Endoscopic transcervical odontoidectomy for pediatric basilar invagination and cranial settling

Report of 4 cases

Restricted access

✓ Pediatric basilar invagination and cranial settling have traditionally been approached through a transoral–transpharyngeal route with or without extended maxillotomy or mandibulotomy for resection of the anterior portion of C-1 and the odontoid. The authors hypothesize that application of a recently described endoscopic transcervical odontoidectomy (ETO) technique would allow an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.

The authors performed ETO in a consecutive series of pediatric patients presenting with myelopathy or bulbar dysfunction resulting from basilar invagination or cranial settling. All clinical, radiographic, surgical, and follow-up data were prospectively collected. The initial experience with ETO in the pediatric population is analyzed and outcomes are reported. Three patients required ETO for basilar invagination and 1 required ETO with anterior C-1 arch and distal clivus resection for cranial settling. All patients presented with myelopathy. One patient was wheelchair bound with severe quadriparesis. The mean age was 14 ± 3 years (mean ± standard deviation [SD]) in the 2 male and 2 female patients. The ETO and posterior fusion were performed as a 2-stage procedure in 2 (50%) and as a single-stage procedure in 2 (50%) cases. Prolonged intubation or postoperative placement of a gastrostomy tube was not needed in any case. The postoperative hospitalization lasted 9 ± 4 days (mean ± SD). At last follow-up (mean 5 months), head and neck pain had resolved and motor strength had improved or stabilized in all cases. All 4 children were independently functioning and ambulatory at the last follow-up.

In the authors' initial experience, ETO has allowed ventral brainstem decompression without the need for prolonged intubation, worsening dysphagia requiring enteral tube feeding, or prolonged hospitalization, and has resulted in cosmetically appealing results. The ETO technique allows an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.

Abbreviations used in this paper: CT = computed tomography; ETO = endoscopic transcervical odontoidectomy; MR = magnetic resonance; SD = standard deviation.

Article Information

Address correspondence to: Jean-Paul Wolinsky, M.D., Department of Neurosurgery, The Johns Hopkins Hospital, Meyer 7-109, 600 North Wolfe Street, Baltimore, Maryland 21287. email: jwolins3@jhmi.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Case 3. A: Preoperative 2D sagittally reconstructed CT scan demonstrating evidence of basilar invagination in a patient with Oc–C1 assimilation and Klippel-Feil syndrome. B: Postoperative photograph of a typical incision used for the endoscopic transcervical approach. C: Postoperative CT scan demonstrating resection of the dens via an endoscopic transcervical approach.

  • View in gallery

    Case 3. Left: Preoperative axial CT scan demonstrating evidence of basilar invagination and increased atlantodental interval. Right: Postoperative CT scan demonstrating resection of the dens via an endoscopic transcervical approach.

  • View in gallery

    Case 4. Left: Preoperative 2D sagittally reconstructed CT scan demonstrating evidence of cranial settling in a patient with osteogenesis imperfecta. Right: Postoperative CT scan demonstrating resection of the dens, anterior arch of C-1, and distal clivus via an endoscopic transcervical approach.

References

  • 1

    Alfieri AJho HDTschabitscher M: Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir (Wien) 144:2192252002

    • Search Google Scholar
    • Export Citation
  • 2

    Anand VKHarkey HLAl-Mefty O: Open-door maxillotomy approach for lesions of the clivus. Skull Base Surg 1:2172251991

  • 3

    Apfelbaum RAnterior screw fixation for odontoid fractures. Rengachary SWilkins R: Neurosurgical Operative Atlas ed 3BaltimoreWilliams & Wilkins1992. Vol 2:189199

    • Search Google Scholar
    • Export Citation
  • 4

    Apfelbaum RILonser RRVeres RCasey A: Direct anterior screw fixation for recent and remote odontoid fractures. J Neurosurg 93:2 Suppl2272362000

    • Search Google Scholar
    • Export Citation
  • 5

    Apuzzo MLWeiss MHHeiden JS: Transoral exposure of the atlantoaxial region. Neurosurgery 3:2012071978

  • 6

    Arbit EPatterson RH Jr: Combined transoral and median labio-mandibular glossotomy approach to the upper cervical spine. Neurosurgery 8:6726741981

    • Search Google Scholar
    • Export Citation
  • 7

    Balasingam VAnderson GJGross NDCheng CMNoguchi ADogan A: Anatomical analysis of transoral surgical approaches to the clivus. J Neurosurg 105:3013082006

    • Search Google Scholar
    • Export Citation
  • 8

    Bertrand JLuc BPhilippe MPhilippe P: Anterior mandibular osteotomy for tumor extirpation: a critical evaluation. Head Neck 22:3233272000

    • Search Google Scholar
    • Export Citation
  • 9

    Bruneau MCornelius JFMarneffe VTriffaux MGeorge B: Anatomical variations of the V2 segment of the vertebral artery. Neurosurgery 59:1 SupplONS20ONS242006

    • Search Google Scholar
    • Export Citation
  • 10

    Bull JWNixon WLPratt RT: The radiological criteria and familial occurrence of primary basilar impression. Brain 78:2292471955

  • 11

    Cantarella GMazzola RFBenincasa A: A possible sequela of transoral approach to the upper cervical spine. Velopharyngeal incompetence. J Neurosurg Sci 42:51551998

    • Search Google Scholar
    • Export Citation
  • 12

    Collignon FPCohen-Gadol AAKrauss WE: Circumferential decompression of the foramen magnum for the treatment of syringomyelia associated with basilar invagination. Neurosurg Rev 27:1681722004

    • Search Google Scholar
    • Export Citation
  • 13

    Crockard HA: [Ventral approaches to the upper cervical spine.]. Orthopade 20:1401461991. (Ger)

  • 14

    Crockard HAPozo JLRansford AOStevens JMKendall BEEssigman WK: Transoral decompression and posterior fusion for rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br 68:3503561986

    • Search Google Scholar
    • Export Citation
  • 15

    da Silva JA: Basilar impression and Arnold-Chiari malformation. Surgical findings in 209 cases. Neurochirurgia (Stuttg) 35:1891951992

    • Search Google Scholar
    • Export Citation
  • 16

    de Divitiis OConti AAngileri FFCardali SLa Torre DTschabitscher M: Endoscopic transoral-transclival approach to the brainstem and surrounding cisternal space: anatomic study. Neurosurgery 54:1251302004

    • Search Google Scholar
    • Export Citation
  • 17

    Delgado TEGarrido EHarwick RD: Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine. Neurosurgery 8:6756791981

    • Search Google Scholar
    • Export Citation
  • 18

    Di Lorenzo N: Craniocervical junction malformation treated by transoral approach. A survey of 25 cases with emphasis on postoperative instability and outcome. Acta Neurochir (Wien) 118:1121161992

    • Search Google Scholar
    • Export Citation
  • 19

    El-Khoury GYWener MHMenezes AHDolan KDKathol ME: Cranial settling in rheumatoid arthritis. Radiology 137:6376421980

  • 20

    Epstein BSEpstein JA: The association of cerebellar tonsillar herniation with basilar impression incident to Paget's disease. Am J Roentgenol Radium Ther Nucl Med 107:5355421969

    • Search Google Scholar
    • Export Citation
  • 21

    Frank EBerger TTew JM Jr: Basilar impression and platybasia in osteogenesis imperfecta tarda. Surg Neurol 17:1161191982

  • 22

    Frempong-Boadu AKFaunce WAFessler RG: Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction. Neurosurgery 51:5 SupplS60S662002

    • Search Google Scholar
    • Export Citation
  • 23

    Goel A: Progressive basilar invagination after transoral odontoidectomy: treatment by atlantoaxial facet distraction and craniovertebral realignment. Spine 30:E551E5552005

    • Search Google Scholar
    • Export Citation
  • 24

    Hajdu NKauntze R: Cranioskeletal dysplasia. Br J Radiol 21:42481948

  • 25

    Hurwitz LJShepherd WH: Basilar impression and disordered metabolism of bone. Brain 89:2232341966

  • 26

    James DCrockard HA: Surgical access to the base of skull and upper cervical spine by extended maxillotomy. Neurosurgery 29:4114161991

    • Search Google Scholar
    • Export Citation
  • 27

    Kanamori YMiyamoto KHosoe HFujitsuka HTatematsu NShimizu K: Transoral approach using the mandibular osteotomy for atlantoaxial vertical subluxation in juvenile rheumatoid arthritis associated with mandibular micrognathia. J Spinal Disord Tech 16:2212242003

    • Search Google Scholar
    • Export Citation
  • 28

    Kassam ABSnyderman CGardner PCarrau RSpiro R: The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 57:1 SupplE2132005

    • Search Google Scholar
    • Export Citation
  • 29

    Kingdom TTNockels RPKaplan MJ: Transoral-transpharyngeal approach to the craniocervical junction. Otolaryngol Head Neck Surg 113:3934001995

    • Search Google Scholar
    • Export Citation
  • 30

    Luyendijk WMatricali BThomeer RT: Basilar impression in an achondroplastic dwarf: causative role in tetraparesis. Acta Neurochir (Wien) 41:2432531978

    • Search Google Scholar
    • Export Citation
  • 31

    Menezes AHCongenital and acquired abnormalities of the craniovertebral junction. Youmans J: Youmans Neurological Surgery ed 4PhiladelphiaWB Saunders1996. Vol 2:10351089

    • Search Google Scholar
    • Export Citation
  • 32

    Menezes AHVanGilder JC: Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69:8959031988

    • Search Google Scholar
    • Export Citation
  • 33

    Menezes AHVanGilder JCClark CRel-Khoury G: Odontoid upward migration in rheumatoid arthritis. An analysis of 45 patients with “cranial settling”. J Neurosurg 63:5005091985

    • Search Google Scholar
    • Export Citation
  • 34

    Menezes AHVanGilder JCGraf CJMcDonnell DE: Cranio-cervical abnormalities. A comprehensive surgical approach. J Neurosurg 53:4444551980

    • Search Google Scholar
    • Export Citation
  • 35

    O'Connell JETurner JW: Basilar impression of the skull. Brain 73:4054261950

  • 36

    Ozgen SPait TGCaglar YS: The V2 segment of the vertebral artery and its branches. J Neurosurg Spine 1:2993052004

  • 37

    Paradis RWSax DS: Familial basilar impression. Neurology 22:5545601972

  • 38

    Rhoton AL Jr: The foramen magnum. Neurosurgery 47:3 SupplS155S1932000

  • 39

    Sakou TMorizono YMorimoto N: Transoral atlantoaxial anterior decompression and fusion. Clin Orthop Relat Res 187:1341381984

  • 40

    Salcman MJamaris JLeveque HDucker TB: Transoral cervical corpectomy with the aid of the microscope. Spine 4:2092121979

  • 41

    Sawin PDMenezes AH: Basilar invagination in osteogenesis imperfecta and related osteochondrodysplasias: medical and surgical management. J Neurosurg 86:9509601997

    • Search Google Scholar
    • Export Citation
  • 42

    Sciubba DMGaronzik IMSuk IGallia GLTufaro AWolinsky JP: Frameless stereotaxy in a transmandibular, circumglossal, retropharyngeal cervical decompression in a Klippel-Feil patient: technical note. Eur Spine J 15:128612912006

    • Search Google Scholar
    • Export Citation
  • 43

    Shaha ARJohnson RMiller JMilhorat T: Transoral-transpharyngeal approach to the upper cervical vertebrae. Am J Surg 166:3363401993

    • Search Google Scholar
    • Export Citation
  • 44

    Wolinsky JPSciubba DMSuk IGokaslan ZL: Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note. J Neurosurg Spine 6:1841912007

    • Search Google Scholar
    • Export Citation
  • 45

    Yamazaki MKoda MAramomi MAHashimoto MMasaki YOkawa A: Anomalous vertebral artery at the extraosseous and intraosseous regions of the craniovertebral junction: analysis by three-dimensional computed tomography angiography. Spine 30:245224572005

    • Search Google Scholar
    • Export Citation
  • 46

    Zileli MCagli S: Combined anterior and posterior approach for managing basilar invagination associated with type I Chiari malformation. J Spinal Disord Tech 15:2842892002

    • Search Google Scholar
    • Export Citation

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 128 129 23
Full Text Views 72 72 3
PDF Downloads 93 93 2
EPUB Downloads 0 0 0

PubMed

Google Scholar