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Visocchi M, Benato A, Davila MF, Bayati AA, Zeoli F, Signorelli F. A Three-Step Submandibular Retropharyngeal Approach to the Craniovertebral Junction: Is Less Always More? J Clin Med 2024; 13:3755. [PMID: 38999320 PMCID: PMC11242438 DOI: 10.3390/jcm13133755] [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: 05/28/2024] [Revised: 06/19/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Accessing the craniovertebral junction poses unique challenges due to its anatomical complexity and proximity to critical structures, such as the cord-brainstem junction, great vessels of the neck, cranial nerves, oropharynx, and rhinopharynx. Among the approaches that have been developed over the years, the submandibular retropharyngeal approach offers good antero-lateral access without the need of transgressing mucosal layers. In its traditional form, however, this approach involves multiple sequential steps and requires intricate dissection, extensive retraction, and meticulous maneuvering, which can increase operative time and produce approach-related morbidity. Methods: With this paper, we propose a simplified technique for a submandibular retropharyngeal approach involving only three surgical steps. The advantages and limitations of this technique are illustrated through three surgical cases of neoplastic and degenerative craniovertebral junction pathologies. Results: In two out of the three cases, our technique allowed for a wide exposure of the lesions that could be resected totally or sub-totally with good outcome. In one case with involvement of the clivus and the occipital condyle, the exposure was inadequate; a biopsy was obtained, and the lesion was subsequently resected via and endoscopic transmucosal approach. Conclusions: Our technique represents a significant simplification of the traditional submandibular retropharyngeal approach; with appropriate indication, it permits a fast, safe, and adequate exposure of craniovertebral junction pathologies.
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Affiliation(s)
- Massimiliano Visocchi
- Operative Unit and Academic Research Center on Surgical Approaches to the Craniovertebral Junction, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Alberto Benato
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Mario Flavio Davila
- Guatemalan Institute of Social Security, 01003 Ciudad de Guatemala, Guatemala
| | | | - Fabio Zeoli
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
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Visocchi M, Signorelli F. Combined Transoral Exoscope and OARM-Assisted Approach for Craniovertebral Junction Surgery. New Trends in an Old-Fashioned Approach. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:243-246. [PMID: 38153476 DOI: 10.1007/978-3-031-36084-8_37] [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: 12/29/2023]
Abstract
BACKGROUND The introduction of recent innovations in the field of intraoperative imaging and neuronavigation, such as the O-arm StealthStation, allows for obtaining crucial intraoperative data by performing safer and controlled surgical procedures. As part of the improvement of surgical visual magnification and wide expansion of surgical corridors, the 3D 4 K exoscope (EX) has nowadays become an interesting and useful tool. The transoral approach (TOA) is the historical gold-standard direct microsurgical route to ventral craniovertebral junction (CVJ). METHODS We herein report our experience, consisting of ten cases via TOA concerning the simultaneous application of an O-arm with a StealthStation navigation system (Medtronic, Memphis, TN) and an imaging system, along with the 3D 4 K exoscopes in the TOA, for the treatment of CVJ pathologies. RESULTS No intraoperative neurophysiological changes or postoperative infections occurred, but neurological improvement was evident in all the patients. A complete decompression and a stable instrumentation and fusion of the CVJ were accomplished in all cases at the maximum follow-up time. CONCLUSIONS With EX, the role of the surgeon becomes self-sufficient with better individual surgical freedom compared to endoscopic surgery and excellent 3D vision and magnification. O-arms offer absolutely reliable intraoperative support for more-effective CVJ decompression. Nevertheless, with O-arm-assisted neuronavigation, it can be difficult to navigate C1 lateral masses and C2 isthmi, and converting 3D into 2D real-time navigation can be quite complicated. Finally, the combination of an EX with an O-arm appears more time-consuming compared to the old-fashion one.
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Affiliation(s)
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy.
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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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Visocchi M, Mattogno PP, Signorelli F. Exoscope and OArm: what we can learn in craniovertebral junction surgery. J Neurosurg Sci 2020; 65:616-617. [PMID: 33320469 DOI: 10.23736/s0390-5616.20.05221-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Pier Paolo Mattogno
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy -
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Visocchi M, Mattogno PP, Ciappetta P, Barbagallo G, Signorelli F. Combined transoral exoscope and OArm-assisted approach for craniovertebral junction surgery: Light and shadows in single-center experience with improving technologies. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 11:293-299. [PMID: 33824559 PMCID: PMC8019117 DOI: 10.4103/jcvjs.jcvjs_176_20] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/04/2022] Open
Abstract
Background The introduction of recent innovations in the field of intraoperative imaging and neuronavigation, such as OArm Stealth Station, allows to obtain crucial intraoperative data by performing safer and controlled surgical procedures. As part of the improvement of surgical visual magnification and wide expansion of surgical corridors, the 3D-4K exoscope (EX) represents nowadays an interesting and useful tool. Transoral approach (TOA) represents the historical gold standard direct microsurgical route to ventral craniovertebral junction (CVJ). Methods We herein report a preliminary experience on 6 cases of 33 patients operated by TOA concerning the simultaneous application of OArm with Stealth Navigation system (Medtronic, Memphis, TN) and imaging system along with the 3D-4K EXs in TOA for the treatment of CVJ pathologies. Results Neither intraoperative neurophysiological changes nor postoperative infections occurred, but a neurological improvement was evident in all the patients. A complete decompression along with stable instrumentation and fusion of the CVJ was accomplished in all cases at the maximum follow-up (mean: 16.8 months). Conclusions With EX, the role of surgeon become self-sufficient with a better individual surgical freedom compared to endoscopic surgery and excellent 3D vision and magnification. OArm allows an absolutely reliable intraoperative support for a more effective CVJ decompression. Nevertheless, with OArm-assisted neuronavigation, it can be difficult to navigate C1 lateral masses and C2 isthmi, and to convert 3D into 2D real-time navigation, it can become quite complicate. Finally, the association of EX and OArm appears more time consuming compared to the old fashion one.
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Affiliation(s)
- Massimiliano Visocchi
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Pier Paolo Mattogno
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | | | - Giuseppe Barbagallo
- Departement of Neurological Surgery, Policlinico Gaspare Rodolico University Hospital, Catania, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Operative Unit, Research Center and Master II Degree Surgical Approaches Craniovertebral Junction, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
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Visocchi M. Considerations on "Endoscopic endonasal approach to the craniocervical junction: the importance of anterior C1 arch preservation or its reconstruction". ACTA OTORHINOLARYNGOLOGICA ITALICA 2017; 36:228-30. [PMID: 27214835 PMCID: PMC4977011 DOI: 10.14639/0392-100x-927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/15/2015] [Indexed: 12/04/2022]
Affiliation(s)
- M Visocchi
- Institute of Neurosurgery, Catholic University of Rome, Italy
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Aldahak N, Richter B, Bemora JS, Keller JT, Froelich S, Abdel Aziz KM. The endoscopic endonasal approach to cranio-cervical junction: the complete panel. Pan Afr Med J 2017; 27:277. [PMID: 29187946 PMCID: PMC5660904 DOI: 10.11604/pamj.2017.27.277.12220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022] Open
Abstract
We aim to establish a complete summary on the Endoscopic Endonasal Approach (EEA) to Cranio Cervical Junction (CCJ): evolution since first description, criteria to predict the feasibility and limitations, anatomical landmarks, indications and biomechanical evaluation after performing the approach. A comprehensive literature search to identify all available literature published between March 2002 and June 2015, the articles were divided into four categories according to their main purpose: 1- surgical technique, 2- anatomical landmarks and limitations, 3- literature reviews to identify main indications, 4- biomechanical studies. Thereafter, we demonstrate the approach step-by-step, using 1 fresh and 3 silicon injected embalmed cadaveric specimen heads. 61 articles and one poster were identified. The approach was first described on cadaveric study in 2002, and firstly used to perform odontoidectomy in 2005. The main indication is odontoid rheumatoid pannus and basilar invagination. The nasopalatine line (NPL), the superior nostril-hard palate Line (SN-HP), the naso-axial line (NAxL), the rhinopalatine Line (RPL) and other methods were described to predict the anatomical feasibility of the approach. The craniocervical fusion is potentially unnecessary after removal of < 75% of one occipital condyle. A recent cadaveric study stated the possibility of C1-C2 fusion via EEA. This paper reviews all available clinical and anatomical studies on the EEA to CCJ. The approach marked a significant evolution since its first description in 2002. Because of its lesser complications compared to the transoral approach, the EEA became when feasible, the approach of choice to the ventral CCJ.
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Affiliation(s)
- Nouman Aldahak
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA.,Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Bertram Richter
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
| | - Joseph Synèse Bemora
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Jeffery Thomas Keller
- Departments of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, P.O Box 670515 Cincinnati, Ohio 45267-0515, USA
| | - Sebastien Froelich
- Department of Neurosurgery, Lariboisière Hospital, Assistance Publique, Hôpitaux de Paris, University of Paris VII-Diderot 2, Rue Ambroise Paré 75475 Paris Cedex 10, Paris, France
| | - Khaled Mohamed Abdel Aziz
- Department of Neurosurgery, Allegheny General Hospital, Drexel University College of Medicine, 420 East North Avenue, Suite 302, Pittsburgh, PA, 15212, USA
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Mourad F, Giovannico G, Maselli F, Bonetti F, Fernández de las Peñas C, Dunning J. Basilar impression presenting as intermittent mechanical neck pain: a rare case report. BMC Musculoskelet Disord 2016; 17:7. [PMID: 26754441 PMCID: PMC4707768 DOI: 10.1186/s12891-015-0847-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 12/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Neck pain is one of the most common musculoskeletal disorders in clinical practice. However neck pain may mask more serious pathology. Although uncommon in most musculoskeletal physiotherapy practices, it is possible to encounter rare and extremely life-threatening conditions, such as craniovertebral congenital anomalies. Basilar invagination is an abnormality where the odontoid peg projects above the foramen magnum and is the commonest malformation of the craniocervical junction. Its prevalence in the general population is estimated to be 1 %. Furthermore, it is a well-recognised cause of neck pain insomuch as it can be easily overlooked and mistaken for a musculoskeletal disorder. Diagnosis is based on the patient’s symptoms in conjunction with magnetic resonance imaging (MRI). If life-threatening symptoms, or pressure on the spinal cord are present, the recommended treatment is typically surgical correction. Case presentation This case report describes the history, relevant examination findings, and clinical reasoning used for a 37 year old male who had the chief complaint of neck pain and occipital headache. After the history and the physical examination, there were several key indicators in the patient’s presentation that appeared to warrant further investigation with diagnostic imaging: (1) the drop attack after a triggering event (i.e., heading a football), (2) several episodes of facial numbness immediately and shortly after the trauma, (3) the poorly defined muscle upper extremity muscle weakness, and (4) the modification of symptoms during the modified Sharp-Purser test. Therefore, the decision was made to contact the referring neurosurgeon to discuss the patient’s history and his physical examination. The physician requested immediate cervical spine MRI, which revealed a “basilar impression”. Conclusion This case report highlights the need for more research into a number of issues surrounding the prevalence, diagnosis, and the central role of primary care clinicians such as physiotherapists. Furthermore it underlines the importance of including Basilar invagination in the differential diagnosis. Physiotherapists working within a direct access environment must take a comprehensive history and be capable of screening for non-musculoskeletal medical conditions (on a systems, not diagnosis level) in order to avoid providing potentially harmful musculoskeletal treatments (e.g., cervical mobilization or manipulation, stretching, exercise) to patients with sinister medical pathologies, not benign musculoskeletal disorders.
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Affiliation(s)
- Firas Mourad
- Alumno de Doctorado, Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Alcorcon, Madrid, Spain.
| | | | - Filippo Maselli
- DINOGMI, Genova University, Genova, Italy. .,SSR Puglia INAIL, Bari, Italy.
| | | | | | - James Dunning
- Alabama Physical Therapy & Acupuncture, Montgomery, AL, USA. .,Nova Southeastern University, Ft. Lauderdale, FL, USA.
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