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Navigation-Guided Measurement of the Inferior Limit Through the Endonasal Route to the Craniovertebral Junction. World Neurosurg 2020; 144:e553-e560. [PMID: 32916362 DOI: 10.1016/j.wneu.2020.08.226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The endoscopic endonasal approach (EEA) has been accepted as an alternative option for diseases at the craniovertebral junction. However, the inferior destination through the endoscopic endonasal approach is anatomically higher than that of the transoral approach. Therefore, preoperative assessment of accessibility is mandatory for appropriate selection of indication. Using a navigation system, we examined the inferior limit through the endonasal route and evaluated the relationships between surrounding anatomicl structures and the lowest point. METHODS This study included patients who underwent endoscopic transsphenoidal surgery for intrasellar lesions at our hospital (N = 23). At the start of surgery, the lowest point (target point [TP]) was marked with a straight probe under guidance of the navigation system. We measured 4 parameters on preoperative computed tomography: nasal length, hard palate length, anterior-posterior diameter of the nasopharynx, and nasopalatine angle. Patients were classified into groups depending on whether the TP was at or above (group A) or below (group B) the hard palatine line. RESULTS TPs were above the hard palatine line in 15 patients (group A) and below the hard palatine line in 8 patients (group B). No TPs reached the nasopalatine line. Nasal length (P = 0.03) and nasopalatine angle (P = 0.01) were larger in group B than in group A. There were no significant differences in anterior-posterior diameter of the nasopharynx or hard palate length. CONCLUSIONS The hard palatine line is a reliable parameter for assessing the inferior limit of the endoscopic endonasal approach. Nostril size affects accessibility with surgical instruments.
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Aldahak N, Richter B, Bemora JS, Keller JT, Froelich S, Abdel Aziz KM. The endoscopic endonasal approach to cranio-cervical junction: the complete panel. Pan Afr Med J 2017; 27:277. [PMID: 29187946 PMCID: PMC5660904 DOI: 10.11604/pamj.2017.27.277.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022] Open
Abstract
We aim to establish a complete summary on the Endoscopic Endonasal Approach (EEA) to Cranio Cervical Junction (CCJ): evolution since first description, criteria to predict the feasibility and limitations, anatomical landmarks, indications and biomechanical evaluation after performing the approach. A comprehensive literature search to identify all available literature published between March 2002 and June 2015, the articles were divided into four categories according to their main purpose: 1- surgical technique, 2- anatomical landmarks and limitations, 3- literature reviews to identify main indications, 4- biomechanical studies. Thereafter, we demonstrate the approach step-by-step, using 1 fresh and 3 silicon injected embalmed cadaveric specimen heads. 61 articles and one poster were identified. The approach was first described on cadaveric study in 2002, and firstly used to perform odontoidectomy in 2005. The main indication is odontoid rheumatoid pannus and basilar invagination. The nasopalatine line (NPL), the superior nostril-hard palate Line (SN-HP), the naso-axial line (NAxL), the rhinopalatine Line (RPL) and other methods were described to predict the anatomical feasibility of the approach. The craniocervical fusion is potentially unnecessary after removal of < 75% of one occipital condyle. A recent cadaveric study stated the possibility of C1-C2 fusion via EEA. This paper reviews all available clinical and anatomical studies on the EEA to CCJ. The approach marked a significant evolution since its first description in 2002. Because of its lesser complications compared to the transoral approach, the EEA became when feasible, the approach of choice to the ventral CCJ.
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Affiliation(s)
- Nouman Aldahak
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA.,Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Bertram Richter
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
| | - Joseph Synèse Bemora
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Jeffery Thomas Keller
- Departments of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, P.O Box 670515 Cincinnati, Ohio 45267-0515, USA
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Khaled Mohamed Abdel Aziz
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
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Chabot JD, Patel CR, Hughes MA, Wang EW, Snyderman CH, Gardner PA, Fernandez-Miranda JC. Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 2017; 128:1463-1472. [PMID: 28731395 DOI: 10.3171/2017.2.jns161582] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The vascularized nasoseptal flap (NSF) has become the workhorse for skull base reconstruction during endoscopic endonasal surgery (EES) of the ventral skull base. Although infrequently reported, as with any vascularized flap the NSF may undergo ischemic necrosis and become a nidus for infection. The University of Pittsburgh Medical Center's experience with NSF was reviewed to determine the incidence of necrotic NSF in patients following EES and describe the clinical presentation, imaging characteristics, and risk factors associated with this complication. METHODS The electronic medical records of 1285 consecutive patients who underwent EES at the University of Pittsburgh Medical Center between January 2010 and December 2014 were retrospectively reviewed. From this first group, a list of all patients in whom NSF was used for reconstruction was generated and further refined to determine if the patient returned to the operating room and the cause of this reexploration. Patients were included in the final analysis if they underwent endoscopic reexploration for suspected CSF leak or meningitis. Those patients who returned to the operating room for staged surgery or hematoma were excluded. Two neurosurgeons and a neuroradiologist, who were blinded to each other's results, assessed the MRI characteristics of the included patients. RESULTS In total, 601 patients underwent NSF reconstruction during the study period, and 49 patients met the criteria for inclusion in the final analysis. On endoscopic exploration, 8 patients had a necrotic, nonviable NSF, while 41 patients had a viable NSF with a CSF leak. The group of patients with a necrotic, nonviable NSF was then compared with the group with viable NSF. All 8 patients with a necrotic NSF had clinical and laboratory evidence indicative of meningitis compared with 9 of 41 patients with a viable NSF (p < 0.001). Four patients with necrotic flaps developed epidural empyema compared with 2 of 41 patients in the viable NSF group (p = 0.02). The lack of NSF enhancement on MR (p < 0.001), prior surgery (p = 0.043), and the use of a fat graft (p = 0.004) were associated with necrotic NSF. CONCLUSIONS The signs of meningitis after EES in the absence of a clear CSF leak with the lack of NSF enhancement on MRI should raise the suspicion of necrotic NSF. These patients should undergo prompt exploration and debridement of nonviable tissue with revision of skull base reconstruction.
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Affiliation(s)
| | - Chirag R Patel
- 2Department of Otolaryngology, Loyola University School of Medicine, Chicago, Illinois
| | | | - Eric W Wang
- 4Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Carl H Snyderman
- 4Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Singh H, Rote S, Jada A, Bander ED, Almodovar-Mercado GJ, Essayed WI, Härtl R, Anand VK, Schwartz TH, Greenfield JP. Endoscopic endonasal odontoid resection with real-time intraoperative image-guided computed tomography: report of 4 cases. J Neurosurg 2017. [PMID: 28621629 DOI: 10.3171/2017.1.jns162601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors present 4 cases in which they used intraoperative CT (iCT) scanning to provide real-time image guidance during endonasal odontoid resection. While intraoperative CT has previously been used as a confirmatory test after resection, to the authors' knowledge this is the first time it has been used to provide real-time image guidance during endonasal odontoid resection. The operating room setup, as well as the advantages and pitfalls of this approach, are discussed. A mobile intraoperative CT scanner was used in conjunction with real-time craniospinal neuronavigation in 4 patients who underwent endoscopic endonasal odontoidectomy for basilar invagination. All patients underwent a successful decompression. In 3 of the 4 patients, real-time intraoperative CT image guidance was instrumental in achieving a comprehensive decompression. In 3 (75%) cases in which the right nostril was the predominant working channel, there was a tendency for asymmetrical decompression toward the right side, meaning that residual bone was seen on the left, which was subsequently removed prior to completion of the surgery. Endoscopic endonasal odontoid resection with real-time intraoperative image-guided CT scanning is feasible and provides accurate intraoperative localization of pathology, thereby increasing the chance of a complete odontoidectomy. For right-handed surgeons operating predominantly through the right nostril, special attention should be paid to the contralateral side of the resection, where there is often a tendency for residual pathology.
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Affiliation(s)
- Harminder Singh
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and.,Departments of2Neurosurgery and
| | | | | | | | | | | | | | - Vijay K Anand
- 3Otolaryngology, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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Essayed WI, Singh H, Lapadula G, Almodovar-Mercado GJ, Anand VK, Schwartz TH. Endoscopic endonasal approach to the ventral brainstem: anatomical feasibility and surgical limitations. J Neurosurg 2017; 127:1139-1146. [PMID: 28084906 DOI: 10.3171/2016.9.jns161503] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sporadic cases of endonasal intraaxial brainstem surgery have been reported in the recent literature. The authors endeavored to assess the feasibility and limitations of endonasal endoscopic surgery for approaching lesions in the ventral portion of the brainstem. METHODS Five human cadaveric heads were used to assess the anatomy and to record various measurements. Extended transsphenoidal and transclival approaches were performed. After exposing the brainstem, white matter dissection was attempted through this endoscopic window, and additional key measurements were taken. RESULTS The rostral exposure of the brainstem was limited by the sella. The lateral limits of the exposure were the intracavernous carotid arteries at the level of the sellar floor, the intrapetrous carotid arteries at the level of the petrous apex, and the inferior petrosal sinuses toward the basion. Caudal extension necessitated partial resection of the anterior C-1 arch and the odontoid process. The midline pons and medulla were exposed in all specimens. Trigeminal nerves were barely visible without the use of angled endoscopes. Access to the peritrigeminal safe zone for gaining entry into the brainstem is medially limited by the pyramidal tract, with a mean lateral pyramidal distance (LPD) of 4.8 ± 0.8 mm. The mean interpyramidal distance was 3.6 ± 0.5 mm, and it progressively decreased toward the pontomedullary junction. The corticospinal tracts (CSTs) coursed from deep to superficial in a craniocaudal direction. The small caliber of the medulla with very superficial CSTs left no room for a safe ventral dissection. The mean pontobasilar midline index averaged at 0.44 ± 0.1. CONCLUSIONS Endoscopic endonasal approaches are best suited for pontine intraaxial tumors when they are close to the midline and strictly anterior to the CST, or for exophytic lesions. Approaching the medulla is anatomically feasible, but the superficiality of the eloquent tracts and interposed nerves limit the safe entry zones. Pituitary transposition after sellar opening is necessary to access the mesencephalon.
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Affiliation(s)
- Walid I Essayed
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Harminder Singh
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Gennaro Lapadula
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York.,Departments of Neurology and Psychiatry, and Neurosurgery, "Sapienza," University of Rome, Rome, Italy
| | - Gustavo J Almodovar-Mercado
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Vijay K Anand
- Department of Otolaryngology, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - Theodore H Schwartz
- Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
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