Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion

Gladi, Maurizio; Iacoangeli, Maurizio; Specchia, Nicola; Re, Massimo; Alvaro, Lorenzo; Moriconi, Elisa; Scerrati, Massimo

doi:10.1007/s00586-012-2220-4

Cited by 66 publications

(51 citation statements)

References 24 publications

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“…A linear incision in the mucosa has been suggested as preferable and both are viable in our hands. 12 Finally, we found that in spite of achieving an adequate anatomical decompression of the CMJ as well as symptomatic relief, it was not uncommon to find a small shell of residual odontoid on the left side, seen in 43% of patients. This finding is puzzling since a right-sided approach should direct the surgeon more to the left.…”

Section: -2830mentioning

confidence: 82%

“…20 Although we performed fusion in all patients in this series who underwent an odontoidectomy, rather than just a biopsy, prior reports have claimed that fusion may not be necessary after endonasal odontoidectomy. 12 This was attributed to a reduction in instability due to the minimally invasive endonasal approach and preserving the C-1 arch. 12 In our series, we have not been able to remove the odontoid adequately without removing the anterior ring of C-1.…”

Section: -2830mentioning

confidence: 99%

“…12 This was attributed to a reduction in instability due to the minimally invasive endonasal approach and preserving the C-1 arch. 12 In our series, we have not been able to remove the odontoid adequately without removing the anterior ring of C-1. However, there are likely patients whose spines may have already autofused who may not require an instrumented fusion.…”

Section: -2830mentioning

confidence: 99%

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

Goldschlager

Härtl²,

Greenfield³

et al. 2015

JNS

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A recent paper by Choi and Crockard compared transoral odontoid surgery to the crocodile; it has persisted from prehistoric times but still has a place today.5 Indeed, the transoral approach is considered the gold-standard approach to surgically address periodontoid pathology. 16 However, the evolution of endoscopic endonasal surgery has led to the development of a minimally invasive alternative approach to the odontoid. While both the transoral and endonasal approaches are "natural orifice" surgery, the biggest advantage of the endonasal endoscopic approach arises from the location of the mucosal incision in the nasopharynx and not the oropharynx. In theory, minimizing disruption of the oropharynx allows patients to be extubated and to begin oral feeding sooner, thereby reducing the length of stay and the complications that may arise from prolonged intubated and delayed feeding. 20 Likewise, the palate does not need to be split, as is sometimes the case with transoral surgery. However, few cases have been reported in the literature to support this claim.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 o...

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Section: -2830mentioning

confidence: 82%

Section: -2830mentioning

confidence: 99%

Section: -2830mentioning

confidence: 99%

See 1 more Smart Citation

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

Goldschlager

Härtl²,

Greenfield³

et al. 2015

JNS

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“…25,47,55 Although these extended approaches can lead to significant enhancement of the surgical exposure, they also significantly increase surgical complexity and the depth of the operative corridor, rates of morbidities such as infections from bacterial oral flora, velopharyngeal insufficiency, hypernasal speech, nasal regurgitation, soft palate dehiscence, tongue edema, and necrosis, and the potential need for tracheotomy and nasogastric feeding tube, resulting in a longer hospital recovery time. 10,37,41,45 In the last decade, some minimally invasive endoscopic approaches, such as the EEA, 7,8,11,18,19,[21][22][23][24]26,27,29,30,[33][34][35]40,44,51 the ETA, 16,17 a combined EEA/ETA with or without the assistance of robotics, 12,13,31,32,50,54 and a transcervical approach, 53 have been adopted to address CVJ pathology. The growing number of publications in the last decade shows that the EEA can be an excellent minimal-access alternative to traditional transoral surgery and offers certain anatomical advantages.…”

Section: Discussionmentioning

confidence: 99%

“…All these publications highlight the benefits of endoscopic endonasal odontoidectomy as a safe, effective, and welltolerated technique. 7,8,11,18,19,[21][22][23][24]26,27,29,30,[33][34][35]40,44,51 The main advantages of the EEA over the traditional microscopic approaches are the location of the incision (in the nasopharynx rather than the oropharynx) and the wider, closer, and brighter view provided by the endoscope.…”

Section: Discussionmentioning

confidence: 99%

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

Corte

Aldana

Ferroli

et al. 2015

FOC

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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.

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Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review

Fang

Friedman

Schild

et al. 2015

Int Forum Allergy Rhinol

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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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Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion

Abstract: Compared with the standard transoral technique, the EEA provides the same good exposure but with potentially less complications. The preservation of the anterior C1 arch can contribute to avoid cranial settling and posterior fusion with its related risk of subaxial instability.

Cited by 66 publications

References 24 publications

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

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

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

Purely endoscopic endonasal surgery of the craniovertebral junction: A systematic review

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