateral mass resection, and future studies can serve to validate these findings.
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Affiliation(s)
- Pranay Soni
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 2Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic; and
| | - Jeremy G Loss
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Callan M Gillespie
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Robb W Colbrunn
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Richard Schlenk
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Michael P Steinmetz
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Pablo F Recinos
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 2Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic; and
| | - Edward C Benzel
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 3Spine Research Lab, Lutheran Hospital, Cleveland Clinic Center for Spine Health, Cleveland, Ohio
| | - Varun R Kshettry
- 1Department of Neurological Surgery, Neurological Institute, Cleveland Clinic
- 2Rose Ella Burkhardt Brain Tumor & Neuro-Oncology Center, Cleveland Clinic; and
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25
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Erdogan K, Solmaz S, Abbasoglu B, Caglar Y, Dogan I. Posterior midline approach to odontoidectomy: A novel method to treat basilar invagination. J Craniovertebr Junction Spine 2022; 13:146-153. [PMID: 35837436 PMCID: PMC9274675 DOI: 10.4103/jcvjs.jcvjs_12_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Basilar invagination (BI) is a common malformation of the craniocervical region where the odontoid process protrudes into the foramen magnum. Surgery in this region is difficult because of the complex anatomy of the craniocervical junction. Serious life-threatening complications have been observed with previously described approaches. Therefore, we conceived a novel surgical approach that can be implemented by neurosurgeons with different skill levels to facilitate better outcomes. Methods: We describe a new surgical technique for the treatment of BI that we used in two patients in whom cervical myelopathy and direct ventral compression of the cervicomedullary junction were confirmed through clinical and radiological findings. We present the technique of posterior odontoidectomy in a step-by-step, didactic, and practical manner with surgical tips and tricks. Results: The resection was completed without intraoperative or postoperative complications in both cases. The patients experienced substantial neurological improvements, and full recovery was observed during the 9-month and 12-month follow-up visits after discharge. Compared with the transoral approach, our technique provides a larger decompression area. Conclusions: We describe a novel method for the treatment of BI that was applied in two patients and suggest that the posterior approach might be a safe and effective method for ventral decompression of the craniocervical junction. Posterior odontoidectomy followed by craniocervical fixation helped achieve complete cervicomedullary decompression.
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26
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Heller RS, Glaspy T, Mhaskar R, Bhadelia R, Heilman CB. Endoscopic Endonasal Versus Transoral Odontoidectomy for Non-Neoplastic Craniovertebral Junction Disease: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:380-385. [PMID: 34460927 DOI: 10.1093/ons/opab303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Odontoidectomy is a challenging yet effective operation for decompression of non-neoplastic craniovertebral junction disease. Though both the endoscopic endonasal approach (EEA) and the transoral approach (TOA) have been discussed in the literature, there remain few direct comparisons between the techniques. OBJECTIVE To evaluate the perioperative outcomes of EEA vs TOA odontoidectomy. METHODS A retrospective review of all cases undergoing odontoidectomy by either the EEA or TOA was performed. Attention was paid to the need for prolonged nutritional support, prolonged respiratory support, and hospitalization times. RESULTS During the study period between 2000 and 2018, 25 patients underwent odontoid process resection (18 TOA and 7 EEA). The most common indication for surgery was basilar invagination. Hospital length of stay, intensive care unit length of stay, and intubation days were all significantly shorter in the EEA group compared to the TOA group (P < .01, P = .01, P < .01, respectively). Prolonged nutritional support in the form of a gastrostomy tube was required in 5 patients and tracheostomy was required in 4 patients; all of these underwent odontoidectomy by the TOA. There was no statistical difference in neurological outcomes between the EEA and TOA groups (P = .17). CONCLUSION Odontoidectomy can be performed safely through both the EEA and TOA. The results of this study suggest the EEA has shorter hospitalizations and a lower probability of requiring prolonged nutritional support. These advantages are likely the results of decreased oropharyngeal mucosa disruption as compared to the TOA.
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Affiliation(s)
- Robert S Heller
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.,Department of Neurosurgery and Brain Repair, Tampa General Hospital, University of South Florida, Tampa, Florida, USA
| | - Tyler Glaspy
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Tampa, Florida, USA
| | - Rafeeque Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carl B Heilman
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Yagnik KJ, Pinheiro-Neto CD, Peris-Celda M. Commentary: Endoscopic Endonasal Versus Transoral Odontoidectomy for Non-Neoplastic Craniovertebral Junction Disease: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:E465-E466. [PMID: 34624884 DOI: 10.1093/ons/opab352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/10/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Karan J Yagnik
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Carlos D Pinheiro-Neto
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Villeneuve LM, Voronovich Z, Evans A, El Rassi ET, Dunn IF, Smith ZA. A combined approach for stabilization and endoscopic/ endonasal odontoid and clivus resection for treatment of basilar invagination. Surg Neurol Int 2021; 12:511. [PMID: 34754561 PMCID: PMC8571294 DOI: 10.25259/sni_658_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Basilar invagination (BI) is a complex condition characterized by prolapse of the odontoid into the brain stem/upper cervical cord. This lesion is often associated with Chiari malformations, and rheumatoid arthritis (RA). Treatment options for BI typically include cervical traction, an isolated anterior transoral odontoidectomy, anterior endonasal odontoidectomy, an isolated posterior fusion, or combined anterior/ posterior surgical approach. Case Description: A 45-year-old female with a Chiari I malformation and RA underwent a combined posterior C0-C5 posterior decompression/fusion, followed by an anterior odontoidectomy (i.e. endoscopic/endonasal under neuronavigation). Postoperatively, the patient’s symptoms and neurological signs resolved. Conclusion: BI in was successfully managed with a combined posterior C0-C5 decompression/fusion followed by an anterior endoscopic/endonasal odontoidectomy performed under neuronavigation.
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Affiliation(s)
- Lance Michael Villeneuve
- Department of Neurosurgery, Oklahoma University Health Science Center, Oklahoma City, United States
| | - Zoya Voronovich
- Department of Neurosurgery, Oklahoma University Health Science Center, Oklahoma City, United States
| | - Alexander Evans
- Department of Neurosurgery, Oklahoma University Health Science Center, Oklahoma City, United States
| | - Edward T El Rassi
- Department of Otolaryngology, Oklahoma University Health Science Center, Oklahoma City, United States
| | - Ian F Dunn
- Department of Neurosurgery, Oklahoma University Health Science Center, Oklahoma City, United States
| | - Zachary A Smith
- Department of Neurosurgery, Oklahoma University Health Science Center, Oklahoma City, United States
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Fava A, Russo PD, Tardivo V, Passeri T, Câmara B, Penet N, Abbritti R, Giammattei L, Mammar H, Bernat AL, Mandonnet E, Froelich S. Endoscope-assisted far-lateral transcondylar approach for craniocervical junction chordomas: a retrospective case series and cadaveric dissection. J Neurosurg 2021; 135:1335-1346. [PMID: 33799304 DOI: 10.3171/2020.9.jns202611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 09/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Craniocervical junction (CCJ) chordomas are a neurosurgical challenge because of their deep localization, lateral extension, bone destruction, and tight relationship with the vertebral artery and lower cranial nerves. In this study, the authors present their surgical experience with the endoscope-assisted far-lateral transcondylar approach (EA-FLTA) for the treatment of CCJ chordomas, highlighting the advantages of this corridor and the integration of the endoscope to reach the anterior aspect and contralateral side of the CCJ and the possibility of performing occipitocervical fusion (OCF) during the same stage of surgery. METHODS Nine consecutive cases of CCJ chordomas treated with the EA-FLTA between 2013 and 2020 were retrospectively reviewed. Preoperative characteristics, surgical technique, postoperative results, and clinical outcome were analyzed. A cadaveric dissection was also performed to clarify the anatomical landmarks. RESULTS The male/female ratio was 1.25, and the median age was 36 years (range 14-53 years). In 6 patients (66.7%), the lesion showed a bilateral extension, and 7 patients (77.8%) had an intradural extension. The vertebral artery was encased in 5 patients. Gross-total resection was achieved in 5 patients (55.6%), near-total resection in 3 (33.3%), and subtotal resection 1 (11.1%). In 5 cases, the OCF was performed in the same stage after tumor removal. Neither approach-related complications nor complications related to tumor resection occurred. During follow-up (median 18 months, range 5-48 months), 1 patient, who had already undergone treatment and radiotherapy at another institution and had an aggressive tumor (Ki-67 index of 20%), showed tumor recurrence at 12 months. CONCLUSIONS The EA-FLTA provides a safe and effective corridor to resect extensive and complex CCJ chordomas, allowing the surgeon to reach the anterior, lateral, and posterior portions of the tumor, and to treat CCJ instability in a single stage.
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Affiliation(s)
- Arianna Fava
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
| | - Paolo di Russo
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
| | - Valentina Tardivo
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
| | - Thibault Passeri
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 3University of Paris; and
| | - Breno Câmara
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Nicolas Penet
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
- 3University of Paris; and
| | - Rosaria Abbritti
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
| | - Lorenzo Giammattei
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
- 3University of Paris; and
| | - Hamid Mammar
- 4Proton Therapy Center, Institut Curie, Orsay, France
| | - Anne Laure Bernat
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 3University of Paris; and
| | - Emmanuel Mandonnet
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 3University of Paris; and
| | - Sébastien Froelich
- 1Department of Neurosurgery, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris
- 2Laboratory of Experimental and Skull Base Neurosurgery, Department of Neurosurgery, Lariboisière Hospital, Paris
- 3University of Paris; and
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30
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Visocchi M, Signorelli F, Parrilla C, Paludetti G, Rigante M. Multidisciplinary approach to the craniovertebral junction. Historical insights, current and future perspectives in the neurosurgical and otorhinolaryngological alliance. ACTA ACUST UNITED AC 2021; 41:S51-S58. [PMID: 34060520 PMCID: PMC8172108 DOI: 10.14639/0392-100x-suppl.1-41-2021-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/22/2021] [Indexed: 11/23/2022]
Abstract
Historically considered as a nobody’s land, craniovertebral junction (CVJ) surgery or specialty recently gained high consideration as symbol of challenging surgery as well as selective top level qualifying surgery. The alliance between Neurosurgeons and Otorhinolaringologists has become stronger in the time. CVJ has unique anatomical bone and neurovascular structures architecture. It not only separates from the subaxial cervical spine but it also provides a special cranial flexion, extension, and axial rotation pattern. Stability is provided by a complex combination of osseous and ligamentous supports which allows a large degree of motion. The perfect knowledge of CVJ anatomy and physiology allows to better understand surgical procedures of the occiput, atlas and axis and the specific diseases that affect the region. Although many years passed since the beginning of this pioneering surgery, managing lesions situated in the anterior aspect of the CVJ still remains a challenging neurosurgical problem. Many studies are available in the literature so far aiming to examine the microsurgical anatomy of both the anterior and posterior extradural and intradural aspects of the CVJ as well as the differences in all the possible surgical exposures obtained by 360° approach philosophy. Herein we provide a short but quite complete at glance tour across the personal experience and publications and the more recent literature available in order to highlight where this alliance between Neurosurgeon and Otorhinolaringologist is mandatory, strongly advisable or unnecessary.
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Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudio Parrilla
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Gaetano Paludetti
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
| | - Mario Rigante
- Otorhinolaryngology, Head and Neck Surgery, "A. Gemelli" Hospital Foundation IRCCS, Catholic University of the Sacred Heart, Rome, Italy.,Craniovertebral Junction Operative Unit, Master II Degree, Cadaver Lab and Research Center on Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
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31
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Vidal CHF, Fonseca RB, Leimig B, Matias-Filho WF, Carneiro-Filho GS. Increase of the clivus-canal angle in patients with basilar invagination, without atlantoaxial displacement, treated with a simple maneuver of indirect decompression of the odontoid with the head clamp, during posterior occipitocervical arthrodesis. Surg Neurol Int 2021; 12:260. [PMID: 34221591 PMCID: PMC8247686 DOI: 10.25259/sni_284_2021] [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: 03/18/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Basilar invagination (BI) can be defined as the insinuation of the content of the craniovertebral junction through the foramen magnum toward the posterior fossa. BI is a prevalent condition in Northeast Brazil. The present study describes the changes in the clivus-canal angle (CCA) in the postoperative period in patients with symptomatic BI operated by a posterior approach, using a simple technique of indirect reduction of the odontoid associated with occipitocervical fixation. Methods: Patients underwent radiological evaluations by magnetic resonance imaging in the pre and postoperative periods, where the height of the odontoid tip was measured in relation to the Chamberlain line and the ACC. All patients underwent posterior occipitocervical fixation with specific maneuvers of distraction and extension of the cephalic segment with the aid of a head clamp with three fixation points for anterior reduction of the odontoid. Results: Among the 8 patients evaluated in the series, all had increased ACC in the postoperative period, with a mean of 14.81 ± 1.54°, and statistically significant difference between the pre and postoperative periods (P < 0.05). Conclusion: The indirect surgical reduction of the odontoid process by a posterior approach through the manipulation (distraction-extension) of a “Mayfield” type of head clamp followed by occipitocervical fixation proved to be effective in improving the ACC, being easily reproducible.
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Affiliation(s)
| | - Ricardo Brandao Fonseca
- Department of Neurosurgery, Universidade Federal do Vale do São Francisco, Petrolina, Pernambuco, Brazil
| | - Bruno Leimig
- Department of Neurosurgery, Hospital Getulio Vargas, Recife, Pernambuco, Brazil
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Kawabata T, Suga H, Takeuchi K, Nagata Y, Sakakibara M, Ushida K, Ozone C, Enomoto A, Kawamoto I, Itagaki I, Tsuchiya H, Arima H, Wakabayashi T. A new primate model of hypophyseal dysfunction. Sci Rep 2021; 11:10729. [PMID: 34031474 PMCID: PMC8144576 DOI: 10.1038/s41598-021-90209-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/19/2021] [Indexed: 11/09/2022] Open
Abstract
For pituitary regenerative medicine, the creation of a hypophyseal model in monkeys is necessary to conduct future preclinical studies; however, previous studies reported that hypophysectomy in monkeys is not always safe or satisfactory. This study aimed to create a hypophyseal dysfunction model in a cynomolgus monkey using a safer surgical technique and establish the protocol of pituitary hormone replacement therapy for this model. Surgical resection of the pituitary gland of a 7.8-year-old healthy adult cynomolgus male monkey weighing 5.45 kg was performed to create a hypophyseal dysfunction model for future regenerative studies. Endoscopic transoral transsphenoidal surgery was used to perform hypophysectomy under navigation support. These procedures were useful for confirming total removal of the pituitary gland without additional bone removal and preventing complications such as cerebrospinal fluid leakage. Total removal was confirmed by pathological examination and computed tomography. Hypopituitarism was verified with endocrinological examinations including stimulation tests. Postoperatively, the monkey's general condition of hypopituitarism was treated with hormone replacement therapy, resulting in long-term survival. The success of a minimally invasive and safe surgical method and long-term survival indicate the creation of a hypophyseal dysfunction model in a cynomolgus monkey; hence, this protocol can be employed in the future.
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Affiliation(s)
- Teppei Kawabata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Hidetaka Suga
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Kazuhito Takeuchi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Yuichi Nagata
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
| | - Mayu Sakakibara
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kaori Ushida
- Department of Pathology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Technical Center, Nagoya University, Nagoya, Japan
| | - Chikafumi Ozone
- Department of Endocrinology and Diabetes, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Atsushi Enomoto
- Department of Pathology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ikuo Kawamoto
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Iori Itagaki
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Hideaki Tsuchiya
- Research Center for Animal Life Science, Shiga University of Medical Science, Shiga, Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Graduate School of Medicine, Nagoya University, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Toshihiko Wakabayashi
- Department of Neurosurgery, Graduate School of Medicine, Nagoya University, Nagoya, Japan
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33
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Viola Á, Kozma I, Süvegh D. Surgery for craniovertebral junction pathologies: minimally invasive anterior submandibular retropharyngeal key-hole approach. BMC Surg 2021; 21:199. [PMID: 33874919 PMCID: PMC8054389 DOI: 10.1186/s12893-021-01198-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/08/2021] [Indexed: 11/12/2022] Open
Abstract
Background Our objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches. Methods During the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1–C2 fusion according to Harms. C1–C2 decompressive laminectomy was performed in all four cases. Ventral C1–C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR—similarly to the traditional anterior retropharyngeal surgery—preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor. Results The MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2/6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement. Conclusion Based on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01198-z.
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Affiliation(s)
- Árpád Viola
- Department of Neurotraumatology, Semmelweis University, Fiumei út 17, 1081, Budapest, Hungary. .,Department of Neurosurgery and Neurotraumatology, Péterfy Hospital - Manninger Jenő National Traumatology Institution, Fiumei út 17, 1081, Budapest, Hungary.
| | - István Kozma
- Péterfy Hospital - Manninger Jenő National Traumatology Institution, Fiumei út 17, 1081, Budapest, Hungary
| | - Dávid Süvegh
- Department of Neurotraumatology, Semmelweis University, Fiumei út 17, 1081, Budapest, Hungary
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Abstract
INTRODUCTION Since the early use of the endoscopic view for treating simple intrasellar pituitary adenomas, the skull base surgery has experienced an unprecedented revolution elevating the treatment of skull base lesions to the next level in proficiency and excellence of care. METHODS We have reviewed the preclinical and clinical evidence supporting the use of the endoscope in the treatment of skull base lesions. In this article, we aim to discuss and provide a wide view of the current indications and future perspectives of the endoscopic endonasal approaches (EEA) and of the endoscopic transcranial approaches. RESULTS As in the development of any other technique, EEA have gone through a transformation process from theoretical anatomic models to a pragmatic clinical use. Along the way, EEA have required several modifications, as well as pushbacks in the application of this technique in some indications. This process has resulted in the provision of an additional tool to the current surgical armamentarium that allows the skull base surgeon to face most challenging lesions along the skull base. CONCLUSIONS The judicious combination of transcranial and endoscopic-transnasal approaches warrants highest chances of achieving satisfactory tumors resection with a reduced risk of complications.
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Srivastava A, Singh S, Sardhara J, Behari S. Transoral odontoidectomy for pediatric craniovertebral junction anomaly: Is it redundant now? J Pediatr Neurosci 2021; 16:87-90. [PMID: 35018174 PMCID: PMC8706587 DOI: 10.4103/jpn.jpn_36_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/30/2020] [Accepted: 08/22/2020] [Indexed: 11/04/2022] Open
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Signorelli F, Olivi A, De Giorgio F, Pascali VL, Visocchi M. A 360° Approach to the Craniovertebral Junction in a Cadaveric Laboratory Setting: Historical Insights, Current, and Future Perspectives in a Comparative Study. World Neurosurg 2020; 140:564-573. [PMID: 32797988 DOI: 10.1016/j.wneu.2020.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 04/07/2020] [Accepted: 04/09/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND We herein outline the experience matured in our equipped Cranio-Vertebral Junction Laboratory for anatomic dissection. METHODS An extreme lateral approach (ELA) was performed on 4 fresh cadavers and submandibular approach was performed on 5. An endoscope and navigation-assisted far lateral approach (FLA) was performed in 5 injected specimens. In these specimens, a transoral approach was also performed, as well as a neuronavigation-assisted comparison between transoral and transnasal explorable distances. RESULTS As calculated with neuronavigation, statistically significant differences both in the explored craniocaudal (P = 0.003) and lateral (P = 0.008) distances were observed between the transoral approach and endoscopic endonasal approach. In FLA, neuronavigation facilitated identification and partial removal of the occipital condyle; in one case, during endoscopic intradural exploration, tearing of the emerging roots of the 11th cranial nerve occurred. In ELA, the site where the accessory nerve pierces into the sternocleidomastoid muscle was found at a distance from the tip of the mastoid between 3 and 4 cm. CONCLUSIONS During dissections, as in the clinical setting, endoscope and image guidance give the surgeon a constant orientation, increasing the accuracy and the safety of the approach. Nonetheless, the encumbrance of the endoscope could represent a limit in deep and narrow corridors as those running across the craniovertebral junction, especially in "oblique" FLA and ELA, in which the surgical target is often hidden by a delicate tangle of nerves and vessels. Its use appears more suitable and safer in "straight" approaches as transoral and transnasal in which there are no neurovascular structures interposed.
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Affiliation(s)
- Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Alessandro Olivi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy
| | - Fabio De Giorgio
- Institute of Public Health, Section of Legal Medicine, Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Lorenzo Pascali
- Institute of Public Health, Section of Legal Medicine, Catholic University School of Medicine, Rome, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy; Craniovertebral Junction Operative Unit, Master II Degree and Research Center Craniocervical Junction Surgery, Catholic University School of Medicine, Rome, Italy
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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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Fiani B, Houston R, Siddiqi I, Arshad M, Reardon T, Gilliland B, Davati C, Kondilis A. Retro-Odontoid Pseudotumor Formation in the Context of Various Acquired and Congenital Pathologies of the Craniovertebral Junction and Surgical Techniques. Neurospine 2020; 18:67-78. [PMID: 33211944 PMCID: PMC8021814 DOI: 10.14245/ns.2040402.201] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/24/2020] [Indexed: 12/03/2022] Open
Abstract
Retro-odontoid pseudotumor formation consists of an abnormal growth of granulation tissue typically posterior to the odontoid process, resulting as a manifestation of atlantoaxial instability. This instability can occur as a result of conditions ranging from severe mechanical trauma to metabolic disease or autoimmune conditions such as rheumatoid arthritis. A pseudotumor may impinge on the spinal nerves or even the spinal cord and brainstem, manifesting symptoms from severe neck pain to cervicomedullary compression or myelopathy, and in some cases even sudden death. The objective of this review is to consolidate the findings in published case reports and relevant prior literature reviews regarding the formation of retro-odontoid pseudotumor. We address the pathophysiology involved in acquired and congenital pseudotumor formation, including those associated with rheumatoid arthritis (panni). Additionally, we discuss past and current operative techniques designed to curtail and ultimately regress a retro-odontoid pseudotumor and pannus. Surgical techniques that are addressed include ventral decompression (both transoral and transnasal), dorsal decompression, and indications for posterior instrumentation in pannus formation, particularly in cases that may be sufficiently treated in lieu of an anterior approach. Finally, we will examine the role of external orthoses as both a method of conservative treatment as well as a potential adjunct to the aforementioned surgical procedures.
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Affiliation(s)
- Brian Fiani
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Rebecca Houston
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Imran Siddiqi
- Western University of Health Sciences College of Osteopathic Medicine, Pomona, CA, USA
| | - Mohammad Arshad
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Taylor Reardon
- University of Pikeville, Kentucky College of Osteopathic Medicine, Pikeville, KY, USA
| | | | - Cyrus Davati
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, NY, USA
| | - Athanasios Kondilis
- Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
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Sai Kiran NA, Vidyasagar K, Sivaraju L, Raj V, Aryan S, Thakar S, Mohan D, Hegde AS. Outcome of Surgery for Congenital Craniovertebral Junction Anomalies with Atlantoaxial Dislocation/Basilar Invagination: A Retrospective Study of 94 Patients. World Neurosurg 2020; 146:e313-e322. [PMID: 33096283 DOI: 10.1016/j.wneu.2020.10.082] [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: 06/29/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the results of surgery for congenital craniovertebral junction (CVJ) anomalies with atlantoaxial dislocation (AAD)/basilar invagination (BI) and compare the results of transoral odontoidectomy and posterior fusion (TOO+PF) with only posterior fusion (PF) in patients with irreducible AAD/BI. METHODS AND RESULTS All 94 patients with congenital CVJ anomalies with AAD/BI operated on during the 3-year study period (June 2013-May 2016) were included. Of these patients, 55 had irreducible AAD/BI and the remaining 39 had reducible AAD/BI. TOO+PF was restricted to patients (34/94; 36.2%) with irreducible AAD/BI when reduction and realignment by intraoperative C1-C2 facet joint manipulation were considered technically difficult and risky. The remaining patients with irreducible AAD/BI and all the patients with reducible AAD/BI (60/94; 63.8%) were managed with only posterior fusion. Poor preoperative Nurick grade, preoperative dyspnea/lower cranial nerve deficits, and syringomyelia were associated with significantly higher incidence of postoperative pulmonary complications. Follow-up ≥3 months (final follow-up) was available for 87 patients. Good outcome (Nurick grade 0-3) at final follow-up was noted in 90% (45/50) of the patients with irreducible AAD/BI and 91.9% (34/37) of the patients with reducible AAD/BI. Preoperative poor Nurick grade (4-5) was the only factor associated with poor outcome. No significant difference in perioperative complications, outcome, and fusion was noted between patients who underwent TOO+PF or only PF for irreducible AAD/BI. CONCLUSIONS Many of the patients with congenital AAD/BI showed remarkable recovery after surgery. Preoperative poor Nurick grade (4-5) is associated with poor outcome. TOO+PF is a safe alternative treatment option for irreducible AAD/BI when only PF techniques are technically difficult/risky.
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Affiliation(s)
- Narayanam Anantha Sai Kiran
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Kanneganti Vidyasagar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India.
| | - Laxminadh Sivaraju
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Vivek Raj
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Saritha Aryan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Sumit Thakar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Dilip Mohan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Alangar S Hegde
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
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Govindasamy R, Preethish-Kumar V, Gopal S, Rudrappa S. Is Transoral Surgery Still a Relevant Procedure in Atlantoaxial Instability? Int J Spine Surg 2020; 14:657-664. [PMID: 33077434 PMCID: PMC7671436 DOI: 10.14444/7096] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The treatment of atlantoaxial instability (AAI) involves stable fixation and fusion with adequate decompression of spinal cord. After the advent of the Goel posterior joint manipulation technique, most of the once irreducible atlantoaxial dislocations (AAD) could be reduced and the need for transoral odontoidectomy became almost nil. Here we tried to iterate the indications of anterior transoral odontoid surgery for AAI in the current scenario. METHODS A retrospective study compiling the clinical, radiological, and surgical characteristics of 6 cases (5 scenarios). These patients underwent anterior transoral surgery alone or in combination with a posterior approach. RESULTS Two patients had a well-formed occipito-cervical fusion mass, with a displaced odontoid and unreduced C1-C2 joint causing cervical myelopathy. A middle-aged woman presented with unreduced AAD following failed C1-C2 joint distraction technique. A displaced dystopic os odontoideum ossicle was found in an adolescent boy, prohibiting the reduction of AAD. A young man had displacement of the fractured odontoid segment with intact transverse alar ligament and C1-C2 joint complex. One patient had a rare scenario of abnormal orientation of the C1-C2 joint. All 6 patients were successfully treated with adequate spinal cord decompression achieved by the anterior transoral route and stabilization by either the anterior approach itself or in combination with posterior surgery. All had significantly better postoperative outcomes except for 1 patient who expired due to poor respiratory reserve. CONCLUSION We tried to emphasize the indications for using transoral anterior odontoid surgery over the posterior approach in the management of AAI. This will prevent the surgical technique of anterior odontoidectomy from becoming an obsolete procedure in the current practice.
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Affiliation(s)
- Ramachandran Govindasamy
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
- Department of Spine Surgery, Sakra World Hospital, Bellandur, Bangalore, India
| | | | - Swaroop Gopal
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
| | - Satish Rudrappa
- Institute of Neurosciences, Sakra World Hospital, Bellandur, Bangalore, India
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Miyazawa R, Miyawaki S, Yamada K, Amemiya S, Ikemura M, Hinata M, Uchikawa H, Shiode T, Kin T, Takai K, Nakatomi H, Saito N. Retro-odontoid Pseudotumor: Two Cases of Intradural Ganglion Cysts Arising From the Odontoid Process with Syringobulbia. World Neurosurg 2020; 144:148-153. [PMID: 32827740 DOI: 10.1016/j.wneu.2020.08.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/16/2020] [Accepted: 08/16/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ganglion cysts mostly occur in the knuckles and wrists, but they rarely present in the odontoid process and can cause neurological symptoms by compressing the spinal cord. They are mostly localized in the epidural space, but may very rarely appear in the intradural space. There are no reports of cases of intradural ganglion cyst involving syringobulbia. CASE DESCRIPTION We report the presentation and management of 2 cases of an intradural ganglion cyst of the odontoid process. Several treatment options for ganglion cysts of the odontoid process have been reported, such as rest and use of a neck collar, posterior decompression and fusion, and transoral anterior decompression. Because our 2 cases progressed rapidly and had severe neurological symptoms, surgical treatment was performed for rapid decompression and definitive pathological diagnosis. The mass was resected as much as possible using the lateral occipital fossa approach, and the operation was completed without dissection of the brain stem or manipulation of the syringobulbia. Postoperatively, neurological symptoms promptly improved, and the syringobulbia reduced. CONCLUSIONS For intradural ganglion cysts with syringobulbia, we suggest relief of the compression by resection of the mass and treatment of the syringobulbia in 2 stages, if necessary, to avoid the risk of damage to the brainstem.
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Affiliation(s)
- Ryota Miyazawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Miyawaki
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Keisuke Yamada
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shiori Amemiya
- Department of Radiology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masako Ikemura
- Department of Pathology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Munetoshi Hinata
- Department of Pathology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Uchikawa
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taketo Shiode
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taichi Kin
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Hirofumi Nakatomi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Dong C, Yang F, Wei H, Tan M. Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal? 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 2020; 30:507-516. [PMID: 32654012 DOI: 10.1007/s00586-020-06527-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD). METHODS From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded. RESULTS All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21-60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group. CONCLUSION The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.
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Affiliation(s)
- Chunke Dong
- Beijing University of Chinese Medicine, 11 North Third Ring Road East, Chaoyang District, Beijing, 100029, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Feng Yang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Hongyu Wei
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Mingsheng Tan
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
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Du YQ, Qiao GY, Yin YH, Li T, Yu XG. Posterior atlantoaxial facet joint reduction, fixation and fusion as revision surgery for failed suboccipital decompression in patients with basilar invagination and atlantoaxial dislocation: Operative nuances, challenges and outcomes. Clin Neurol Neurosurg 2020; 194:105793. [PMID: 32283470 DOI: 10.1016/j.clineuro.2020.105793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 01/21/2020] [Accepted: 03/16/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report the technical nuances and clinical outcomes of posterior atlantoaxial facet joint reduction, fixation and fusion (AFRF) technique as a revision procedure for BI and AAD patients with failed suboccipital decompression and large occipital bone defect. PATIENTS AND METHODS We reviewed 32 patients with BI and AAD who were misdiagnosed as a simple Chiari malformation and received a suboccipital decompression surgery before admission. All patients underwent AFRF as a revision surgery. The separating, fusing, opacifying and false-coloring-volume rendering (SFOF-VR) technique was used to identify the course of the VA. Clinical and radiological outcomes were assessed after revision surgeries. RESULTS Clinical symptoms improved in all patients. The postoperative atlantodens interval, Wackenheim line and clivus-canal angle significantly improved (all P < 0.01). Intraoperative dural tear and cerebrospinal fluid leakage occurred in 3 patients and were managed by suture repair and lumbar drain. Abnormal VA was identified in 7 patients and no VA injury occurred with the aid of SFOF-VR technique. The average follow-up was 19.1 months and atlantoaxial bone fusion was confirmed in 31 patients. CONCLUSION For BI and AAD patients with failed suboccipital decompression, revision surgery is challenging. Occipitocervical fixation and posterior midline bone grafting are rather difficult due to the large occipital bone defect. The current study demonstrated that the posterior AFRF is a simple, safe and highly effective technique in revision surgery for such cases. For VA variations, the SFOF-VR technique is an effective tool to delineate the course VA.
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Affiliation(s)
- Yue-Qi Du
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guang-Yu Qiao
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Yi-Heng Yin
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Teng Li
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Xin-Guang Yu
- Department of Neurosurgery, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Di Carlo DT, Voormolen EH, Passeri T, Champagne PO, Penet N, Bernat AL, Froelich S. Hybrid antero-lateral transcondylar approach to the clivus: a laboratory investigation and case illustration. Acta Neurochir (Wien) 2020; 162:1259-1268. [PMID: 32333275 DOI: 10.1007/s00701-020-04343-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/09/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Surgical treatment of lesions involving the ventral craniovertebral junction (CVJ) and the lower clivus, traditionally involved complex lateral or transoral approaches to the skull base. However, mid or upper clivus involvement requires more extensive lateral approaches. Recently, the endoscopic endonasal approach (EEA) has become the standard for upper CVJ lesions and medial clival, and a valuable alternative for those tumors extending in its upper third as well as laterally. However, the EEA is associated with an increased risk of post-operative CSF leakage and infection when the tumor is characterized by an intradural extension. Furthermore, whenever the tumor has significant lateral and/or inferior extension below the odontoid process, the chances for a complete resection decrease. METHOD To analyze the extent of exposure of a hybrid microscopic-endoscopic transcondylar antero-lateral approach to the CVJ and clival region, and to verify its effectiveness in terms of mid and upper clival access. Five silicone-injected cadaver heads were used. Following a standard antero-lateral approach, condylectomy and jugular tubercle drilling were performed, after which angled endoscopes were utilized to extend the bone resection to the clivus. A volumetric assessment of the amount of clival removal was carried out. A case of CVJ chordoma operated through this approach is presented. RESULTS The hybrid antero-lateral transcondylar approach provides adequate exposure of the ventral CVJ, up to the dorsum sellae and the sphenoid sinus, the contralateral petrous apex, and the contralateral paraclival internal carotid artery (ICA). Approximately 60% of the total clival volume can be removed with this approach. The main limitation is the limited visualization of the ipsilateral paraclival ICA and petrous apex. CONCLUSION The hybrid antero-lateral transcondylar approach is a valuable surgical option for CVJ tumor extending from C2 to the mid and upper clivus.
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Affiliation(s)
- Davide Tiziano Di Carlo
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Eduard Hj Voormolen
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Thibault Passeri
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Pierre-Olivier Champagne
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Nicolas Penet
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Anne Laure Bernat
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France
| | - Sébastien Froelich
- Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France.
- Laboratory of experimental neurosurgery, Department of Neurosurgery, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Université de Paris, 2 rue Ambroise Pare, 75010, Paris, France.
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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Wu A, Jin H, Dou H, Pan X, Sheng S, Huang C, Wang X. Anterior decompression through transoral axis slide and rotation osteotomy for salvage of failed posterior occipitocervical fusion: a novel technique note. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:129. [PMID: 32175422 DOI: 10.21037/atm.2020.02.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Atlantoaxial dislocation could be caused by odontoid fractures or Os odontoideum. The previous surgical techniques in treatment of atlantoaxial dislocation were based on arch remove decompression or anterior atlantoaxial release and atlantoaxial (occipital-cervical) screw fixation-based reduction and fusion. However, for some clinical situations, all of above techniques cannot be applied. In this study, a patient with atlantoaxial dislocation caused by Os odontoideum treated by posterior occipitocervical fusion 20 years ago and failed. We design a novel anterior decompression through transoral axis slide and rotation osteotomy for salvage of this failed posterior occipitocervical fusion case. The C2 body and odontoid process was ventrally slide and rotation at good position after operation as well as the position of plate and screws, the spinal canal was increased significantly after operation too. We suggest this anterior decompression through transoral "C2 slide and rotation" technique is good choice for salvage of failed posterior occipitocervical fusion and some irreducible atlantoaxial dislocation because of the anterior bony fusion, it could direct decompress the spinal cord anteriorly, avoid the odontoid resection, and is feasible and safe technique.
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Affiliation(s)
- Aimin Wu
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Haiming Jin
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Haicheng Dou
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Xiangxiang Pan
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Sunren Sheng
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Chongan Huang
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
| | - Xiangyang Wang
- Division of Spine Surgery, Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang Spine Surgery Center, Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou 325027, China
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Husain Q, Kim MH, Hussain I, Anand VK, Greenfield JP, Schwartz TH, Kacker A. Endoscopic endonasal approaches to the craniovertebral junction: The Otolaryngologist's perspective. World J Otorhinolaryngol Head Neck Surg 2020; 6:94-99. [PMID: 32596653 PMCID: PMC7296474 DOI: 10.1016/j.wjorl.2020.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/19/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction (CVJ), analyze postoperative outcomes, and discuss important technical considerations. Methods A retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017. Demographic information, presenting symptoms, imaging results, treatment course, postoperative functional status, and follow-up were recorded. Results There was a total of 30 patients in this series, with a mean follow-up of 11.7 months. The average age was 33.6 years (range, 5–75 years), with 18 females and 12 males. The majority of patients (n = 22, 73.3%) had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery. Intraoperative cerebrospinal fluid leak (CSF) was noted in 3 cases of odontoid resection and a single case of skull base resection. There were no postoperative CSF leaks. Overall, 81% of patients resumed regular diet by post-operative day 2 (range, 0–8 days). Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy. On average, patients were extubated by postoperative day 0.93 (range 0–3 days), with 85% extubated by postoperative day 1. A tracheotomy was required in one patient. Conclusion The endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.
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Affiliation(s)
- Qasim Husain
- Department of Otolaryngology - Head & Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School - Boston, MA, USA
| | - Matthew H Kim
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College - New York, NY, USA
| | - Ibrahim Hussain
- Department of Neuroscience, Weill Cornell Medical College - New York, NY, USA
| | - Vijay K Anand
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College - New York, NY, USA
| | | | - Theodore H Schwartz
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College - New York, NY, USA.,Department of Neuroscience, Weill Cornell Medical College - New York, NY, USA
| | - Ashutosh Kacker
- Department of Otolaryngology - Head & Neck Surgery, Weill Cornell Medical College - New York, NY, USA
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48
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Grose E, Moldovan ID, Kilty S, Agbi C, Lamothe A, Alkherayf F. Clinical Outcomes of Endoscopic Endonasal Odontoidectomy: A Single-Center Experience. World Neurosurg 2020; 137:e406-e415. [PMID: 32035208 DOI: 10.1016/j.wneu.2020.01.219] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Odontoidectomy for basilar invagination and craniovertebral junction pathology traditionally has been performed using a transoral route. However, the endoscopic endonasal approach to the anterior craniovertebral junction may offer safer and more effective access when compared with transoral approaches. The objective of this study is to review the surgical outcomes and complications associated with endoscopic endonasal odontoidectomy. METHODS This study is a retrospective chart review of all adult patients who underwent an endoscopic endonasal odontoidectomy at a single tertiary care center between January 2011 and May 2019. RESULTS Seventeen patients who underwent endoscopic endonasal odontoidectomy were included. The median age at admission was 67 years (range: 33-84 years) and 65% of the patients were female. One patient (1/17, 6%) had vertebral artery injury, which had to be coiled with no neurologic deficits, and 4 patients (4/17, 24%) had intraoperative CSF leaks with no postoperative leak. Fourteen (14/17, 82%) patients were extubated by postoperative day 1. Three patients (3/17, 18%) developed postoperative sinus infections and required antibiotics. Eight patients (8/17, 47%) developed transient postoperative dysphagia. One patient (1/17, 6%) had postoperative epistaxis and 1 patient (1/17, 6%) had postoperative lower cranial nerve symptoms. The median length of hospital stay was 13 days (range: 2-44 days). CONCLUSIONS Although the transoral approach has been the traditional route for anterior decompression of the craniovertebral junction, endoscopic endonasal odontoidectomy is a feasible and well-tolerated procedure associated with satisfactory patient outcomes and low morbidity.
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Affiliation(s)
| | - Ioana D Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Shaun Kilty
- University of Ottawa, Ottawa, Ontario, Canada; Department of Otolaryngology-Head & Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Charles Agbi
- University of Ottawa, Ottawa, Ontario, Canada; Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andre Lamothe
- Department of Otolaryngology-Head & Neck Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Fahad Alkherayf
- University of Ottawa, Ottawa, Ontario, Canada; Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Fahad Alkherayf Medical Professional Corporation, Ottawa, Ontario, Canada
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Tong HY, Qiao GY, Zhao B, Yin YH, Li T, Yu XG, Zong R. Can Posterior Reduction Replace Odontoidectomy as Treatment for Patients With Congenital Posterior Atlantoaxial Dislocation and Basilar Invagination? Oper Neurosurg (Hagerstown) 2019; 18:660-667. [DOI: 10.1093/ons/opz287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 07/19/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
For patients with odontoid process protrusion and basilar invagination, posterior screw–rod fixation can usually achieve satisfactory horizontal reduction, but in some cases satisfactory reduction in the vertical direction cannot be achieved at the same time.
OBJECTIVE
To propose a method for calculation of the theoretical maximum vertical reduction possible in individual patients.
METHODS
The computed tomography imaging data of patients with occipitalization and basilar invagination who were treated at our institute between January 2013 and June 2016 were retrospectively analyzed. The direction of odontoid reduction was decided by the inclination of the lateral joint. The atlanto-dental distance was assumed to be the maximum possible reduction in the horizontal direction. The maximum vertical reduction possible was calculated based on these values.
RESULTS
A total of 82 patients (34 males and 48 females) were included. The theoretical vertical reduction value was 4.2 ± 3.0 mm, which was significantly smaller than that of the dental protrusion (14.5 ± 3.8 mm, P = .000). Analysis of follow-up data (29 cases) showed that, the difference between the theoretical vertical reduction value H (4.7 ± 3.5 mm) and the actual vertical reduction value Ha (5.6 ± 3.5 mm) was not significant (P = .139).
CONCLUSION
The theoretical calculation method we proposed can well predict the actual degree of vertical reduction. The theoretical vertical reduction value is significantly lower than the odontoid protrusion value, indicating that satisfactory reduction in the vertical direction is difficult with a posterior approach alone.
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Affiliation(s)
- Huai-yu Tong
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Guang-yu Qiao
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Bo Zhao
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Yi-heng Yin
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Teng Li
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Xin-guang Yu
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
| | - Rui Zong
- Department of Neurosurgery, General Hospital of People's Liberation Army, Haidian District, Beijing, China
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Joaquim AF, Osorio JA, Riew KD. Transoral and Endoscopic Endonasal Odontoidectomies – Surgical Techniques, Indications, and Complications. Neurospine 2019; 16:462-469. [PMID: 30943709 PMCID: PMC6790742 DOI: 10.14245/ns.1938248.124] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/16/2019] [Indexed: 12/02/2022] Open
Abstract
Odontoidectomy is indicated for some cases of ventral compression in the upper cervical spine. In this paper, we discuss the indications, surgical steps, and nuances of transoral odondoidectomy (TO) and endoscopic endonasal (EE) odontoidectomy. We compare both approaches and discuss the advantages and disadvantages of each. A broad narrative literature review was performed. We also added tips and surgical pearls of the senior author (KDR) in performing odontoidectomies. Surgical techniques were presented. EE is performed in patients where the dens is located above the nasopalatine line. Although technically more demanding, EE has less soft tissue injury and potentially less risk of dysphonia and dysphagia. The TO approach provides a wider exposure and is not limited by the nasopalatine line. Additionally, the TO approach allows the ability for a more extensive resection of C2; these could include the C2 body and the C2–3 disc space. Ventral reconstructions with cages and plates are also feasible via the TO approach. However, there are additional risks of prolonged intubation and tracheostomy with the TO approach. Surgeons who manage upper cervical spine disease should be comfortable performing both approaches, and selecting the best approach should be determined using patient-specific characteristics.
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Affiliation(s)
- Andrei Fernandes Joaquim
- Department of Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP), Campinas-SP, Brazil
| | | | - K Daniel Riew
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
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