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Barrie U, Tao J, Azam F, Kenfack YJ, Lout E, Oduguwa E, Rail B, Naik A, Jenkins A, Smith P, O'Leary S, Ranganathan S, Reimer C, Elguindy M, Caruso JP, Hall K, Al Tamimi M, Aoun SG, Bagley CA. Basilar Impression: A Systematic Review and Meta-Analysis of Clinical Features, Operative Strategies, and Outcomes. World Neurosurg 2024:S1878-8750(24)00746-0. [PMID: 38729521 DOI: 10.1016/j.wneu.2024.04.174] [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: 04/11/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE Basilar impression (BI) is a rare yet debilitating abnormality of the craniovertebral junction, known to cause life-threatening medullary brainstem compression. Our study analyzes surgical approaches for BI and related outcomes. METHODS A systematic review was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to critically assess primary articles examining BI. RESULTS We analyzed 87 patients from 65 articles, mostly female (55.17%) with a mean age of 46.31 ± 17.94 years, commonly presenting with motor (59.77%) and sensory deficits (55.17%). Commonly employed procedures included posterior occipitocervical fusion (24.14%), anterior decompression (20.69%), and combined anterior decompression with posterior fusion (21.84%). Patients who underwent anterior approaches were found to be older (55.38 ± 17.67 vs. 45.49 ± 18.78 years, P < 0.05) and had a longer duration from symptom onset to surgery (57.39 ± 64.33 vs. 26.02 ± 29.60 months, P < 0.05) compared to posterior approaches. Our analysis revealed a significant association between a longer duration from symptom onset to surgery and an increased likelihood of undergoing odontoidectomy and decompression (odds ratio: 1.02, 95% confidence interval: 1.00-1.03, P < 0.05). Furthermore, after adjusting for all other covariates, a history of rheumatoid arthritis and the use of a posterior approach were significantly associated with an elevated risk of postoperative complications (P < 0.05). CONCLUSIONS The treatment approach to complex craniovertebral junction disease should be tailored to the surgeon's experience and the nature of the compressive pathology.
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Affiliation(s)
- Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Jonathan Tao
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Faraaz Azam
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yves J Kenfack
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emerson Lout
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emmanuella Oduguwa
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Benjamin Rail
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anant Naik
- Department of Neurosurgery, Carle Illinois College of Medicine, University of Illinois Urbana-Champaign, Champaign, IL, USA
| | - Abigail Jenkins
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parker Smith
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sean O'Leary
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | | | - Claudia Reimer
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mahmoud Elguindy
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - James P Caruso
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kristen Hall
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mazin Al Tamimi
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos A Bagley
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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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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Cárdenas Ruiz-Valdepeñas E, Kaen A, Perez Prat G. How I do it? Cranial setup for cranial settling. Acta Neurochir (Wien) 2017; 159:1919-1923. [PMID: 28577039 DOI: 10.1007/s00701-017-3231-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/18/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Expanded endonasal endoscopic techniques allow us to treat several pathologies related to the odontoid process and craniocervical junction. Cases such as giant basilar invagination represent a surgical challenge. METHODS The authors provide technical nuances and describe how to complete an endoscopic endonasal odontoidectomy and release the craniocervical junction with the aim of restoring a correct sagittal balance in cases with giant basilar invagination. The study of cadaveric specimens adds clarifying dissections. CONCLUSIONS Endonasal endoscopic odontoidectomy and craniocervical junction joint release allow the treatment of irreducible basilar invagination and restoration of better sagittal balance before posterior cervical occipitocervical fusion.
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Affiliation(s)
| | - A Kaen
- Department of Neurological Surgery, Hospital Virgen Del Rocío, Avenida Manuel siurot s/n 41013, Sevilla, Spain
| | - G Perez Prat
- Department of Neurological Surgery, Hospital Virgen Del Rocío, Avenida Manuel siurot s/n 41013, Sevilla, Spain
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Abstract
Transoral microscopic odontoidectomy followed by posterior fixation has been accepted as a standard procedure to treat nonreducible basilar invagination during the half past century. In recent years, the development of endoscopic techniques has raised challenges regarding the traditional treatment algorithm. The endoscopic transnasal odontoidectomy is a feasible and effective method in the treatment of irreducible ventral cervicomedullary junction compression, which has several advantages over the transoral approach. The endoscopic odontoidectomy includes transnasal, transoral, and transcervical approaches. The 3 different approaches for endoscopic odontoidectomy present complementary advantages and limitations. The necessity of posterior fixation after odontoidectomy should be considered in every single case on the basis of the peculiar anatomic and clinical conditions.
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Chan AK, Benet A, Ohya J, Zhang X, Vogel TD, Flis DW, El-Sayed IH, Mummaneni PV. The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example. Neurosurg Focus 2016; 40:E11. [DOI: 10.3171/2015.11.focus15498] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption.
METHODS
A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video.
RESULTS
The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1–27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6–23.7 mm) and 16.70 mm on the left side (range 8.1–26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2–41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range −4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range −1.5 to 7.3 mm); and palatal line relative to the C-1 arch, −2.75 mm (range −5.8 to 0 mm).
CONCLUSIONS
The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.
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Affiliation(s)
| | - Arnau Benet
- Departments of 1Neurological Surgery and
- 2Otolaryngology, University of California, San Francisco, California
| | | | - Xin Zhang
- Departments of 1Neurological Surgery and
| | | | - Daniel W. Flis
- 2Otolaryngology, University of California, San Francisco, California
| | - Ivan H. El-Sayed
- 2Otolaryngology, University of California, San Francisco, California
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Liu JK, Patel J, Goldstein IM, Eloy JA. Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances. Neurosurg Focus 2015; 38:E17. [PMID: 25828493 DOI: 10.3171/2015.1.focus14813] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The transoral approach is considered the gold-standard surgical route for performing anterior odontoidectomy and ventral decompression of the craniovertebral junction for pathological conditions that result in symptomatic cervicomedullary compression, including basilar invagination, rheumatoid pannus, platybasia with retroflexed odontoid processes, and neoplasms. Extended modifications to increase the operative corridor and exposure include the transmaxillary, extended "open-door" maxillotomy, transpalatal, and transmandibular approaches. With the advent of extended endoscopic endonasal skull base techniques, there has been increased interest in the last decade in the endoscopic endonasal transclival transodontoid approach to the craniovertebral junction. The endonasal route represents an attractive minimally invasive surgical alternative, especially in cases of irreducible basilar invagination in which the pathology is situated well above the palatine line. Angled endoscopes and instrumentation can also be used for lower-lying pathology. By avoiding the oral cavity and subsequently using a transoral retractor, the endonasal route has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia. Postoperative recovery is quicker, and hospital stays are shorter. In this report, the authors describe and illustrate their method of purely endoscopic endonasal transclival odonotoidectomy for anterior decompression of the craniovertebral junction and describe various operative pearls and nuances of the technique for avoiding complications.
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Ridder T, Anderson RCE, Hankinson TC. Ventral Decompression in Chiari Malformation, Basilar Invagination, and Related Disorders. Neurosurg Clin N Am 2015; 26:571-8. [PMID: 26408067 DOI: 10.1016/j.nec.2015.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ventral brainstem compression is an uncommon clinical diagnosis seen by pediatric neurosurgeons and associated with Chiari malformation, type I. Presenting clinical symptoms often include headaches, lower cranial neuropathies, myelopathy, central sleep apnea, ataxia, and nystagmus. When ventral decompression is required, both open and endoscopic transoral/transnasal approaches are highly effective.
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Affiliation(s)
- Thomas Ridder
- Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA.
| | - Richard C E Anderson
- Department of Neurosurgery, Columbia University Medical Center, New York, NY 10032, USA
| | - Todd C Hankinson
- Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045, USA; Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
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Fujii T, Platt A, Zada G. Endoscopic Endonasal Approaches to the Craniovertebral Junction: A Systematic Review of the Literature. J Neurol Surg B Skull Base 2015; 76:480-8. [PMID: 26682128 DOI: 10.1055/s-0035-1554904] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Accepted: 03/11/2015] [Indexed: 02/07/2023] Open
Abstract
Background We reviewed the current literature pertaining to extended endoscopic endonasal approaches to the craniovertebral junction. Methods A systematic literature review was utilized to identify published surgical cases of endoscopic endonasal approaches to the craniovertebral junction. Full-text manuscripts were examined for various measures of surgical indications, patient characteristics, operative technique, and surgical outcomes. Results We identified 71 cases involving endoscopic endonasal approaches for surgical management of a variety of pathologies located within the craniovertebral junction. Patient ages ranged from 3 to 87 years, with 40 females and 31 males. Five patients required tracheostomy, two were reintubated, and all others experienced an average intubation duration of 0.54 days following surgery. Fifty-eight patients (81.7%) underwent an additional posterior decompression or fusion either before or after the endonasal procedure. A complete resection of the pathologic lesion was reported in 57 cases (83.8%), another five were successful biopsies, and four resulted in partial resection. The follow-up time ranged from 0.5 to 57 months. Conclusion Although the transoral approach has been the standard for anterior surgical management for the past several decades, our systematic review illustrates that the extended endoscopic endonasal approach is a safe and effective alternative for most pathologies affecting the craniovertebral junction.
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Affiliation(s)
- Tatsuhiro Fujii
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Andrew Platt
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California, United States
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Ponce-Gómez JA, Ortega-Porcayo LA, Soriano-Barón HE, Sotomayor-González A, Arriada-Mendicoa N, Gómez-Amador JL, Palma-Díaz M, Barges-Coll J. Evolution from microscopic transoral to endoscopic endonasal odontoidectomy. Neurosurg Focus 2015; 37:E15. [PMID: 25270134 DOI: 10.3171/2014.7.focus14301] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to compare the indications, benefits, and complications between the endoscopic endonasal approach (EEA) and the microscopic transoral approach to perform an odontoidectomy. Transoral approaches have been standard for odontoidectomy procedures; however, the potential benefits of the EEA might be demonstrated to be a more innocuous technique. The authors present their experience with 12 consecutive cases that required odontoidectomy and posterior instrumentation. METHODS Twelve consecutive cases of craniovertebral junction instability with or without basilar invagination were diagnosed at the National Institute of Neurology and Neurosurgery in Mexico City, Mexico, between January 2009 and January 2013. The EEA was used for 5 cases in which the odontoid process was above the nasopalatine line, and was compared with 7 cases in which the odontoid process was beneath the nasopalatine line; these were treated using the transoral microscopic approach (TMA). Odontoidectomy was performed after occipital-cervical or cervical posterior augmentation with lateral mass and translaminar screws. One case was previously fused (Oc-C4 fusion). The senior author performed all surgeries. American Spinal Injury Association scores were documented before surgical treatment and after at least 6 months of follow-up. RESULTS Neurological improvement after odontoidectomy was similar for both groups. From the transoral group, 2 patients had postoperative dysphonia, 1 patient presented with dysphagia, and 1 patient had intraoperative CSF leakage. The endoscopic procedure required longer surgical time, less time to extubation and oral feeding, a shorter hospital stay, and no complications in this series. CONCLUSIONS Endoscopic endonasal odontoidectomy is a feasible, safe, and well-tolerated procedure. In this small series there was no difference in the outcome between the EEA and the TMA; however, fewer complications were documented with the endonasal technique.
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Affiliation(s)
- Juan Antonio Ponce-Gómez
- Departments of Neurological Surgery, National Institute of Neurology and Neurosurgery "Manuel Velasco Suarez," Mexico City, Mexico
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Fang CH, Friedman R, Schild SD, Goldstein IM, Baredes S, Liu JK, Eloy JA. Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review. Int Forum Allergy Rhinol 2015; 5:754-60. [PMID: 25946171 DOI: 10.1002/alr.21537] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/18/2015] [Accepted: 03/03/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Endoscopic endonasal surgery (EES) is a relatively novel approach to the craniovertebral junction (CVJ). The purpose of this analysis is to determine the surgical outcomes of patients who undergo purely EES of the CVJ. METHODS A search for articles related to EES of the CVJ was performed using the MEDLINE/PubMed database. A bibliographic search was done for additional articles. Demographics, presenting symptoms, imaging findings, complications, follow-up, and patient outcomes were analyzed. RESULTS Eighty-five patients from 30 articles were included. The mean patient age was 47.9 ± 24.8 years (range, 3 to 96 years), with 44.7% being male. The most common presenting symptom was myelopathy (n = 64, 75.3%). The most common indications for surgery were brainstem compression secondary to basilar invagination (n = 41, 48.2%) and odontoid pannus (n = 20, 23.5%). Odontoidectomy was performed in 97.6% of cases. Intraoperative complications occurred in 16 patients (18.8%) and postoperative complications occurred in 18 patients (21.2%). Six patients developed postoperative respiratory failure necessitating a tracheostomy. Neurologic improvement was seen in 89.4% of patients at a mean follow-up of 22.2 months. CONCLUSION Our analysis found that EES of the CVJ results in a high rate of neurologic improvement with acceptable complication rates. Given its minimally invasive nature and high success rate, this approach appears to be a reasonable alternative to the traditional transoral approach in select cases. This study represents the largest pooled sample size of EES of the CVJ to date. Increasing use of the endoscopic endonasal approach will allow for further studies with greater statistical power.
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Affiliation(s)
- Christina H Fang
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Remy Friedman
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Sam D Schild
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Ira M Goldstein
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - James K Liu
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
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11
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Basilar Invagination: Case Report and Literature Review. World Neurosurg 2015; 83:1180.e7-11. [PMID: 25701769 DOI: 10.1016/j.wneu.2015.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 02/12/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Basilar invagination is a rare clinical condition characterized by upward protrusion of the odontoid process into the intracranial space, leading to bulbomedullary compression. It is often encountered in adults with rheumatoid arthritis. Transoral microscopic or endonasal endoscopic decompression may be pursued, with or without posterior fixation. We present a case of basilar invagination with C1-C2 autofusion and discuss an algorithm for choice of anterior versus posterior approaches. CASE DESCRIPTION A 47-year-old woman with rheumatoid arthritis presented with severe occipital and cervical pain, dysphagia, hoarseness, and arm paresthesias. Findings on magnetic resonance imaging revealed moderate cranial settling with the odontoid indenting the ventral medulla but no posterior compression. Computed tomography demonstrated bony fusion at C1-C2 without lateral sag. Given autofusion of C1-C2 in proper occipitocervical alignment and the absence of posterior compression, the patient underwent endoscopic endonasal odontoidectomy without further posterior fusion, with satisfactory resolution of symptoms. CONCLUSION Endoscopic endonasal odontoidectomy offers a safe and effective method for anterior decompression of basilar invagination. Preoperative assessment for existing posterior fusion, absence of posterior compression, and preservation of the anterior C1 ring during operative decompression help stratify the need for lone anterior approach versus a combined anterior and posterior treatment.
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12
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Burns TC, Mindea SA, Pendharkar AV, Lapustea NB, Irime I, Nayak JV. Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis. J Neurol Surg Rep 2015; 76:e37-42. [PMID: 26251807 PMCID: PMC4520966 DOI: 10.1055/s-0034-1395492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/14/2014] [Indexed: 01/29/2023] Open
Abstract
Ventral epidural abscess with osteomyelitis at the craniocervical junction is a rare occurrence that typically mandates spinal cord decompression via a transoral approach. However, given the potential for morbidity with transoral surgery, especially in the setting of immunosuppression, together with the advent of extended endonasal techniques, the transnasal approach could be attractive for selected patients. We present two cases of ventral epidural abscess and osteomyelitis at the craniocervical junction involving C1/C2 that were successfully treated via the endoscopic transnasal approach. Both were treated in staged procedures involving posterior cervical fusion followed by endoscopic transnasal resection of the ventral C1 arch and odontoid process for decompression of the ventral spinal cord and medulla. Dural repairs were successfully performed using multilayered, onlay techniques where required. Both patients tolerated surgery exceedingly well, had brief postoperative hospital stays, and recovered uneventfully to their neurologic baselines. Postoperative magnetic resonance imaging confirmed complete decompression of the foramen magnum and upper C-spine. These cases illustrate the advantages and low morbidity of the endonasal endoscopic approach to the craniocervical junction in the setting of frank skull base infection and immunosuppression, representing to our knowledge a unique application of this technique to osteomyelitis and epidural abscess at the craniocervical junction.
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Affiliation(s)
- Terry C Burns
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Stefan A Mindea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Nicolae B Lapustea
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Ioana Irime
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, United States
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, United States
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