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

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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 of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.

ABBREVIATIONSCMJ = cervicomedullary junction; POD = postoperative day.

Article Information

Correspondence Theodore H. Schwartz, Department of Neurosurgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, 525 E. 68th St., Box 99, New York, NY 10065. email: schwarh@med.cornell.edu.

INCLUDE WHEN CITING Published online October 31, 2014; DOI: 10.3171/2014.9.JNS14733.

DISCLOSURE The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Dr. Härtl is a consultant for DePuy-Synthes, Lanx, AOSpine, and Brainlab.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Illustration showing the endoscopic endonasal approach to the odontoid along the hard palate. Note the absence of trauma to the oropharynx, which facilitates early extubation and feeding. Inset: View of the odontoid, after removal of the anterior ring of C-1. B: Staged views of operation. Upper Left: The nasopharyngeal fascia between the eustachian tubes overlies the bottom of the clivus and the top of the odontoid. The sphenoid sinus is opened here for orientation purposes but does not need to be opened in this operation. Upper Right: Anterior arch of C-1 after removal of nasopharyngeal fascia and longus colli muscles. Lower Left: Odontoid process following removal of anterior arch of C-1. Lower Right: Ventral dura in front of CMJ following odontoid removal. Copyright Holt Medical Illustration. Published with permission. Figure is available in color online only.

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    Case 7. Example of pre- and postoperative midline sagittal T2-weighted MR images. Note the increased T2 signal and CSF space ventral to the CMJ, indicating successful radiological decompression.

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    Graph showing the measurement of the distance between the back of odontoid and front of CMJ before and after decompression based on MRI findings. Each line represents 1 patient. Images were not available in 1 patient.

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    Illustrative example of pre- and postoperative axial, coronal, and sagittal CT images demonstrating small residual fragment of bone on the left.

References

  • 1

    Baird CJConway JESciubba DMPrevedello DMQuiñones-Hinojosa AKassam AB: Radiographic and anatomic basis of endoscopic anterior craniocervical decompression: a comparison of endonasal, transoral, and transcervical approaches. Neurosurgery 65:6 Suppl1581642009

  • 2

    Bandopadhayay PGoldschlager TRosenfeld JV: The role of evidence-based medicine in neurosurgery. J Clin Neurosci 15:3733782008

  • 3

    Beech TJMcDermott ALKay ADAhmed SK: Endoscopic endonasal resection of the odontoid peg—case report and literature review. Childs Nerv Syst 28:179517992012

  • 4

    Bhangoo RSCrockard HA: Transmaxillary anterior decompressions in patients with severe basilar impression. Clin Orthop Relat Res 3591151251999

  • 5

    Choi DCrockard HA: Evolution of transoral surgery: three decades of change in patients, pathologies, and indications. Neurosurgery 73:2963042013

  • 6

    Crockard HA: Transoral surgery: some lessons learned. Br J Neurosurg 9:2832931995

  • 7

    Dasenbrock HHClarke MJBydon ASciubba DMWitham TFGokaslan ZL: Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination. Neurosurgery 70:3513602012

  • 8

    de Almeida JRZanation AMSnyderman CHCarrau RLPrevedello DMGardner PA: Defining the nasopalatine line: the limit for endonasal surgery of the spine. Laryngoscope 119:2392442009

  • 9

    El-Sayed IHWu JCDhillon NAmes CPMummaneni P: The importance of platybasia and the palatine line in patient selection for endonasal surgery of the craniocervical junction: a radiographic study of 12 patients. World Neurosurg 76:1831882011

  • 10

    Fraser JFAnand VKSchwartz TH: Endoscopic biopsy sampling of tophaceous gout of the odontoid process. Case report and review of the literature. J Neurosurg Spine 7:61642007

  • 11

    Gempt JLehmberg JGrams AEBerends LMeyer BStoffel M: Endoscopic transnasal resection of the odontoid: case series and clinical course. Eur Spine J 20:6616662011

  • 12

    Gladi MIacoangeli MSpecchia NRe MDobran MAlvaro L: Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion. Eur Spine J 21:Suppl 1S55S602012

  • 13

    Grammatica ABonali MRuscitti FMarchioni DPinna GCunsolo EM: Transnasal endoscopic removal of malformation of the odontoid process in a patient with type I Arnold-Chiari malformation: a case report. Acta Otorhinolaryngol Ital 31:2482522011

  • 14

    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

  • 15

    Han SDing XTie XLiu YXia JYan A: Endoscopic endonasal trans-sphenoidal approach for pituitary adenomas: is one nostril enough?. Acta Neurochir (Wien) 155:160116092013

  • 16

    Hsu WWolinsky JPGokaslan ZLSciubba DM: Transoral approaches to the cervical spine. Neurosurgery 66:3 Suppl1191252010

  • 17

    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

  • 18

    Kassam ABAbla ASnyderman CCarrau RSpiro R: An endoscopic transnasal odontoidectomy to treat cervicomedullary compression with basilar invagination. Op Tech Neurosurg 8:1982042005

  • 19

    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:E2132005

  • 20

    Komotar RJStarke RMRaper DMSAnand VKSchwartz TH: Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 77:7137242012

  • 21

    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

  • 22

    Leng LZAnand VKHartl RSchwartz TH: Endonasal endoscopic resection of an os odontoideum to decompress the cervicomedullary junction: a minimal access surgical technique. Spine (Phila Pa 1976) 34:E139E1432009

  • 23

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

  • 24

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

  • 25

    Nayak JVGardner PAVescan ADCarrau RLKassam ABSnyderman CH: Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease. Am J Rhinol 21:6016062007

  • 26

    Patel AJBoatey JMuns JBollo RJWhitehead WEGiannoni CM: Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: case report and literature review. Childs Nerv Syst 28:197119752012

  • 27

    Rawal RBShah RNZanation AM: Endonasal odontoidectomy for basilar impression and brainstem compression due to radiation fibrosis. Laryngoscope 123:5845872013

  • 28

    Scholtes FSignorelli FMcLaughlin NLavigne FBojanowski MW: Endoscopic endonasal resection of the odontoid process as a standalone decompressive procedure for basilar invagination in Chiari type I malformation. Minim Invasive Neurosurg 54:1791822011

  • 29

    Schwartz THAnand VK: The endoscopic endonasal transsphenoidal approach to the suprasellar cistern. Clin Neurosurg 54:2262352007

  • 30

    Sinha SMirza SBishop NZaki HMcMullan J: Endoscopic endonasal resection of the odontoid peg for paediatric basilar invagination. Br J Neurosurg 26:4874892012

  • 31

    Vishteh AGBeals SPJoganic EFReiff JLDickman CASonntag VKH: Bilateral sagittal split mandibular osteotomies as an adjunct to the transoral approach to the anterior craniovertebral junction. Technical note. J Neurosurg 90:2 Suppl2672701999

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