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Focused endoscopic endonasal craniocervical junction approach for resection of retro-odontoid lesions: surgical techniques and nuances

  • How I Do it - Neurosurgical Anatomy
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Abstract

Background

Lesions posterior to the odontoid process pose a surgical challenge. Posterolateral approaches to this region are considerably risky for the spinal cord. Transoral approaches are limited in terms of exposure and can also carry morbidity.

Methods

We describe a focused endoscopic endonasal approach (EEA) for removing an osteochondroma located dorsal to the odontoid process. The surgical pearls and pitfalls using stepwise image-guided EEA cadaveric dissections are highlighted defining the importance of various craniocervical junction (CCJ) lines on imaging.

Conclusion

EEA to CCJ can be offered, with lower morbidity than other approaches, even for lesions that extend posterior and caudal to the odontoid process. Radiologic predictors of exposure and intraoperative techniques to enhance endoscopic visualization are discussed.

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Abbreviations

EEA:

Expanded endoscopic endonasal approaches

CCJ:

Craniocervical junction

CT-A:

Computed tomography angiography

SCG:

Supracondylar groove

LPT:

Lateral pharyngeal tubercle

AOJ:

Atlanto-occipital joint

aAOM/AAOM:

Anterior atlanto-occipital membrane

ET:

Eustachian tubes

IGS:

Image guidance system

HC:

Hypoglossal canal

ICA:

Internal carotid artery

SSEP:

Somatosensory evoked potential

MEP:

Motor evoked potential

References

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Acknowledgments

We thank Ricardo Carrau, MD, and Bradley Otto, MD, for their contribution to this project.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, The Ohio State University Medical Center, N-1049 Doan Hall, 410 West 10th, Avenue, Columbus, OH, 43210, USA

    Giuliano Silveira-Bertazzo & Daniel M. Prevedello

  2. Department of Neurological Surgery, McLaren Hospital, Bay Region, Bay City, MI, USA

    Sunil Manjila

  3. Department of Otolaryngology-Head and Neck Surgery, The Ohio State University Medical Center, Columbus, OH, USA

    Nyall R. London Jr & Daniel M. Prevedello

  4. Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA

    Nyall R. London Jr

  5. National Institute on Deafness and Other Communication Disorders, NIH, Bethesda, MD, USA

    Nyall R. London Jr

Authors
  1. Giuliano Silveira-Bertazzo
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  2. Sunil Manjila
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  3. Nyall R. London Jr
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  4. Daniel M. Prevedello
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Corresponding author

Correspondence to Daniel M. Prevedello.

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Conflict of interest

This study was performed at ALT-VISION at the Ohio State University. This laboratory receives educational support from the following companies: Carl Zeiss Microscopy, Intuitive Surgical Corp., KLS Martin Corp., Karl Storz Endoscopy, Leica Microsystems, Medtronic Corp., Stryker Corp., and Vycor Medical. Dr. Prevedello is a consultant for Stryker Corp., Medtronic Corp., and Integra; he has received an honorarium from Mizuho and royalties from KLS-Martin company. N London holds stock in Navigen Pharmaceuticals currently of no value and was a consultant for Cooltech Inc., both of which are unrelated to this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Ohio State University Wexner Medical Center institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

A summary of 10 key points

1. The neuromonitoring of SSEPs and MEPs can assess the spinal cord and brainstem functions [5].

2. The knowledge of CCJ anatomy is supplemented by verification of neuronavigation landmarks such as SCG, LPT, PT, AOJ, and the C-1 anterior tubercle [7].

3. The use of intraoperative IGS with CT-angiography (CT-A) with/without MRI fusion and micro-Doppler is helpful to avoid vascular injury during lateral decompression [5].

4. After drilling of the anterior arch of the atlas, C2, and retro-odontoid lesion, a well-decompressed pulsatile dura mater should be seen rostrocaudally, defining the posterior extent of midline decompression [2].

5. The removal of the lower clivus maximizes the rostral decompression (especially in cranial settling), and the removal of the superior edge of the hard palate increases the surgical freedom of movement and caudal exposure, respectively [4].

6. The use of angled shaft elongated endonasal high-speed drills, Cavitron ultrasonic aspirator, and bayoneted handheld instruments can provide precise dissection, reaching down caudally to the lower C2 body.

7. Meticulous hemostasis should be achieved to avoid postoperative hematomas.

8. In the case of CSF leak, we recommend a collagen matrix plugging the defect followed by a fat graft from the abdomen and followed by the nasopharyngeal flaps buttressed with Surgicel, Gelfoam, and Merocel.

9. Considering the epicenter and direct access to the retro-odontoid lesion, there is no need for rostral clivectomy, bilateral sphenoidotomies, middle turbinectomy, or nasoseptal flaps.

10. Preoperative neuroimaging evaluation of the anatomy and predicted area of surgical exposure, with the evaluation of CCJ-lines, will allow for better patient selection and surgical planning [4, 5].

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Silveira-Bertazzo, G., Manjila, S., London, N.R. et al. Focused endoscopic endonasal craniocervical junction approach for resection of retro-odontoid lesions: surgical techniques and nuances. Acta Neurochir 162, 1275–1280 (2020). https://doi.org/10.1007/s00701-020-04319-4

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  • DOI: https://doi.org/10.1007/s00701-020-04319-4

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