Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression

Report of 2 cases

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Object

In rare cases, children with a Chiari malformation Type I (CM-I) suffer from concomitant, irreducible, ventral brainstem compression that may result in cranial neuropathies or brainstem dysfunction. In these circumstances, a 360° decompression supplemented by posterior stabilization and fusion is required. In this report, the authors present the first experience with using an endoscopic transnasal corridor to accomplish ventral decompression in children with CM-I that is complicated by ventral brainstem compression.

Methods

Two children presented with a combination of occipital headaches, swallowing dysfunction, myelopathy, and/or progressive scoliosis. Imaging studies demonstrated CM-I with severely retroflexed odontoid processes and ventral brainstem compression. Both patients underwent an endoscopic transnasal approach for ventral decompression, followed by posterior decompression, expansive duraplasty, and occipital-cervical fusion.

Results

In both patients the endoscopic transnasal approach provided excellent ventral access to decompress the brainstem. When compared with the transoral approach, endoscopic transnasal access presents 4 potential advantages: 1) excellent prevertebral exposure in patients with small oral cavities; 2) a surgical corridor located above the hard palate to decompress rostral pathological entities more easily; 3) avoidance of the oral trauma and edema that follows oral retractor placement; and 4) avoidance of splitting the soft or hard palate in patients with oral-palatal dysfunction from ventral brainstem compression.

Conclusions

The endoscopic transnasal approach is atraumatic to the oral cavity, and offers a more superior region of exposure when compared with the standard transoral approach. Depending on their comfort level with endoscopic surgical techniques, pediatric neurosurgeons should consider this approach in children with pathological entities requiring ventral brainstem decompression.

Abbreviation used in this paper: CM-I = Chiari malformation Type I.
Article Information

Contributor Notes

Address correspondence to: Todd C. Hankinson, M.D., M.B.A., Division of Pediatric Neurosurgery, Children's Hospital of Alabama, University of Alabama Birmingham, 1600 7th Avenue South, ACC Suite 400, Birmingham, Alabama 35233. email: tch12@columbia.edu.
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References
  • 1

    Grabb PAMapstone TBOakes WJ: Ventral brain stem compression in pediatric and young adult patients with Chiari I malformations. Neurosurgery 44:5205281999

    • Search Google Scholar
    • Export Citation
  • 2

    Greenlee JGarell PCStence NMenezes AH: Comprehensive approach to Chiari malformation in pediatric patients. Neurosurg Focus 6:6e41999

    • Search Google Scholar
    • Export Citation
  • 3

    Hadley MNSpetzler RFSonntag VKH: The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71:16231989

    • Search Google Scholar
    • Export Citation
  • 4

    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
  • 5

    Laufer IGreenfield JPAnand VKHärtl RSchwartz TH: Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report. J Neurosurg Spine 8:3763802008

    • Search Google Scholar
    • Export Citation
  • 6

    Magrini SPasquini EMazzatenta DMascari CGalassi EFrank G: Endoscopic endonasal odontoidectomy in a patient affected by Down syndrome: technical case report. Neurosurgery 63:E373E3742008

    • Search Google Scholar
    • Export Citation
  • 7

    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
  • 8

    Spetzler RFHadley MNSonntag VK: The transoral approach to the anterior superior cervical spine. A review of 29 cases. Acta Neurochir Suppl (Wien) 43:69741988

    • Search Google Scholar
    • Export Citation
  • 9

    Wu JCHuang WCCheng HLiang MLHo CYWong TT: Endoscopic transnasal transclival odontoidectomy: a new approach to decompression: technical case report. Neurosurgery 63:1 Suppl 1ONSE92ONSE942008

    • Search Google Scholar
    • Export Citation
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