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Portonero I, Lo Bue E, Penner F, Di Perna G, Baldassarre BM, De Marco R, Pesaresi A, Garbossa D, Pecorari G, Zenga F. Lesson learned in endoscopic endonasal dens resection for C1-C2 spinal cord decompression. 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 2024; 33:438-443. [PMID: 37934268 DOI: 10.1007/s00586-023-08001-y] [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: 11/21/2022] [Revised: 07/01/2023] [Accepted: 10/12/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Endoscopic endonasal approach (EEA) is the safest and most effective technique for odontoidectomy. Nevertheless, this kind of approach is yet not largely widespread. The aim of this study is to share with the scientific community some tips and tricks with our ten-year-old learned experience in endoscopic endonasal odontoidectomy (EEO), which remains a challenging surgical approach. MATERIAL AND METHODS Our case series consists of twenty-one (10 males, 11 females; age range of 34-84 years) retrospectively analyzed patients with ventral spinal cord compression for non-reducible CVJ malformation, treated with EEA from July 2011 to March 2019. RESULTS The results have recently been reported in a previous paper. The only intraoperative complication observed was intraoperative cerebrospinal fluid (CSF) leak (9.5%), without any sign of post-operative CSF leak. CONCLUSIONS Considering our experience, EEO represents a valid and safe technique to decompress neural cervical structures. Despite its technical complexity, mainly due to the use of endoscope and the challenging surgical area, with this study we encourage the use of EEO displaying our experience-based surgical tips and tricks.
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Affiliation(s)
- Irene Portonero
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy.
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy.
| | - Enrico Lo Bue
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Federica Penner
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | | | - Bianca Maria Baldassarre
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
- UOC Neurochirurgia, Ospedale SS Annunziata, Tartanto, Italy
| | - Raffaele De Marco
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Alessandro Pesaresi
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
| | - Giancarlo Pecorari
- ENT Surgery Unit, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Via Cherasco 15, 10126, Turin, Italy
- Skull Base Unit, Department of Neuroscience "Rita Levi Montalcini", "Città Della Salute E Della Scienza" University Hospital, University of Turin, Via Cherasco 15, Turin, Italy
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Tessitore E, Mastantuoni C, Cabrilo I, Schonauer C. Novelties for increased safety in cranio-vertebral surgery: a review. Acta Neurochir (Wien) 2023; 165:3027-3038. [PMID: 37659044 PMCID: PMC10542741 DOI: 10.1007/s00701-023-05769-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 08/05/2023] [Indexed: 09/05/2023]
Abstract
The cranio-vertebral junction (CVJ) was formerly considered a surgical "no man's land" due to its complex anatomical and biomechanical features. Surgical approaches and hardware instrumentation have had to be tailored in order to achieve successful outcomes. Nowadays, thanks to the ongoing development of new technologies and surgical techniques, CVJ surgery has come to be widely performed in many spine centers. Accordingly, there is a drive to explore novel solutions and technological nuances that make CVJ surgery safer, faster, and more precise. Improved outcome in CVJ surgery has been achieved thanks to increased safety allowing for reduction in complication rates. The Authors present the latest technological advancements in CVJ surgery in terms of imaging, biomaterials, navigation, robotics, customized implants, 3D-printed technology, video-assisted approaches and neuromonitoring.
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Affiliation(s)
- Enrico Tessitore
- Department of Neurosurgery, Faculty of Medicine, Geneva University Hospital, Rue Gabrielle Perret Gentil 4, 1205 Geneva, Switzerland
| | - Ciro Mastantuoni
- Department of Neurosurgery, Faculty of Medicine, Geneva University Hospital, Rue Gabrielle Perret Gentil 4, 1205 Geneva, Switzerland
| | - Ivan Cabrilo
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
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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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Marengo N, Di Perna G, Baldassarre BM, Cofano F, De Marco R, Zeppa P, Petrone S, Ajello M, Garbossa D, Zenga F. 3D-printed guides for cervical pedicle screw placement in primary spine tumor: Case report and technical description. Front Surg 2022; 9:1011846. [PMID: 36504577 PMCID: PMC9727165 DOI: 10.3389/fsurg.2022.1011846] [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: 08/04/2022] [Accepted: 10/24/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction For spine surgeons, dealing with unstable cervical spine has been usually challenging, and this becomes more difficult when facing a primary craniovertebral junction tumor. Primary spine tumor surgery should always include column reconstruction in order to guarantee biomechanical stability of the spine, but surgeons should always be aware that instrumentations could create interferences with postoperative radiations. However, although carbon fiber instrumentations have started to be used in thoracolumbar oncology for few years, these options are still not available for cervical spine. In the reported case, the adopted strategy to obtain adequate column reconstruction was based on the idea of reducing the amount of titanium needed for posterior fixation and maximizing the distance between the radiation target and titanium rods. Case report and aim We present the case of a 53-year-old woman harboring a craniovertebral junction chordoma. A short occipito-C3 construct was selected. Specifically, titanium cervical pedicle screws were placed by using a new technology consisting in patient-tailored and customized 3D-printed guides. The aim of this case report is to determine the feasibility and safety of 3D-printed guides for cervical pedicle screw (CPS) positioning, even in the case of cervical spine tumor. Conclusion CPS could represent a good solution by providing strong biomechanical purchase and tailored 3D-printed guides could increase the safety and the accuracy of this challenging screw placement, even in oncological patients.
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Affiliation(s)
- Nicola Marengo
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Giuseppe Di Perna
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Casa di Cura Clinica Città di Bra, Bra, Italy
| | - Bianca Maria Baldassarre
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
| | - Fabio Cofano
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Raffaele De Marco
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy,Correspondence: Raffaele De Marco
| | - Pietro Zeppa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Salvatore Petrone
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy,Spine Surgery Unit, Humanitas Gradenigo Hospital, Turin, Italy
| | - Marco Ajello
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Diego Garbossa
- Department of Neuroscience “Rita Levi Montalcini,” Neurosurgery Unit, University of Turin, Turin, Italy
| | - Francesco Zenga
- Skull Base and Pituitary Surgery Unit, AOU Città Della Salute e Della Scienza, Turin, Italy
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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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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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Shao X, Li J, Yang Q, Li K, Yao Y, Sun F, Li Z. Transnasal Endoscopic and Transoral Approaches in the Biopsies of Ventral Atlas and Axis Vertebrae: A Comprehensive Retrospective Study for Preprocedural Scheme, Biopsy Procedure, Core Technique Analysis, Diagnostic Yield and Clinical Outcome. Orthop Surg 2022; 14:1593-1606. [PMID: 35706342 PMCID: PMC9363750 DOI: 10.1111/os.13366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 05/22/2022] [Accepted: 05/22/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study aims to describe and analyze the transoral and transnasal approaches for pathologies of the ventral atlas and axis vertebrae, which are considered technically challenging regions for diagnostic biopsy. METHODS A series of transnasal endoscopic approach (TNA) and transoral approach (TOA) biopsies for the pathologies of the first and second cervical vertebrae were conducted and retrospectively analyzed from July 2014 to May 2021. The depth of the biopsy trajectory was measured on computed tomography images for all nine patients (eight males and one female with an average age of 58.11 ± 11.60 years), as were the coronal, sagittal, and vertical biopsy safe ranges. The characteristics of each lesion, including radiographic features, blood supply, and destruction of anterior or posterior vertebral body edges, were evaluated to guide the biopsy. Four biopsy core techniques (BCTs), including "lesion perforating", "aspiration", "cutting-and-scraping" and "biopsy forceps utilization" were elaborated in this study. The biopsy procedures and periprocedural precautions were demonstrated. Patient demographics, clinical data, lesion characteristics, diagnostic yield, and complications were recorded for each case. RESULTS Eight TOA biopsies for the axis vertebral body and one TNA biopsy for the atlas anterior arch were successfully performed and yielded adequate pathologies. All biopsies were organized based on the preprocedural radiographic measurements, which showed that the average length of biopsy trajectory and coronal, sagittal, and vertical safe biopsy ranges were 85.00 ± 5.88, 20.63 ± 4.75, 16.25 ± 1.49, and 24.63 ± 2.26 mm, respectively, and these corresponding data were 95, 36, 9, and 26 mm in the TNA patient. Six osteolytic lesions (66.7%), one osteoblastic lesion (11.1%), and two mixed lesions (22.2%) were observed, among which seven lesions had a rich blood supply. Biopsy forceps and core needles were utilized to obtain samples in six and three patients, respectively. All the TNA and TOA biopsies were performed with cooperative application of multiple BCTs under compound anatomic and stereotactic navigations. Intraprocedural or postprocedural complications occurred in no patients who underwent the biopsy in the follow-up period (1-39 months). No significant differences were found between the preprocedural and postprocedural blood indexes and visual analogue scale scores. CONCLUSION With a sophisticated preprocedural arrangement, cooperative application of BCTs, and careful periprocedural precautions, transnasal endoscopic and transoral biopsies are two feasible, efficient, and well-tolerated procedures that achieve satisfactory diagnostic yield, complication rate, and clinical outcome.
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Affiliation(s)
- Xianhao Shao
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jianmin Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiang Yang
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Ka Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan Yao
- Department of Radiography, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Feifei Sun
- Department of Pathology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zhenfeng Li
- Department of Orthopaedics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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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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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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Transclival approaches for intradural pathologies: historical overview and present scenario. Neurosurg Rev 2020; 44:279-287. [PMID: 32060761 DOI: 10.1007/s10143-020-01263-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 12/29/2019] [Accepted: 02/06/2020] [Indexed: 12/17/2022]
Abstract
Recently, endoscopic transsphenoidal transclival approaches have been developed and their role is widely accepted for extradural pathologies. Their application to intradural pathologies is still debated, but is undoubtedly increasing. In the past five decades, different authors have reported various extracranial, anterior transclival approaches for intradural pathologies. The aim of this review is to provide a historical overview of transclival approaches applied to intradural pathologies. PubMed was searched in October 2018 using the terms transcliv*, cliv* intradural, transsphenoidal transcliv*, transoral transcliv*, transcervical transcliv*, transsphenoidal brainstem, and transoral brainstem. Exclusion criteria included not reporting reconstruction technique, anatomical studies, reviews without new data, and transcranial approaches. Ninety-one studies were included in the systematic review. Since 1966, transcervical, transoral, transsphenoidal microsurgical, and, recently, endoscopic routes have been used as a corridor for transclival approaches to treat intradural pathologies. Each approach presents a curve that follows Scott's parabola, with evident phases of enthusiasm that quickly faded, possibly due to high post-operative CSF leak rates and other complications. It is evident that the introduction of the endoscope has led to a significant increase in reports of transclival approaches for intradural pathologies. Various reconstruction techniques and materials have been used, although rates of CSF leak remain relatively high. Transclival approaches for intradural pathologies have a long history. We are now in a new era of interest, but achieving effective dural and skull base reconstruction must still be definitively addressed, possibly with the use of newly available technologies.
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Pacca P, Marengo N, Di Perna G, Penner F, Ajello M, Garbossa D, Zenga F. Endoscopic Endonasal Approach for Urgent Decompression of Craniovertebral Junction in Syringobulbia. World Neurosurg 2019; 130:499-505. [PMID: 31295597 DOI: 10.1016/j.wneu.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Syringobulbia is an uncommon lesion that occurs in the central nervous system; it is often defined as a pathologic cavitation in the brainstem. The cases with partial blockage of the cerebrospinal fluid pathways at the level of the foramen magnum are more common and the most important group. The most common treatment of syringobulbia is craniovertebral decompression. CASE DESCRIPTION This paper reports a case of a symptomatic syringobulbia in which an urgent endoscopic endonasal approach to the craniovertebral junction (CVJ) was done to limit bulbo-medullary compression and rapid neurologic deterioration. A 69-year-old man was admitted to the hospital because of acute onset of dysphonia, dysphagia, imbalance, and vomiting. Magnetic resonance imaging revealed a cystic lesion in the brainstem, suggestive of a syringobulbia in Klippel Feil syndrome with CVJ stenosis. CONCLUSIONS This case report details the successful use of endoscopic endonasal anterior decompression to treat syringobulbia, and adds to the growing literature in support of the endonasal endoscopic approach as a safe and feasible means for decompressing the craniocervical junction, even in the setting of urgency. However, prudent patient selection, combined with sound clinical judgment, access to instrumentation, and intraoperative imaging cannot be overemphasized.
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Affiliation(s)
- Paolo Pacca
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
| | - Nicola Marengo
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
| | - Giuseppe Di Perna
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy.
| | - Federica Penner
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
| | - Marco Ajello
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
| | - Diego Garbossa
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
| | - Francesco Zenga
- Division of Neurosurgery, Department of Neurosciences, University of Torino, Turin, Italy
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Ricciardi L, Sturiale CL, Izzo A, Pucci R, Valentini V, Montano N, Polli FM, Visocchi M, Vivas-Buitrago T, Chaichana KL, Quinones-Hinojosa A, Olivi A, Chen S. Submandibular Approach for Single-Stage Craniovertebral Junction Ventral Decompression and Stabilization: A Preliminary Cadaveric Study of Technical Feasibility. World Neurosurg 2019; 127:206-212. [DOI: 10.1016/j.wneu.2019.04.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
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Chibbaro S, Ganau M, Cebula H, Nannavecchia B, Todeschi J, Romano A, Debry C, Proust F, Olivi A, Gaillard S, Visocchi M. The Endonasal Endoscopic Approach to Pathologies of the Anterior Craniocervical Junction: Analytical Review of Cases Treated at Four European Neurosurgical Centres. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:187-195. [PMID: 30610322 DOI: 10.1007/978-3-319-62515-7_28] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Supported by preliminary anatomical and clinical studies exploring the feasibility and usefulness of approaching many ventral pathologies of the craniocervical junction (CCJ) using the endoscopic endonasal approach, four European centres have joined forces to accumulate and share their growing surgical experience of this advanced technique. By describing the steps that led to the development and continuous refinement of this approach to the CCJ, this article delves deeply into an analysis of the cases operated on since 2010 at these four institutions, and discusses in detail the operative nuances that so far have allowed achievement of successful outcomes with excellent perioperative patient comfort and satisfactory long-term quality of life.
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Affiliation(s)
- Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France.
| | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | | | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Romano
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | | | - Francois Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Alessandro Olivi
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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Visocchi M, Signorelli F, Liao C, Rigante M, Ciappetta P, Barbagallo G, Olivi A. Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Which Route Is Better? ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:181-186. [PMID: 30610321 DOI: 10.1007/978-3-319-62515-7_27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several pathologies that affect the craniovertebral junction (CVJ) can be treated by means of a microsurgical transoral approach (TOA) or, alternatively, with an endoscopic endonasal approach (EEA), which is potentially able to overcome some complications associated with the former approach. In this paper, after discussing updates in the recent literature, to which we add our own surgical experience, we critically analyse these procedures with the aim of demonstrating that the TOA still deserves to be considered a viable alternative and that, in selected cases, it can even be considered superior to the EEA. METHODS Our experience involves 25 anterior procedures in 24 paediatric and adult patients (18 TOA and seven EEA). The TOA group (13 male and five female patients) encompassed three tumours, three rheumatoid arthritis cases, one condylus tertius, three basilar invaginations, four impressio basilaris cases, one developmental anomaly of C0-C1, one os odontoideum, one posttraumatic C1-C2 compression and one C2 fracture. The EEA group (three male and four female patients, median age 39 years, operated on over a 7-year period) comprised four tumours, two impressio basilaris cases and one case of impressio basilaris with platybasia. RESULTS In the TOA group, all but one patient were discharged after posterior procedures within 2 weeks and improved or remained unchanged after surgery and during the follow-up period. No major complications occurred in the TOA group. In the EEA group, two patients who developed a cerebrospinal fluid (CSF) infection died, one from disease progression and the other from myocardial infarction. CONCLUSION Our data, in agreement with those from previous reports on other series, suggest that no clear superiority of the EEA over the endoscopic TOA can be postulated so far; in fact, the EEA can produce complications similar to those observed with the TOA in CVJ surgery.
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Affiliation(s)
| | | | - Chenlong Liao
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mario Rigante
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Pasquale Ciappetta
- Section of Neurological Surgery, University of Bari Medical School, Bari, Italy
| | - Giuseppe Barbagallo
- Department of Neurological Surgery, Policlinico "G. Rodolico" University Hospital, Catania, Italy
- Interdisciplinary Research Center on Brain Tumors Diagnosis and Treatment, University of Catania, Catania, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
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The Endoscopic Endonasal Approach to Craniovertebral Junction Pathologies: Surgical Skills and Anatomical Study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2019; 125:25-36. [PMID: 30610299 DOI: 10.1007/978-3-319-62515-7_5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Surgical anterior decompression is the treatment of choice for symptomatic irreducible ventral craniovertebral junction (CVJ) compression. Along with the classic transoral approach, the endoscopic endonasal approach has evolved and is gaining growing success. MATERIALS AND METHODS In this work we discuss the surgical technique, give a complete step-by-step description of dissection of the craniovertebral junction and report a specific case of endoscopic endonasal odontoidectomy with use of a high-definition (HD) three-dimensional (3D) endoscope. DISCUSSION The extended endonasal approach exploits an anatomical corridor to the odontoid process, involving only a small incision in the nasopharynx and sparing palate integrity. The most important limitation of the technique is 2D visualization, which hinders correct recognition of anatomical structures. CONCLUSION The endoscopic endonasal route to the odontoid process has proven to be a feasible, safe and well-tolerated procedure. Anatomical study is very important for better understanding of the 3D anatomy of the CVJ and relation of critical neurovascular structures to specific bony and muscular landmarks.
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Super Giant Growth Hormone-Secreting Pituitary Adenoma in Young Woman: From Ventricles to Nose. World Neurosurg 2018; 122:544-548. [PMID: 30472284 DOI: 10.1016/j.wneu.2018.11.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Giant pituitary adenomas are rare tumors that can have a devastating impact on a patient's life. They require a well-studied therapeutic approach that often combines different strategies. CASE DESCRIPTION A 29-year-old woman was diagnosed with the largest GH-secreting pituitary adenoma reported in the literature, to the best of the author's knowledge. The tumor was removed with a combined approach: endoscopic endonasal transsphenoidal and transcortical transventricular. All available acromegaly drugs were used. After 2 surgeries, a large part of the tumor was removed. Both postoperative courses were uneventful. Because the disease was still active, medical therapy was initiated. The combination of pasireotide, pegvisomant, and cabergoline permitted satisfactory control of hormonal levels. CONCLUSIONS Giant adenomas, >4 cm, are rare pituitary tumors. Therefore in order to achieve the best clinical results, they require complex management that involves a multidisciplinary team of ear, nose, and throat surgeons; endocrinologists; radiation therapists; ophthalmologists; and neurosurgeons.
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Visocchi M, Signorelli F, Liao C, Rigante M, Paludetti G, Barbagallo G, Olivi A. Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Never Say Never. World Neurosurg 2018; 110:592-603. [PMID: 29433184 DOI: 10.1016/j.wneu.2017.05.125] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE For many years, the microsurgical transoral approach (TOA) has been accepted as the "gold standard" for the surgical treatment of a variety of congenital, developmental, and acquired pathologies affecting the craniovertebral junction. In the present study, we try to investigate both experimental and clinical fronts of such a challenging surgery, starting from the updated literature experience. TOA is actually presented as an "old-fashioned" surgical technique dealing with possible bacterial contamination, the need of postoperative nose gastric tube feeding for a week, the possible nasopharyngeal incompetence, and the postoperative tongue swelling. Otherwise, the endoscopic endonasal approach (EEA) appears strongly supported by the modern literature as the true "minimally invasive" procedure. METHODS Our clinical experience deals with 23 anterior procedures in paediatric and adult patients (17 TOA and 6 EEA). We further report on our experimental cadaver laboratory study of 12 subjects. RESULTS All the patients of TOA group but one were discharged after posterior procedures within two weeks and improved or remained unchanged after surgery and during the follow-up. No mayor complications occurred in TOA group. In EEA group two patients died for cerebrospinal fluid infection, for disease progression and for heart attack. CONCLUSION Our and other available data suggest that no clear superiority of EEA over endoscopic TOA can be assessed so far; on the other hand, EEA can produce complications similar to TOA in craniovertebral junction surgery.
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Affiliation(s)
| | | | - Chenlong Liao
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mario Rigante
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Gaetano Paludetti
- Institute of Otolaryngology, Catholic University of Rome, Rome, Italy
| | - Giuseppe Barbagallo
- Division of Neurosurgery, Department of Neurosciences, Policlinico "G.Rodolico" University Hospital, Catania, Italy
| | - Alessandro Olivi
- Institute of Neurosurgery Catholic University of Rome, Rome, Italy
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Visocchi M, Iacopino DG, Signorelli F, Olivi A, Maugeri R. Walk the Line. The Surgical Highways to the Craniovertebral Junction in Endoscopic Approaches: A Historical Perspective. World Neurosurg 2018; 110:544-557. [PMID: 29433179 DOI: 10.1016/j.wneu.2017.06.125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/17/2017] [Accepted: 06/19/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND We compiled a comprehensive literature review on the anatomic and clinical results of endoscopic approaches to the craniocervical junction (CVJ) to better contribute to identify the best strategy. METHODS An updated literature review was performed in the PubMed, OVID, and Google Scholar medical databases, using the terms "Craniovertebral junction," "Transoral approach," "Transnasal approach," "Transcervical approach," "Endoscopic endonasal approach," "Endoscopic transoral approach," "Endoscopic transcervical approach." Clinical series, anatomic studies, and comparative studies were reviewed. RESULTS Pure endonasal and cervical endoscopic approaches still have some disadvantages, including the learning curve and the deeper surgical field. Endoscopically assisted transoral surgery with 30° endoscopes represents an emerging option to standard microsurgical techniques for transoral approaches to the anterior CVJ. This approach should be considered as complementary rather than an alternative to the traditional microsurgical transoral-transpharyngeal approach. CONCLUSIONS The transoral approach with sparing of the soft palate still remains the gold standard compared with the pure transnasal and transcervical approaches because of the wider working channel provided by the former technique. The transnasal endoscopic approach alone appears to be superior when the CVJ lesion exceeds the upper limit of the inferior third of the clivus.
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Affiliation(s)
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | | | - Alessandro Olivi
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| | - Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy.
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20
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Rossini Z, Milani D, Nicolosi F, Costa F, Lasio GB, D'Angelo VA, Fornari M, Colombo G. Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid: Technical Note and Case Series. World Neurosurg 2017; 110:373-385. [PMID: 29203314 DOI: 10.1016/j.wneu.2017.11.153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure. METHODS On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated. RESULTS Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade (1, 8) was improved versus the average preoperative grade (3). The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P = 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm2. CONCLUSIONS Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma.
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Affiliation(s)
- Zefferino Rossini
- Division of Neurosurgery, Università degli Studi di Milano, Milan, Italy; Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Davide Milani
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy.
| | - Federico Nicolosi
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Francesco Costa
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | | | - Maurizio Fornari
- Division of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | - Giovanni Colombo
- Division of Otorhinolaryngology, Humanitas Clinical and Research Center, Rozzano, Italy
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Zaninovich OA, Martirosyan NL, Ramey WL, Dumont TM. Use of a tubular retractor for transoral odontoidectomy of upper cervical epidural phlegmon extraction and abscess drainage. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2017. [DOI: 10.1016/j.inat.2017.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Endoscopic Endonasal Odontoidectomy with Anterior C1 Arch Preservation in Rheumatoid Arthritis: Long-Term Follow-Up and Further Technical Improvement by Anterior Endoscopic C1-C2 Screw Fixation and Fusion. World Neurosurg 2017; 107:820-829. [DOI: 10.1016/j.wneu.2017.08.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 08/06/2017] [Accepted: 08/10/2017] [Indexed: 12/19/2022]
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Chibbaro S, Cebula H, Aldea S, Baussart B, Tigan L, Todeschi J, Romano A, Ganau M, Debry C, Servadei F, Proust F, Gaillard S. Endonasal Endoscopic Odontoidectomy in Ventral Diseases of the Craniocervical Junction: Results of a Multicenter Experience. World Neurosurg 2017; 106:382-393. [PMID: 28676464 DOI: 10.1016/j.wneu.2017.06.148] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/20/2017] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Over the past decades, supported by preliminary anatomic and clinical studies exploring its feasibility and safety, experience has increased of the use of the endoscopic endonasal approach (EEA) to ventral diseases at the craniocervical junction (CCJ). METHODS A multicenter study was carried out over a 4-year period of 14 patients managed by EEA odontoidectomy for CCJ diseases causing irreducible atlantoaxial dislocation. The surgical setup included an IGS system based on computed tomography and magnetic resonance images fusion, and 0° and 30° angled endoscopes with dedicated endoscopic tools. RESULTS Nine men and 5 women, with a mean age of 60.7 years, were included. The mean follow-up was 28.5 months; 9 patients had basilar impression, whereas 5 had a degenerative pannus. The quality of anterior decompression was excellent in all cases; nonetheless, a posterior stabilization was deemed necessary in 13 patients, and no external orthosis was used during the postoperative course. No tracheostomy or gastrostomy was required after surgery; no deaths, no new neurologic deficits/complications, and no postoperative cerebrospinal fluid leak were recorded. At follow-up, the neurologic status assessed with Frankel grade did not deteriorate in any of the patients but improved in 13 of them; and no new listhesis was shown on neuroradiologic follow-up. CONCLUSIONS The results show that EEA provides a direct surgical corridor to the CCJ, allowing an adequate decompression as with the more invasive transoral route. Morbidity is less than with a transoral approach, resulting in higher patient comfort and faster recovery.
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Affiliation(s)
- Salvatore Chibbaro
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France.
| | - Helene Cebula
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Sorin Aldea
- Department of Neurosurgery, Foch Hospital, Suresnes (Paris), France
| | | | - Leonardo Tigan
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Julien Todeschi
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Romano
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | - Mario Ganau
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
| | - Christian Debry
- Department of ENT, Strasbourg University Hospital, Strasbourg, France
| | - Franco Servadei
- Department of Neurosurgery, Parma University Hospital, Parma, Italy
| | - Francois Proust
- Department of Neurosurgery, Strasbourg University Hospital, Strasbourg, France
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Endoscopic transnasal skull base surgery: pushing the boundaries. J Neurooncol 2016; 130:319-330. [DOI: 10.1007/s11060-016-2274-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/31/2016] [Indexed: 12/22/2022]
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Riley K, Singh H, Meyer SA, Jenkins AL. Minimally Invasive Surgical Approach for Odontoid Lesions: A Technical Description in a Case of High Cervical Osteomyelitis and Abscess. World Neurosurg 2016; 91:332-9. [PMID: 27102634 DOI: 10.1016/j.wneu.2016.04.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cervical approaches to the dens are limited by the presence of several structures, including the spinal cord, vertebral arteries, C1 articular pillars, and C2 nerves. Surgical approaches to access the high anterior cervical spine classically encompass the extended anterior retropharyngeal route, transoral route, and extreme lateral route, each of which has its own pattern of morbidity or complications. Percutaneous procedures to drain infections in this area have a limited yield. Osteomyelitis of the dens is a rare but serious condition that is associated with significant mortality. Patients with cervical osteomyelitis and epidural abscess are likely to have significant coexistent medical comorbidities and are often poor candidates for extensive surgical procedures. A minimally invasive approach that gives access to the entire odontoid process would allow for more aggressive treatments and potentially even a complete odontoidectomy without resection of the C1 anterior arch. CASE DESCRIPTION We describe a minimally invasive approach to drainage and debridement of an atlantoaxial epidural abscess and osteomyelitis. Using minimally invasive techniques from a posterolateral trajectory in a cadaveric specimen, we were able to safely access the anterior epidural space, odontoid, and retropharynx. We then performed this approach in our patient who was unable to tolerate a large surgical procedure. CONCLUSIONS We developed, tested, and then applied a minimally invasive approach that combined tubular retractors with positioning of the head and neck to optimize the exposure in a patient with a complex abscess that involved the ventral epidural space, odontoid process, and retropharyngeal space. The abscesses were successfully drained along with local tissue debridement without complication. A posterolateral minimally invasive approach is a safe alternative in patients with an atlantoaxial epidural abscess, odontoid osteomyelitis, or retropharyngeal abscess with significant medical comorbidities who are unlikely to tolerate a more extensive surgery. It can also be used for resections of lesions of an oncologic nature and could even be used to resect pannus or os odontoideum, without necessitating an anterior approach or resection even of the C1 arch.
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Affiliation(s)
- Kyle Riley
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Harshpal Singh
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; North Jersey Brain & Spine, Oradell, New Jersey, USA
| | - Scott A Meyer
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Atlantic Neurosurgical Specialists, Morristown, New Jersey, USA
| | - Arthur L Jenkins
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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