Full-Endoscopic Transcervical Ventral Decompression for Pathologies of Craniovertebral Junction: Case Series.
ABSTRACT: Odontoidectomy is very effective for the decompression of the ventral craniovertebral junction (CVJ). Various approaches are available for the direct ventral decompression of the CVJ. Because there are many disadvantages of open transoral approach, endoscopic odontoidectomy was developed. There are 3 approaches in endoscopic odontoidectomy. We report transcervical retropharyngeal endoscopic approach for the ventral CVJ in this paper. Three patients with different pathologies received operations using this approach. The decompression was enough and surgical invasion was less in all patients. Each endoscopic approach has some advantages and different working regions due to their approach trajectories, but transcervical retropharyngeal approach is very familiar for our neurospinal surgeons and has a relatively large working area. This approach might have the chance to take the place of open transoral approach for endoscopic spinal surgeons.
Project description:<h4>Background</h4>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.<h4>Methods</h4>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.<h4>Results</h4>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<sup>2</sup>/6.05 cm<sup>2</sup>) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.<h4>Conclusion</h4>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.
Project description:OBJECTIVE:Endoscopic approaches to the craniovertebral junction (CVJ) have been established as viable and effective surgical treatments in the past decade. One of the major complications is leakage of the cerebrospinal fluid (CSF). This study aimed to investigate the efficacy and feasibility of suture closure at the nasopharyngeal mucosa upon durotomy. METHODS:A series of consecutive patients who underwent different endoscopic approaches to the CVJ were retrospectively reviewed. The pathologies, surgical corridors, neurological and functional outcomes, radiological evaluations, and complications were analyzed. Different strategies of repair for the intraoperative CSF leakage were described and compared. RESULTS:A total of 22 patients covering 13 years were analyzed. There were 12, 2, and 8 patients who underwent transnasal, transoral, and combined approaches, respectively. There were 8 patients (36.4%) who experienced intraoperative CSF leakage, and were grouped into 2: 4 in the nonsuture (NS) group and 4 in the suture-repaired (SR) group. The NS group had 3 (75%) persistent CSF leakages postoperation that caused 1 mortality, whereas patients of the SR group had only 1 minor CSF rhinorrhea that healed spontaneously within days. CONCLUSION:In this series of 22 patients who required anterior endoscopic resection of pathologies at the CVJ, there was 1 (4.5%) serious complication related to CSF leakage. For patients who had no durotomy, the mucosal incision at the nasopharynx usually healed rapidly and there were few procedure-related complications. For patients with intraoperative CSF leakage, suture closure was technically challenging but could significantly lower the risks of postoperative complications.
Project description:Craniovertebral junction (CVJ) deformity is a challenging pathology that can result in progressive deformity, myelopathy, severe neck pain, and functional disability, such as difficulty swallowing. Surgical management of CVJ deformity is complex for anatomical reasons; given the discreet relationships involved in the surrounding neurovascular structures and intricate biochemical issues, access to this region is relatively difficult. Evaluation of the reducibility, CVJ alignment, and direction of the mechanical compression may determine surgical strategy. If CVJ deformity is reducible, posterior in situ fixation may be a viable solution. If the deformity is rigid and the C1-2 facet is fixed, osteotomy may be necessary to make the C1-2 facet joint reducible. C1-2 facet release with vertical reduction technique could be useful, especially when the C1-2 facet joint is the primary pathology of CVJ kyphotic deformity or basilar invagination. The indications for transoral surgery are becoming as narrow as a treatment for CVJ deformity. In this article, we will discuss CVJ alignment and various strategies for the management of CVJ deformity and possible ways to prevent complications and improve surgical outcomes.
Project description: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.
Project description:BACKGROUND:Odontoid process pathologies can cause upper motor neuron lesions. These pathologies can be approached through either a high retropharyngeal approach or a transoral approach. The introduction of the surgical microscope, proper instrumentations, and proper antibiotics has increased utilization of the transoral approach. QUESTIONS/PURPOSES:Our approach to anterior odontoid resection through transoral approach for different pathologies resulting in compression the cervical cord or causing craniocervical instability is described here. We aim to explore the safety and efficacy of this approach. METHODS:Twenty cases of different odontoid pathologies were managed by transoral surgery. Patients were assessed clinically for axial neck pain and radicular symptoms using visual analog scale. The Nurick score was used to get an overall functional evaluation of the difficulty of ambulation and walking. Radiological evaluation of the patients included plain radiographs, CT scans, and MRI of the cervical spine. Posterior surgery was done as a first stage for restoring the sagittal profile of the cervical spine. Transoral surgery was done as a second stage for odontoid resection and anterior decompression of the cord. RESULTS:Average follow-up was 29.4?±?3.8 months. Mean preoperative Nurick scale was 1.3?±?1.2. Mean postoperative Nurcik scale was 0.5?±?0.61. Patients with axial neck pain were improved after surgery except the 6 patients; mean VAS preoperative 8.2?±?2.3 SD, mean postoperative VAS 3.7?±?0.8SD, and radicular symptoms were not significantly changed after surgery; gait changes were improved in all patients with preoperative gait disturbance. CONCLUSION:The transoral approach is a safe and effective surgical method for the direct decompression of ventral midline extradural compressive disease of the craniovertebral junction.
Project description:Different disorders may produce irreducible atlanto-axial dislocation with compression of the ventral spinal cord. Among the surgical approaches available for a such condition, the transoral resection of the odontoid process is the most often used. The aim of this anatomical study is to demonstrate the possibility of an anterior cervico-medullary decompression through an endoscopic endonasal approach. Three fresh cadaver heads were used. A modified endonasal endoscopic approach was made in all cases. Endoscopic dissections were performed using a rigid endoscope, 4 mm in diameter, 18 cm in length, with 0 degree lenses. Access to the cranio-vertebral junction was possible using a lower trajectory, when compared to that necessary for the sellar region. The choana is entered and the mucosa of the rhinopharynx is dissected and transposed in the oral cavity in order to expose the cranio-vertebral junction and to obtain a mucosal flap useful for the closure. The anterior arch of the atlas and the odontoid process of C2 are removed, thus exposing the dura mater. The endoscopic endonasal approach could be a valid alternative to the transoral approach for anterior odontoidectomy.
Project description:Background:Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction. Methods:Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery. Results:A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0. Conclusions:The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.
Project description:OBJECTIVES: To describe our method of performing the transoral approach and the extended approaches to the ventral foramen magnum and craniovertebral junction and review the technical aspects and operative nuances. DESIGN: Review. RESULTS: The transoral approach provides direct midline exposure to access extradural disease located at the craniovertebral junction and ventral foramen magnum. The corridor of exposure is generally limited by the extent to which the patient can open his or her mouth. The location of the hard palate relative to the craniovertebral junction limits superior exposure, whereas the mandible and base of the tongue limit the inferior exposure. In most cases, exposure can be obtained from the inferior clivus to the middle to lower C2 vertebral body. Extended transoral approaches can be performed to increase exposure if necessary. These approaches include transmaxillary (Le Fort I maxillotomy), transmaxillary with a midline palatal split (extended "open-door" maxillotomy), transpalatal, and median labiomandibular glossotomy (transmandibular split). CONCLUSIONS: The transoral approach effectively provides direct access to extradural midline lesions of the craniovertebral junction. A specialized retractor system can expose the inferior clivus to the C2 body. Extended approaches as described can access lesions that extend beyond these limits.
Project description:Retro-odontoid pseudotumor formation consists of an abnormal growth of granulation tissue typically posterior to the odontoid process, resulting as a manifestation of atlantoaxial instability. This instability can occur as a result of conditions ranging from severe mechanical trauma to metabolic disease or autoimmune conditions such as rheumatoid arthritis. A pseudotumor may impinge on the spinal nerves or even the spinal cord and brainstem, manifesting symptoms from severe neck pain to cervicomedullary compression or myelopathy, and in some cases even sudden death. The objective of this review is to consolidate the findings in published case reports and relevant prior literature reviews regarding the formation of retro-odontoid pseudotumor. We address the pathophysiology involved in acquired and congenital pseudotumor formation, including those associated with rheumatoid arthritis (panni). Additionally, we discuss past and current operative techniques designed to curtail and ultimately regress a retro-odontoid pseudotumor and pannus. Surgical techniques that are addressed include ventral decompression (both transoral and transnasal), dorsal decompression, and indications for posterior instrumentation in pannus formation, particularly in cases that may be sufficiently treated in lieu of an anterior approach. Finally, we will examine the role of external orthoses as both a method of conservative treatment as well as a potential adjunct to the aforementioned surgical procedures.
Project description:Transoral endoscopic head and neck surgery is a new approach for the treatment of oropharyngeal tumors. Using either a robotic system and/or laser, surgeons gain access through the mouth via minimally invasive technique and thus have improved visualization of the tumors of the oropharynx, without disfiguring incisions. This transoral route of access minimizes long-term speech and swallowing dysfunction. Surgeons view this approach as a considerable technologic advance, analogous to the evolution in radiation therapy from conventional two- and three-dimensional conformal techniques to intensity-modulated techniques. Although the use of radiation with or without chemotherapy to treat oropharyngeal cancer (OPC) is supported by evidence from prospective clinical trials, there are no prospective data supporting the use of this new surgical approach for OPC. Here, we review the fundamentals of transoral endoscopic head and neck surgery, with robotics and laser technology, and discuss ongoing clinical trials for patients with OPC.