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Preoperative neuroimaging studies. A and B, sagittal and axial T2 MRI scans revealing basilar invagination with resulting severe bulbomedullary compression and associated myelopathy. A large posterior fossa arachnoid cyst is evident in the sagittal scan. C and D, sagittal CT scans showing the high location of the odontoid process and a congenital fusion of the posterior elements of C2 and C3 (Klippel-Feil deformity) (C). An atlanto-axial subluxation is evident (D). E, axial CT scan revealing a hypoplastic posterior C1 ring.
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Background:
During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working a...
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Background
Cervical spine ligaments that protect the spinal cord and stabilize the spine are frequently injured in motor vehicle collisions and other traumatic situations. These injuries are usually incomplete, and often difficult to notice. The focus of the presented study is placed on analysis of the effect of subfailure load on the mechanical re...
Citations
... Based on the patient's young age and favorable anatomy, the transnasal corridor was considered the most favorable route for removing the lesion. In fact, the anatomy of this young patient, as seen on the sagittal cranial CT scan, allowed wide surgical exposure of the anterior aspect of cranio-vertebral and atlanto-axial junctions through the transnasal approach [22,23] (Figure 2). Moreover, the transnasal endoscopic approach in such a young patient was deemed preferable by virtue of the low rate of post-surgical infection and pharyngeal wound dehiscence compared with transoral approaches [24]. ...
Osteoid osteoma (OO) is a primary benign tumor that accounts for up to 3% of all bone tumors. The cervical spine is less affected by OOs, and very few cases of C2 OOs have been reported in the literature, both in adults and children. Surgery may be required in case of functional torticollis, stiffness, and reduced range of motion (ROM) due to cervical OOs refractory to medical therapy. Several posterior and anterior surgical techniques have been described to remove C2 OOs. In particular, anterior approaches to the cervical spine represent the most used surgical route for treating C2 OOs. We describe the first case of OO of the odontoid process removed through a transnasal endoscopic approach with the aid of neuronavigation in a 6-year-old child. No intraoperative complications occurred, and the post-operative course was uneventful. The patient had immediate relief of neck pain and remained pain-free throughout the follow-up period, with complete functional recovery of the neck range of motion (ROM). In this case, based on the favorable anatomy, the transnasal endoscopic approach represented a valuable strategy for the complete removal of an anterior C2 OO without the need for further vertebral fixation since the preservation of ligaments and paravertebral soft tissue.
... A dekompressziót követő rögzítés szükségességéről az adott eset klinikai és anatómiai sajátosságai alapján döntünk [2]. A ventralis dekompresszió legelterjedtebb formája a transoralis transpharyngealis feltárásból történő densnyúlvány-eltávolítás [3], mely a műtéti terület növelésére kiegészíthető Le Fort-vagy transmandibularis osteotomiával [4]. A ventralis cervicomedullaris kompresszió kezelésének legújabb módszere az endoszkópos endonasalis densreszekció [5], melynek előnye a hagyományos eljárással szemben [2], hogy a kemény és lágy szájpad megőrzése drasztikusan csökkenti a velopharyngealis elégtelenség kockázatát, ugyanakkor direkt hozzáférést enged a densnyúlványhoz [5]. ...
... Az egyébként is magas liquorszivárgás-kockázattal járó transoralis densreszekció helyett az MR-vizsgálattal igazolt dúrasérülésre való tekintettel submandibularis feltárást és ebből történő densreszekciót választottunk. A submandibularis feltárás a lágy részekkel történő tamponálás lehetőségével a liquorszivárgás kockázatát csökkenti [3][4][5][6]. SynFrame (Synthes, West Chester, PA, USA) karbonszálas feltáróval mikroszkóp asszisztálta ventralis submandibularis feltárásból elvégeztük a densnyúlvány középső harmadának, valamint a nyúltvelői kompressziót okozó haematomának és corticalis csontfragmentumnak az eltávolítását. A műtét során a corticalis csontfragmentum okozta durasérülést feltártuk, azt sikerrel tamponáltuk. ...
Absztrakt
Célunk egy új műtéti eljárás, a mikroszkóp asszisztálta submandibularis retropharyngealis densnyúlvány reszekciójának bemutatása „key-hole” behatolásból. Páciensünk motorbaleset kapcsán szenvedte el a CII. nyakcsigolya fognyúlványtörését. Eltávolítottuk a CII. nyakcsigolya densnyúlványának felső kétharmadával együtt a nyúltvelői kompressziót okozó corticalis fragmentumot. Ennél a műtéti eljárásnál elkerülhető a hagyományos transoralis behatoláskor előforduló velopharyngealis elégtelenség, ugyanakkor biztosított a densnyúlványhoz való hozzáférés. Az új eljárás mellett szólt az MR-vizsgálattal igazolt ventralis dúrasérülés, amely a transoralis feltáráskor előforduló velopharyngealis elégtelenség magas kockázatával együtt növeli a sebgyógyulási zavar és a szeptikus állapot előfordulását. A submandibularis „key-hole” technika során szövetragasztó mellett több rétegben volt lehetőség vitális lágy részekkel tamponálni a dúrasérülés helyét. A mikroszkóp asszisztálta submandibularis „key-hole” műtéti eljárást követően elvégzett posztoperatív CT- és MR-vizsgálat visszaigazolta a nyúltvelő teljes dekompresszióját. A páciens tetraplegiás neurológiai állapota teljes mértékben regrediált. Nyolc hónappal a műtétet követően a páciens önellátó. Az általunk alkalmazott technika a továbbiakban mérlegelendő alternatívaként szolgálhat a klasszikus, transoralis transpharyngealis vagy endoszkópos endonasalis densreszekcióval szemben. Orv Hetil. 2020; 161(31): 1302–1306.
... However, large intradural extensions of these lesions may be inaccessible for anterior routes. Moreover, cerebrospinal fluid leakage still represents a major concern following extended anterior approaches, and a careful layer by layer reconstruction is paramount [24,27,28,34,40,51]. ...
Background:
Several far lateral approaches have been proposed to deal with cranio-vertebral junction (CVJ) tumors including the basic, transcondylar, and supracondylar far lateral approaches (B-FLA, T-FLA, and S-FLA). However, the indications on when to use one versus the other are not well systematized yet. Our purpose is to evaluate in an experimental cadaveric setting which approach is best suited to remove tumors of different sizes.
Methods:
We implanted at the CVJ, using a transoral approach, tumor models of different sizes (five 1-cm3and five 3-cm3tumors) in ten embalmed cadaveric heads. The artificial tumors were exposed via the three approaches using endoscopic-assisted microneurosurgical technique and neuronavigation. The skull base area exposed and the maneuverability linked to each approach were evaluated using neuronavigation.
Results:
In 1-cm3tumors, the T-FLA and the S-FLA exposed a significantly larger skull base area than the B-FLA both using the microscope and the endoscope (P < 0.05); the T-FLA executed with the microscope provided wider vertical and horizontal maneuverability than the B-FLA (P = 0.030 and 0.017, respectively); the S-FLA executed with the endoscope provided wider vertical maneuverability than the T-FLA (P = 0.031). The S-FLA executed using the microscope and the endoscope provided wider vertical maneuverability than the B-FLA both in 1 and 3-cm3tumors (P < 0.05).
Conclusions:
In 1-cm3tumors, the S-FLA and the T-FLA expose a wider skull base area than the B-FLA. In larger tumors, the exposure is similar for all three approaches. Use of the endoscope in an assistive mode may further increase the surgical exposure and maneuverability.
... At present, few case reports and small clinical series of endonasal endoscopic odontoidectomy (EEO) have been published. They have highlighted some advantage of this approach including earlier extubation and feeding, significant reduction of hospitalization and patient discomfort as compared to the transoral approach that, however, still represents the gold-standard approach for pathologies of odontoid process [4][5][6][7][8][9][10][11][12][13][14][15][16][17]. ...
... Moreover, some papers, including our previous study on EEO in RA [6], have suggested the possibility to perform EEO without posterior fusion. Indeed, this minimally invasive technique, thanks to its peculiar working angle, may allow the preservation of the anterior C1 arch that plays an important role for craniovertebral junction (CVJ) biomechanical stability and can serve as a pivot for cervical anterior column reconstruction [5,6,13,16,17]. This may avoid the need for a posterior fixation with its related M A N U S C R I P T ...
... These cases were better treated with a posterior-only surgical approach, including decompression and fusion that provides a gradual spontaneous resorption of the soft-tissue pannus [18,19]. Nevertheless, an anterior approach, usually combined with a posterior fusion, is clearly indicated in patients affected by an irreducible ventral spinal cord compression with progressively worsening neurologic symptoms [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17]. ...
Objective:
To examine the long-term outcomes (minimum of 4,5 years) of endoscopic endonasal odontoidectomy (EEO) with preservation of anterior C1 ring to treat irreducible ventral bulbo-medullary compressions in rheumatoid arthritis (RA) and to illustrate a novel technique of anterior pure endoscopic craniovertebral junction (CVJ) reconstruction and fusion. In fact, long-term clinical studies are still lacking to elucidate the effective role of EEO and whether it can obviate the need for posterior fixation.
Methods:
From November 2008 to January 2012, clinical and radiological data of 7 patients presenting with RA and associated irreducible bulbo-medullary compression treated with EEO were retrospectively analyzed. In all patients decompression was achieved by EEO with anterior C1 arch preservation. In the last two patients, after EEO, we used the spared anterior C1 arch for reconstruction of anterior column of CVJ by positioning, under pure endoscopic guidance, autologous bone and two tricortical screws between the anterior arch of C1 and the residual odontoid. All patients were examined clinically with Ranawat classification and radiographically with CT scan, MRI and dynamic x-ray immediately after surgery and during follow-up.
Results:
Adequate bulbo-medullary decompression with anterior C1 arch preservation was obtained in all cases. At follow up (average 66,2 months; range 91-54 months) all patients experienced an improvement at least of one Ranawat classification level and presented no clinical and/or radiological signs of instability.
Conclusions:
EEO with anterior C1 arch sparing provides satisfying long term results for irreducible ventral CVJ lesions in RA. The preservation of anterior C1 arch and, when possible, the reconstruction of anterior CVJ can prevent the need for posterior fusion.
... In the last decades, the development of the endoscopic transnasal techniques has provided new minimally invasive approaches for the treatment of skull base and craniocervical junction lesions [16,19,22]. Some authors have recently proposed an endoscopic transnasal removal for lesions involving the third ventricle. ...
http://rdcu.be/pAkv for a full-text view-only version of the paper
Background: Different surgical approaches have been developed for dealing with third ventricle lesions, all aimed at obtaining a safe removal minimizing brain manipulation. The supraorbital subfrontal trans-lamina terminalis route, commonly employed only for the anterior third ventricle, could represent, in selected cases with endoscopic assistance, an alternative approach to posterior third ventricular lesions.
Methods: Seven patients underwent a supraorbital subfrontal trans-laminar endoscope-assisted approach to posterior third ventricle tumors (two craniopharyngiomas, one papillary tumor of the pineal region, one pineocytoma, two neurocytomas, one glioblastoma). Moreover, a conventional third ventriculostomy was performed via the same translaminar approach in four cases.
Results: Complete tumor removal was accomplished in four cases, subtotal removal in two cases, and a simple biopsy in one case. Adjuvant radiotherapy and/or chemotherapy was administered, if required, on the basis of the histologic diagnosis. No major complications occurred after surgery except for an intratumoral hemorrhage in a patient undergoing a biopsy for a glioblastoma, which simply delayed the beginning of adjuvant radiochemotherapy. No ventriculoperitoneal shunt placement was needed in these patients at the most recent clinical and radiologic session (average 39.57 months, range 13–85 months). Two illustrative cases are presented.
Conclusions: The supraorbital subfrontal trans-laminar endoscope-assisted approach may provide, in selected cases, an efficient and safe route for dealing with posterior third ventricular tumors.
Background
Odontoidectomy for symptomatic, irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent instrumentation. There is no consensus on the importance of C1 anterior arch preservation in prevention of iatrogenic instability. We conducted a systematic review on the impact of C1 anterior arch preservation on post-odontoidectomy spine stability.
Methods
PubMed, EMBASE, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients undergoing odontoidectomy. Random-effect model meta-analyses were performed to compare spine stability between C1 anterior arch preservation versus removal and post-treatment outcomes between transoral (TOA) versus endoscopic endonasal (EEA) approaches.
Results
We included 27 studies comprising 462 patients. The most common lesions were basilar invagination (73.3%) and degenerative arthritis (12.6%). Symptoms included myelopathy (72%) and neck pain (43.9%). Odontoidectomy was performed through TOA (56.1%) and EEA corridors (34.4%). The C1 anterior arch was preserved in 16.7% cases. Post-odontoidectomy stabilization was performed in 83.3% patients. Median follow-up was 27 months (range, 0.1-145). Rates of spine instability were significantly lower (P=0.004) when the C1 anterior arch was preserved. Postoperative clinical improvement and pooled complications were reported in 78.8% and 12.6% patients respectively, with no significant differences between TOA and EEA (P=0.892; P=0.346). Patients undergoing EEA had significantly higher rates of intraoperative cerebrospinal fluid leaks (P=0.002).
Conclusion
Odontoidectomy is safe and effective for treating craniovertebral junction lesions. Preservation of the C1 anterior arch appears to improve maintenance of spine stability. TOA and EEA show comparable outcomes and complications rates.
Objective
Odontoidectomy with preservation of the anterior C1 arch can be increasingly achieved by an endoscopic endonasal approach. It is controversial whether preservation of the anterior C1 arch after odontoidectomy can prevent instability of the craniovertebral junction （CVJ） and avoid posterior fixation. The aim of this research was to investigate the biomechanical effect of the preserved anterior C1 arch after odontoidectomy.
Methods
A validated finite element model of a whole cervical spine (occipital bone to T1) was constructed to study the biomechanical changes due to traditional odontoidectomy (TO) and odontoidectomy with preservation of the anterior C1 arch (OPC1).
Results
The greatest biomechanical changes in the cervical spine model after TO and OPC1 occurred at C0-C1 and C1-C2. At C0-C1 and C1-C2, the motion changes of the TO and OPC1 models had no significant difference in flexion, extension and lateral bending. Compared with the intact model, motion increases of the two surgical models were both extremely significant at C1-C2 in extension (128.2% vs. 128.1%) and lateral bending (178% vs. 156%). In axial rotation, the TO approach produced more motions than the OPC1 approach, especially at C1-C2(90.3° under TO approach, and 74.6° under OPC1 approach).
Conclusions
Preservation of the anterior C1 arch after odontoidectomy can preserve the axial rotational motion at C0-C1 and C1-C2, whereas the motions in extension and lateral bending continue to have an extremely abnormal increase at C1-C2. Thus, instability of the CVJ still exists, and posterior internal fixation may also be required after OPC1.
Background:
Preservation of the anterior arch of C1 in endoscopic endonasal odontoidectomy has been proposed as an alternative to complete C1 arch resections, potentially affording less destabilization of the craniocervical junction. Nonetheless, this approach may limit the decompression achieved. In this case, intra-operative repositioning allowed maximal decompression while preserving the anterior arch of C1.
Case description:
A 79-year-old woman presented with suboccipital pain caused by an expansile and compressive mass centered on the dens. Notably, the mass occluded both vertebral arteries resulting in small cerebellar strokes. An endoscopic endonasal approach for diagnosis and decompression was performed followed by posterior fixation. Given the significant compression, the patient was initially positioned in slight cervical extension. After rhinopharyngeal flap harvest, the top half of the anterior arch of C1 was resected, maintaining its structural integrity. The odontoidectomy was completed flush to the superior border of the reduced C1 arch. After an intra-operative CT scan, performed in a neutral position, the patient was then repositioned with cervical flexion. This maneuver presented the residual odontoid above the C1 arch, but given the partial removal of the dens, it did not result in any change in neuromonitoring. Further odontoid resection was then completed and follow-up CT scan revealed maximal dens removal, which extended below the C1 anterior arch in neutral position.
Conclusion:
In cases of odontoid/atlantoaxial pathology causing significant neural compression, staged intra-operative repositioning can safely maximize the odontoidectomy, while affording preservation of the structural integrity of the anterior arch of C1.
Background
Our objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches.
Methods
During the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1–C2 fusion according to Harms. C1–C2 decompressive laminectomy was performed in all four cases. Ventral C1–C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR—similarly to the traditional anterior retropharyngeal surgery—preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor.
Results
The MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm ² /6.05 cm ² ) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.
Conclusion
Based on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications.
