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How I do it? Cranial setup for cranial settling

  • How I Do it - Neurosurgical Techniques
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Abstract

Background

Expanded endonasal endoscopic techniques allow us to treat several pathologies related to the odontoid process and craniocervical junction. Cases such as giant basilar invagination represent a surgical challenge.

Methods

The authors provide technical nuances and describe how to complete an endoscopic endonasal odontoidectomy and release the craniocervical junction with the aim of restoring a correct sagittal balance in cases with giant basilar invagination. The study of cadaveric specimens adds clarifying dissections.

Conclusions

Endonasal endoscopic odontoidectomy and craniocervical junction joint release allow the treatment of irreducible basilar invagination and restoration of better sagittal balance before posterior cervical occipitocervical fusion.

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Author information

Authors and Affiliations

  1. Department of Neurological Surgery, Hospital Virgen Del Rocío, Avenida Manuel siurot s/n 41013, Sevilla, Spain

    Eugenio Cárdenas Ruiz-Valdepeñas, A. Kaen & G. Perez Prat

Authors
  1. Eugenio Cárdenas Ruiz-Valdepeñas
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  2. A. Kaen
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  3. G. Perez Prat
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Corresponding author

Correspondence to Eugenio Cárdenas Ruiz-Valdepeñas.

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Disclosure

The authors report no financial disclosures.

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Key points

(1) Ensure the patient understands the process, which includes two staged surgeries and a halo vest immobilization.

(2) Follow appropriate surgical indications and planning using CT angiography scans.

(3) Extra-long endoscopic instruments are imperative to access the deepest areas.

(4) Clivus drilling is essential to access the odontoid process tip.

(5) Condyle joint subperiosteal dissection affords a large and safe exposure. Removal of soft tissue before drilling may help prevent unexpected drill rumbling.

(6) Bilateral occipitoatlantal joint drilling is the key for CVJ disengagement.

(7) Odontoid process resection resembles the tumoral resection principles. Start debulking the cancellous bone and then dissect the cortical bone from the dura.

(8) After the odontoidectomy, dural sac reexpansion may increase the risk of CSF leaks. It is desirable to evade the risk of a CSF leakage and to plan its repair in case of need.

(9) Extension and distraction produced by the halo vest make a near total sagittal balance restoration possible.

(10) Posterior occipitocervical instrumentation completes the process, requiring a halo vest before reaching a proper arthrodesis.

Electronic supplementary material

A video with the necessary steps to complete an endonasal endoscopic odontoidectomy as well as to disarticulate the craniocervical junction is attached. This video includes parts of different patients adding those where each concept is most clearly seen. (MP4 22,788 kb)

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Cárdenas Ruiz-Valdepeñas, E., Kaen, A. & Perez Prat, G. How I do it? Cranial setup for cranial settling. Acta Neurochir 159, 1919–1923 (2017). https://doi.org/10.1007/s00701-017-3231-z

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  • DOI: https://doi.org/10.1007/s00701-017-3231-z

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