Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process in same sitting after occipitocervical fixation and decompression—perioperative management and how to avoid vertebral artery injury

Abstract

This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of lesions of the odontoid process (OP). The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an X-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc). The trajectory is immediately above the C2 root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen, and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants). PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.

Case Report: Posterolateral Epidural Supra-C2-Root Approach (PESCA) for Biopsy of a Retro-Odontoid Lesions in Same Sitting After Occipitocervical Fixation and Decompression in a Case of Crowned Dens Syndrome With Brainstem Compression and Displacement

“…PESCA might be a good alternative and is easier to perform in periodontoid lesions than in odontoid lesions because the trajectory is not as deep. Even if the window of PESCA is small, the surgical path is narrow, and the working angle is oriented up, performing surgery in one session is a huge advantage for the patient ( 16 ). To best of our knowledge this is the first case of CDS which had been managed by this concept.…”

“…Main advantage of posteriolateral approaches is that occipitocervical fixation and decompression can be performed in same sitting ( 16 ).…”

“…In our case we used PESCA ( 16 ) which uses a midline incision in combination with previous decompression, thereby enlarging the foramen of magnum and medial C1 removal. The lateral corridor between the lateral part of C1 arch and the lateral part of C2 arch is enlarged by drilling of the inferior lateral part of the C1 arch and the lateral superior part of C2 arch.…”

“…Different landmarks such as the C2 root and remains of the C1 arc, C2 arc, and dural sac were identified. Then, PESCA, which we described in a previous publication, was performed ( 16 ).…”

“…In a previous publication, we advocated for the posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process (OP) in one surgical session after occipitocervical fixation and decompression, which might be a good alternative to classical approaches ( 16 ).…”