Endoscopic biopsy sampling of tophaceous gout of the odontoid process

Endoscopic endonasal resection of craniovertebral junction osteomyelitis: illustrative cases

BACKGROUND

Operative management of craniovertebral junction (CVJ) osteomyelitis has traditionally been extracranial and focused on debriding the infection. In select patients, the endoscopic endonasal approach (EEA) with a focus on additional resection versus debridement may be preferred. The goal of this study is to present the authors' experience with the EEA with gross or subtotal resection for the treatment of osteomyelitis at the CVJ and describe their technique in the context of the literature.

OBSERVATIONS

Two patients of the authors' and 6 detailed case reports in the literature were identified with a mean age of 58.9 years. Most patients (n = 5; 62.5%) underwent skull base surgery and debridement (n = 5; 62.5%). Although more common, debridement was inferior to resection in terms of neurological improvement (66.7% vs. 100.0%) postoperatively. The majority (n = 7; 87.5%) of patients underwent occipitocervical fusion.

LESSONS

Osteomyelitis is an exceedingly rare lesion of the CVJ. Despite the region's delicate biomechanical stability, resection of infected bone may be superior to debridement alone in terms of clinical outcome. Given how well established the safety of the EEA is to this region, further study of outcomes with resection is warranted.

Endoscopic endonasal approaches to the craniovertebral junction: The Otolaryngologist's perspective

Objective

To review indications and techniques for the endoscopic endonasal approach to the craniovertebral junction (CVJ), analyze postoperative outcomes, and discuss important technical considerations.

Methods

A retrospective analysis was performed on all patients undergoing endonasal endoscopic approaches to the CVJ from May 2007 to June 2017. Demographic information, presenting symptoms, imaging results, treatment course, postoperative functional status, and follow-up were recorded.

Results

There was a total of 30 patients in this series, with a mean follow-up of 11.7 months. The average age was 33.6 years (range, 5–75 years), with 18 females and 12 males. The majority of patients (n = 22, 73.3%) had Chiari malformation type 1 with basilar invagination and symptomatic cervicomedullary compression as the indication for surgery. Intraoperative cerebrospinal fluid leak (CSF) was noted in 3 cases of odontoid resection and a single case of skull base resection. There were no postoperative CSF leaks. Overall, 81% of patients resumed regular diet by post-operative day 2 (range, 0–8 days). Severe postoperative dysphagia occurred in two cases with one requiring gastrostomy tube placement and another utilizing total parenteral nutrition for support prior to eventual gastrostomy. On average, patients were extubated by postoperative day 0.93 (range 0–3 days), with 85% extubated by postoperative day 1. A tracheotomy was required in one patient.

Conclusion

The endonasal endoscopic approach is a valuable technique for access to the CVJ with minimal disruption of respiratory and alimentary function.

Odontoid cervical gout causing atlantoaxial instability: case report

The authors present a case report of a patient discovered to have a rotatory subluxation of the C1-2 joint and a large retroodontoid pannus with an enhancing lesion in the odontoid process eventually proving to be caused by gout. This patient represented a diagnostic conundrum as she had known prior diagnoses of not only gout but also sarcoidosis and possible rheumatoid arthritis, and was in the demographic range where concern for an oncological process cannot fully be ruled out. Because she presented with signs and symptoms of atlantoaxial instability, she required posterior stabilization to reduce the rotatory subluxation and to stabilize the C1-2 instability. However, despite the presence of a large retroodontoid pannus, she had no evidence of spinal cord compression on physical examination or imaging and did not require an anterior procedure to decompress the pannus. To confirm the diagnosis but avoid additional procedures and morbidity, the authors proceeded with the fusion as well as a posterior biopsy to the retroodontoid pannus and confirmed a diagnosis of gout.

Obstructive hydrocephalus secondary to odontoid pannus: case report and review of literature

Odontoid pannus or periodontoid pseudotumour is associated with a variety of rheumatological conditions. We report a case of an 80-year old man who presented with acute hydrocephalus following an emergency operation to amputate his infected left big toe. Imaging revealed a large tissue mass causing severe compression at the cervico-medullary junction and obstruction of CSF flow. The acute hydrocephalus was presumed to be related to neck manoeuvring during general anaesthesia. Following an initial emergency CSF diversion through external ventricular drainage catheter insertion, the patient subsequently underwent ventriculo-peritoneal insertion and posterior spinal decompression and fixation. To our knowledge, there have been no reported cases of tophaceous gout of the odontoid pannus causing acute hydrocephalus.

Lumbar spinal stenosis attributable to tophaceous gout: case report and review of the literature

Objectives

Tophaceous gout seldom affects the axial skeleton. Symptoms vary according to the differential localization of urate deposits and the diagnosis is often delayed. Here, we report an unusual case of lumbar spinal stenosis caused by extradural tophaceous deposits.

Methods

We retrospectively reviewed a case of a patient with tophaceous gout of the lumbar spine and reviewed the relevant literature.

Results

A 62-year-old man with a 2-year history of lower back pain and a 3-month history of lower limb radiation pain and intermittent claudication was admitted. After laboratory and imaging investigations he underwent surgical decompression and stabilization. Histological analysis of the extracted specimen confirmed that it was gouty tophus. The patient’s symptoms improved progressively after the operation. He recovered very well with no complications.

Conclusion

The mechanism associated with axial gout is not yet clear. Obesity, inactivity, and previous degenerative disc disease may be the risk factors for spinal tophus. The clinical symptoms are diverse according to the differential localization of urate deposits. It is not easy to diagnose this disease radiographically by routine radiological examination. Analysis of a biopsy specimen is definitely the only way to confirm diagnosis. Surgical treatment should be considered in patients with spinal gout who are experiencing neurological deterioration.

Gout in the Spine: Imaging, Diagnosis, and Outcomes

Gout is characterized by the deposition of monosodium urate crystals and by acute and chronic inflammation in response to crystals so deposited. Multiple case reports and series describe the deposition of monosodium urate in the spine as a rare manifestation of gout, but the actual prevalence of spinal involvement is unknown and likely to be higher than generally anticipated. Here we review the characteristics of 131 previously reported cases of spinal involvement in gout. We focus in particular on the use of imaging modalities and the extent to which they correlate with presenting symptoms and tissue diagnoses. The recent innovation of using dual-energy computerized tomography to identify urate crystal deposition holds promise for reducing the need for surgical intervention and for establishing a true prevalence rate for spinal gout.

The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example

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.

The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies

OBJECT

The endoscopic endonasal approach (EEA) provides a minimally invasive corridor through which the cervicomedullary junction can be decompressed with reduced morbidity rates compared to those with the classic transoral approaches. The limit of the EEA is its inferior extent, and preoperative estimation of its reach is vital for determining its suitability. The aim of this study was to evaluate the actual inferior limit of the EEA in a surgical series of patients and develop an accurate and reliable predictor that can be used in planning endonasal odontoidectomies.

METHODS

The actual inferior extent of surgery was determined in a series of 6 patients with adequate preoperative and postoperative imaging who underwent endoscopie endonasal odontoidectomy. The medians of the differences between several previously described predictive lines, namely the nasopalatine line (NPL) and nasoaxial line (NAxL), were compared with the actual surgical limit and the hard-palate line by using nonparametric statistics. A novel line, called the rhinopalatine line (RPL), was established and corresponded best with the actual limit of the surgery.

RESULTS

There were 4 adult and 2 pediatric patients included in this study. The NPL overestimated the inferior extent of the surgery by an average (± SD) of 21.9 ± 8.1 mm (range 14.7-32.5 mm). The NAxL and RPL overestimated the inferior limit of surgery by averages of 6.9 ± 3.8 mm (range 3.7-13.3 mm) and 1.7 ± 3.7 mm (range -2.8 to 8.3 mm), respectively. The medians of the differences between the NPL and NAxL and the actual surgery were statistically different (both p = 0.0313). In contrast, there was no statistically significant difference between the RPL and the inferior limit of surgery (p = 0.4375).

CONCLUSIONS

The RPL predicted the inferior limit of the EEA to the craniovertebral junction more accurately than previously described lines. The use of the RPL may help surgeons in choosing suitable candidates for the EEA and in selecting those for whom surgery through the oropharynx or the facial bones is the better approach.

Endoscope-assisted endonasal versus supraorbital keyhole resection of olfactory groove meningiomas: comparison and combination of 2 minimally invasive approaches

OBJECTIVE

Although the endonasal endoscopic approach has been applied to remove olfactory groove meningiomas, controversy exists regarding the efficacy and safety of this approach compared with more traditional transcranial approaches. The endonasal endoscopic approach was compared with the supraorbital (eyebrow) keyhole technique, as well as a combined "above-and-below" approach, to evaluate the relative merits of each approach in different situations.

METHODS

Nineteen cases were reviewed and divided according to operative technique into 3 different groups: purely endonasal (6 cases); supraorbital eyebrow (microscopic with endoscopic assistance; 7 cases); and combined endonasal endoscopic with either the bicoronal or eyebrow microscopic approach (6 cases). Resection was judged on postoperative MRI using volumetric analysis. Tumors were assessed based on the Mohr radiological classification and the presence of the lion's mane sign.

RESULTS

The mean age at surgery was 61.4 years. The mean tumor volume was 19.6 cm(3) in the endonasal group, 33.5 cm(3) in the supraorbital group, and 37.8 cm(3) in the combined group. Significant frontal lobe edema was identified in 10 cases (52.6%). The majority of tumors were either Mohr Grade II (moderate) (42.1%) or Grade III (large) (47.4%). Gross-total resection was achieved in 50% of the endonasal cases, 100% of the supraorbital eyebrow cases with endoscopic assistance, and 66.7% of the combined cases. The extent of resection was 87.8% for the endonasal cases, 100% for the supraorbital eyebrow cases, and 98.9% for the combined cases. Postoperative anosmia occurred in 100% of the endonasal and combined cases and only 57.1% of the supraorbital eyebrow cases. Excluding anosmia, permanent complications occurred in 83.3% of the cases in the endoscopic group, 0% of the cases in the supraorbital eyebrow group, and 16.7% of cases in the combined group (p = 0.017). There were 3 tumor recurrences: 2 in the endonasal group and 1 in the combined group.

CONCLUSIONS

The supraorbital eyebrow approach, with endoscopic assistance, leads to a higher extent of resection and lower rate of complications than the purely endonasal endoscopic approach. The endonasal endoscopic approach by itself may be suitable for a small percentage of cases. The combined above-and-below approaches are useful for large tumors with invasion of the ethmoid sinuses.

Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis

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.

The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding

OBJECT

The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid.

METHODS

The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments.

RESULTS

There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency.

CONCLUSIONS

This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.

When gout involves the spine: five patients including two inaugural cases

Spinal involvement is uncommon during gout and may raise diagnostic challenges. We describe five cases seen at a single center.

METHODS

We retrospectively reviewed the medical charts of the five patients with spinal gout seen over a 3-year period.

RESULTS

There were four men and one woman with an age range of 52 to 87 years. One patient presented with acute neck pain and visualization by imaging studies of a discovertebral tophus, another had febrile arthritis of a lumbar facet joint, and a third presented with a synovial cyst in a lumbar facet joint. The remaining two patients had acute febrile discitis confirmed by magnetic resonance imaging, at the cervical spine and lumbar spine, respectively. Laboratory tests showed systemic inflammation in four patients and marked serum uric acid elevation in two patients. Only three patients reported a previous history of peripheral acute gout attacks. Specimens of the spinal lesions were obtained in three patients and consistently showed monosodium urate crystals with tissue inflammation or a tophus. The outcome was rapidly favorable, either with colchicine therapy alone in four patients or after surgical resection of a facet joint cyst (during surgery to stabilize the lumbar spine) in the remaining patient. The patient with neck pain due to a tophus experienced nerve root pain at the acute phase. No other neurological manifestations were recorded.

CONCLUSION

These case reports illustrate the diagnostic challenges raised by spinal involvement due to gout. The spinal lesions can be inaugural, as seen in two of our five patients.

The naso-axial line: a new method of accurately predicting the inferior limit of the endoscopic endonasal approach to the craniovertebral junction

BACKGROUND

The endoscopic endonasal approach (EEA) has developed as an emerging surgical corridor to the craniovertebral junction (CVJ). In addition to understanding its indications and surgical anatomy, the ability to predict its inferior limit is vital for optimal surgical planning.

OBJECTIVE

To develop a method that accurately predicts the inferior limit of the EEA on the CVJ radiologically and to compare this with other currently used methods.

METHODS

Predissection computerized tomographic scans of 9 cadaver heads were used to delineate a novel line, the naso-axial line (NAxL), to predict the inferior EEA limit on the upper cervical spine. A previously described method with the use of the nasopalatine line (NPL or Kassam line) was also used. On computerized tomographic scans obtained following dissection of the EEA, the predicted inferior limits were compared with the actual extent of dissection.

RESULTS

The postdissection inferior EEA limit ranged from the dens tip to the upper half of the C2 body, which matched the limit predicted by NAxL, with no statistically significant difference between them. In contrast to the NAxL, the NPL predicted a significantly lower EEA limit (P < .001), ranging from the lower half of the C2 body to the superior end plate of C3.

CONCLUSION

The novel NAxL more accurately predicts the inferior limit of the EEA than the NPL. This method, which can be easily used on preoperative sagittal scans, accounts for variations in patients' anatomy and can aid surgeons in the assessment of the EEA to address caudal CVJ pathology.

The broad spectrum of urate crystal deposition: unusual presentations of gouty tophi

OBJECTIVES

Gout is typically described as an inflammatory arthropathy that affects the peripheral joints. Our aim was to describe atypical and rare clinical presentations of gouty tophi to help increase physician awareness and aid in patient care.

METHODS

The relevant English literature of unusual gout manifestations was searched using the keywords gout, toph*, monosodium urate, uric acid, unusual, and rare. Well-described case reports, case series, and review articles were evaluated and included, if relevant, in the literature review.

RESULTS

Review of the literature revealed many unusual manifestations of gouty tophi involving the head and neck, skin, viscera, bones, tendons, ligaments, nerves, and axial skeleton. Transplant recipients, women, and elderly people are particularly susceptible to developing tophi. Furthermore, gout can cause diagnostic dilemmas, as it can be a great mimicker of and can coexist with infection, malignancy, and other connective tissue diseases. Imaging modalities can help detect tophi in atypical locations.

CONCLUSIONS

Tophi can present in unexpected locations, even as the first sign of gout, and vigilance is required when unusual symptoms or signs occur in a patient with gout.

Tophaceous gout in the cervical spine

A 58-year-old woman with a three-year progressive history of chronic arthritis, had become disabled due to general malaise and fever. Her laboratory data revealed hyperuricemia and elevated levels of C-reactive protein. Neither rheumatoid factor nor anti-citrullinated peptide antibodies were present. We diagnosed her with tophaceous gout with uric crystalline revealed by the arthrocentesis of the elbow. (99m)Tc scintigraphy also disclosed a significant uptake in the cervical spine. The CT of the patient's cervical spine revealed significant bone erosion and destruction. We diagnosed the cervical involvement of gout based on the exclusion of infections and sarcoidosis. Rheumatologists should be aware of this rare association.

Cervical arthropathy caused by gout: stabilisation without decompression

The cervical spine is a rare site where tophaceous gout has been identified. There are currently 15 described cases in the literature of gouty involvement of the cervical spine with only three cases involving only the atlanto-axial region. We add the fourth of such cases and only the second to be managed operatively.

Tophaceous gout of the odontoid process causing glossopharyngeal, vagus, and hypoglossal nerve palsies

Gout affecting the axial joints is uncommon; however, its involvement may be complicated by neurological symptoms associated with spinal compression at the affected level. Specific involvement of the odontoid process is even rarer. We report the first case of gout involving the odontoid process with resultant glossopharyngeal (CN IX), vagus (CN X) and hypoglossal (CN XII) nerve palsies.

Endoscopic image-guided transoral approach to the craniovertebral junction: an anatomic study comparing surgical exposure and surgical freedom obtained with the endoscope and the operating microscope

OBJECTIVE

The transoral approach is the most direct and commonly used method to access the ventral craniocervical junction. Recently, an endonasal, endoscopic approach to the craniovertebral junction was proposed. We reasoned that the coupling of the endoscope with the direct transoral approach and image guidance could result in a minimally invasive, simple approach to the ventral craniovertebral junction. We investigated the potential usefulness of such an approach in a cadaver model.

METHODS

A direct transoral approach to the craniovertebral junction was performed using computed tomography-based image guidance in 9 fresh adult head specimens. Endoscopic odontoidectomy was performed in 5 specimens. In the remaining 4 specimens, the surgical working area and surgical freedom associated with an endoscopic and a microscopic approach to the ventral craniovertebral junction were evaluated and compared. In these 4 specimens, we also measured and compared the exposure of the clivus provided by the endoscope and by the operating microscope without splitting the soft palate.

RESULTS

With variously angled endoscopic assistance and image guidance, it was possible to tailor the excision of the anterior arch of the atlas and to precisely identify the odontoid process and its related ligaments intraoperatively, resulting in a complete and controlled odontoidectomy. The surgical area exposed over the posterior pharyngeal wall was significantly improved using the endoscope (606.5 +/- 127.4 mm3) compared with the operating microscope (425.7 +/- 100.8 mm3), without any compromise of surgical freedom (P < 0.05). The extent of the clivus exposed with the endoscope (9.5 +/- 0.7 mm) without splitting the soft palate was significantly improved compared with that associated with microscopic approach (2.0 +/- 0.4 mm) (P < 0.05).

CONCLUSION

With the aid of the endoscope and image guidance, it is possible to approach the ventral craniovertebral junction transorally with minimal tissue dissection, no palatal splitting, and no compromise of surgical freedom. In addition, the use of an angled-lens endoscope can significantly improve the exposure of the clivus without splitting the soft palate. An endoscope-assisted transoral approach is a direct and powerful tool for the treatment of surgical pathology at the craniovertebral junction.

Imaging of gout: findings and utility

Imaging is a helpful tool for clinicians to evaluate diseases that induce chronic joint inflammation. Chronic gout is associated with changes in joint structures that may be evaluated with diverse imaging techniques. Plain radiographs show typical changes only in advanced chronic gout. Computed tomography may best evaluate bone changes, whereas magnetic resonance imaging is suitable to evaluate soft tissues, synovial membrane thickness, and inflammatory changes. Ultrasonography is a tool that may be used in the clinical setting, allowing evaluation of cartilage, soft tissues, urate crystal deposition, and synovial membrane inflammation. Also ultrasound-guided puncture may be useful for obtaining samples for crystal observation. Any of these techniques deserve some consideration for feasibility and implementation both in clinical practice and as outcome measures for clinical trials. In clinical practice they may be considered mainly for evaluating the presence and extent of crystal deposition, and structural changes that may impair function or functional outcomes, and also to monitor the response to urate-lowering therapy.

Bacteremia coexisting with tophaceous gout of the spine mimicking spondylodiscitis: a case report

STUDY DESIGN

A case report and review of the literature.

OBJECTIVE

To report a rare case of bacteremia coexisting with spinal gout initially suspected as pyogenic spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Gouty spine is a rare disease. It is even rare when coexisting with bacteremia. The presentation as pain, fever, and positive blood culture will make it more difficult to distinguish from spinal infection.

METHODS

A 64-year-old woman with type II diabetes mellitus and chronic renal insufficiency was admitted to the emergency department with a fever of 39 degrees C, chills, and back pain. Laboratory studies revealed an elevated white count and neutrophils; her serum glucose level was 279 mg/dL. The C-reactive protein level was 25.55 mg/dL and serum uric acid was in the upper range of normal. Blood cultures revealed Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Urine culture revealed 3 separate gram-negative bacilli. Magnetic resonance imaging of the spine revealed contrast enhancement in the L4-L5 and T5-T9 vertebral bodies. Infective spondylodiscitis of the lumbar and thoracic spine was suspected.

RESULTS

Because antibiotic treatment had failed, surgical debridement with diskectomy, partial corpectomy, and allogenous strut graft reconstruction (T8-T9) was performed. During the operation, 600 cc of pleural effusion was drained. Chalky white material was noted at the T8-T9 disc and the adjacent vertebral bodies. Cultures for bacteria, tuberculosis, and fungus were all negative. Histologic examination revealed deposition of eosinophilic crystal-like material, and a diagnosis of tophaceous gout of the spine was established.

CONCLUSION

This is, to our knowledge, the first case of bacteremia coexisting with multiple areas of tophaceous gout of the spine. Although uncommon, gouty spine should be added into the differential diagnosis of patients with back pain and bacteremia.

Endoscopic skull base surgery

Endoscopic skull base surgery has undergone rapid advancement in the past decade moving from pituitary surgery to suprasellar lesions and now to a myriad of lesions extending from the cribriform plate to C2 and laterally out to the infratemporal fossa and petrous apex. Evolution of several technological advances as well as advances in understanding of endoscopic anatomy and the development of surgical techniques both in resection and reconstruction have fostered this capability. Management of benign disease via endoscopic methods is largely accepted now but more data is needed before the controversy on the role of endoscopic management of malignant disease is decided. Continued advances in surgical technique, navigation systems, endoscopic imaging technology, and robotics assure continued brisk evolution in this expanding field.

Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation

✓The authors report a case of a nonachnodroplastic dwarf with severe basilar invagination and compression of the cervicomedullary junction (CMJ) due to juvenile rheumatoid arthritis. Initially excellent reduction of the invagination and decompression of the CMJ was achieved using posterior fixation. However, 1 month postoperatively symptoms recurred and the authors found imaging evidence of recurrence as well. The patient subsequently underwent an endoscopic transnasal resection of the dens with assistance of Iso-C navigation. He recovered well and tolerated regular diet on postoperative Day 2.