Abstract
Recently, a purely transnasal endoscopic approach (TNEA) for decompression of the anterior cranio-cervical junction has been described. At present, there is only a limited number of patients having been operated on in a few specialized centers. The possibilities, safety, and limits of this approach are still under investigation. The relationship between TNEA and occipito-cervical fusion, especially, which may typically be considered in this kind of pathologies, should be further elucidated. So far, the feasibility of TNEA after previous occipito-cervical fusion has only been reported for a single case. In that case, there was a posterior atlanto-axial subluxation and basilar invagination. In the present paper, another example of a surgical procedure of TNEA after previous posterior fusion during the same operative setting is given. It differs from the other case concerning the pathophysiology. In fact, here, there was anterior atlanto-axial subluxation and no basilar invagination. The possibilities and limits of this novel approach are thoroughly discussed. Special interest is given to the problem of CCJ instability and previous occipito-cervical fusion. Technical hints and pitfalls are described in detail.
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Enrico de Divitiis, Naples, Italy
With the publication of this manuscript, the authors reported their single case experience afforded the extension of the endoscopic endonasal approaches. Besides, it is interesting to notice how such area, because of its strategic “position”, often results with this approach when the several widespread neoplastic and/or inflammatory diseases are involved. Furthermore, the treatment of such lesions is still controversial, being debated among different specialists such as ENT surgeons, maxillo-facial surgeons, and/or neurosurgeons. In such a case, collaborative surgery has been performed by two tuned operators using four-hand technique through a binostril approach. The present study could be considered another contribution to demonstrate the feasibility of the endoscopic transnasal approach for many different lesions of the skull base, thus increasing the anatomical and surgical skills and experience of surgeons working in this deep and complex operative field.
Domenico Solari, Paolo Cappabianca, Naples, Italy
In this interesting clinical paper, Cornelius et al. report a single case experience of a pure transnasal endoscopic odontoidectomy, once again shedding light on the possibilities provided by this technique. Several anatomical studies and clinical reviews have demonstrated the feasibility of the endonasal route for different pathologies involving multiple areas of the skull base and, more recently, the CVJ area. This manuscript is another example of the work in progress to improve the knowledge and the refinement of such approaches. The Authors confirmed that this route could be considered in the management of midline CVJ disease as an alternative to the widely accepted microsurgical transoral approach, though it guarantees the respect of the surrounding structures, notwithstanding the narrowness of the field. Besides, the creation of a muscle-mucosal flap seems to be a good solution for the closure, even though the access to intradural lesions seems as yet unsafe.
Another important aspect they weigh in on is the relevance of team approach, which magnifies the efforts and the results provided, to reach the difficult goals of our discipline. As a matter of fact, endoscopic skull base surgery has been developed due to the cooperation among neurosurgeons on one side and ENT and cranio-maxillo-facial surgeons on the other.
Finally, we should be reminded of the relevant role played by image-guidance systems, i.e., the neuronavigator, in providing the surgeon with correct orientation to the targeted area.
Henry W. S. Schroeder, Greifswald, Germany
Cornelius et al. present a patient who underwent a transnasal endoscopic odontoidectomy after a posterior cervicocranial fusion had been performed because of C1/2 instability. The technique is described in detail and discussed. The authors achieved a very good outcome. Only few similar cases have been reported previously. This interesting case report demonstrates nicely an expanded indication for an endonasal endoscopic approach and shows the advantages of the endoscope when dealing with such lesions. Although the microscope provides a high-resolution stereoscopic view, there is a considerable loss of light at the entry point in narrow and deep surgical approaches. Furthermore, the neurosurgeon works within the light beam which further diminishes the light intensity in the surgical field. And last but not least, with the microscope, structures can only be visualized when they are located just in front of the lens. Using the endoscope, the surgeon brings the eye close to the surgical target with perfect illumination even in a very deep surgical field. The panoramic view of the endoscope shows more anatomical details, and therefore orientation is facilitated. Endoscopes with angled optics enable a look around a corner or behind neurovascular structures which is beneficial in many interventions.
Compared with the transoral approach to the odontoid, the endonasal approach is clearly preferable because it causes less postoperative discomfort for the patient. Oral feeding can be initiated early after surgery avoiding the need for gastric tubes.
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Cornelius, J.F., Kania, R., Bostelmann, R. et al. Transnasal endoscopic odontoidectomy after occipito-cervical fusion during the same operative setting—technical note. Neurosurg Rev 34, 115–121 (2011). https://doi.org/10.1007/s10143-010-0295-0
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DOI: https://doi.org/10.1007/s10143-010-0295-0