Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases

Duntze, J.; Eap, C.; Kleiber, Jean‐Charles; Theret, E.; Dufour, Henry; Fuentès, S.; Litré, Claude Fabien

doi:10.1016/j.otsr.2014.07.017

Cited by 45 publications

(31 citation statements)

References 15 publications

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“…23 Endoscopic approaches at this juncture are relatively newer and may be useful in mitigating the morbidity associated with extended transoral approaches that require splitting of the soft palate, mandibulotomy, maxillotomy, or glossotomy to increase surgical exposure. 3,5,6 The relatively small series examining outcomes also suggest that they may allow for earlier extubation and resumption of feeding 10,13,32 and improve visualization in a narrow corridor before performing additional tissue destruction (i.e., splitting the soft palate). 7,16,25 conclusions…”

Section: Discussionmentioning

confidence: 99%

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

Mallory

Arutyunyan²,

Murphy

et al. 2016

SPI

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OBJECT Endoscopic approaches to the anterior craniocervical junction are increasing in frequency. Choice of oral versus endoscopic endonasal approach to the odontoid often depends on the relationship of the C1–2 complex to the hard palate. However, it is not known how this relevant anatomy changes with age. We hypothesize that there is a dynamic relationship of C-2 and the hard palate, which changes with age, and potentially affects the choice of surgical approach. The aim of this study was to characterize the relationship of C-2 relative to the hard palate with respect to age and sex. METHODS Emergency department billing and trauma records from 2008 to 2014 were reviewed for patients of all ages who underwent cervical or maxillofacial CT as part of a trauma evaluation for closed head injury. Patients who had a CT scan that allowed adequate visualization of the hard palate, opisthion, and upper cervical spine (C-1 and C-2) were included. Patients who had cervical or displaced facial/skull base fractures, a history of rheumatoid arthritis, or craniofacial anomalies were excluded. The distance from McGregor's palatooccipital line to the midpoint of the inferior endplate of C-2 (McL–C2) was measured on midsagittal CT scans. Patients were grouped by decile of age and by sex. A 1-way ANOVA was performed with each respective grouping. RESULTS Ultimately, 483 patients (29% female) were included. The mean age was 46 ± 24 years. The majority of patients studied were in the 2nd through 8th decades of life (85%). Significant variation was found between McL–C2 and decile of age (p < 0.001) and sex (p < 0.001). The mean McL–C2 was 27 mm in the 1st decade of life compared with the population mean of 37 mm. The mean McL–C2 was also noted to be smaller in females (mean difference 4.8 mm, p < 0.0001). Both decile of age (p = 0.0009) and sex (p < 0.0001) were independently correlated with McL–C2 on multivariate analysis. CONCLUSIONS The relationship of C-2 and the hard palate significantly varies with respect to age and sex, descending relative to the hard palate a full centimeter on average in adulthood. These findings may have relevance in determining optimal surgical approaches for addressing pathology involving the anterior craniocervical junction.

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Section: Discussionmentioning

confidence: 99%

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

Mallory

Arutyunyan²,

Murphy

et al. 2016

SPI

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“…25,47,55 Although these extended approaches can lead to significant enhancement of the surgical exposure, they also significantly increase surgical complexity and the depth of the operative corridor, rates of morbidities such as infections from bacterial oral flora, velopharyngeal insufficiency, hypernasal speech, nasal regurgitation, soft palate dehiscence, tongue edema, and necrosis, and the potential need for tracheotomy and nasogastric feeding tube, resulting in a longer hospital recovery time. 10,37,41,45 In the last decade, some minimally invasive endoscopic approaches, such as the EEA, 7,8,11,18,19,[21][22][23][24]26,27,29,30,[33][34][35]40,44,51 the ETA, 16,17 a combined EEA/ETA with or without the assistance of robotics, 12,13,31,32,50,54 and a transcervical approach, 53 have been adopted to address CVJ pathology. The growing number of publications in the last decade shows that the EEA can be an excellent minimal-access alternative to traditional transoral surgery and offers certain anatomical advantages.…”

Section: Discussionmentioning

confidence: 99%

“…All these publications highlight the benefits of endoscopic endonasal odontoidectomy as a safe, effective, and welltolerated technique. 7,8,11,18,19,[21][22][23][24]26,27,29,30,[33][34][35]40,44,51 The main advantages of the EEA over the traditional microscopic approaches are the location of the incision (in the nasopharynx rather than the oropharynx) and the wider, closer, and brighter view provided by the endoscope.…”

Section: Discussionmentioning

confidence: 99%

The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies

Corte

Aldana

Ferroli

et al. 2015

FOC

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OBJECT The endoscopic endonasal approach (EEA) provides a minimally invasive corridor through which the cervicomedullary junction can be decompressed with reduced morbidity rates compared to those with the classic transoral approaches. The limit of the EEA is its inferior extent, and preoperative estimation of its reach is vital for determining its suitability. The aim of this study was to evaluate the actual inferior limit of the EEA in a surgical series of patients and develop an accurate and reliable predictor that can be used in planning endonasal odontoidectomies. METHODS The actual inferior extent of surgery was determined in a series of 6 patients with adequate preoperative and postoperative imaging who underwent endoscopie endonasal odontoidectomy. The medians of the differences between several previously described predictive lines, namely the nasopalatine line (NPL) and nasoaxial line (NAxL), were compared with the actual surgical limit and the hard-palate line by using nonparametric statistics. A novel line, called the rhinopalatine line (RPL), was established and corresponded best with the actual limit of the surgery. RESULTS There were 4 adult and 2 pediatric patients included in this study. The NPL overestimated the inferior extent of the surgery by an average (± SD) of 21.9 ± 8.1 mm (range 14.7-32.5 mm). The NAxL and RPL overestimated the inferior limit of surgery by averages of 6.9 ± 3.8 mm (range 3.7-13.3 mm) and 1.7 ± 3.7 mm (range −2.8 to 8.3 mm), respectively. The medians of the differences between the NPL and NAxL and the actual surgery were statistically different (both p = 0.0313). In contrast, there was no statistically significant difference between the RPL and the inferior limit of surgery (p = 0.4375). CONCLUSIONS The RPL predicted the inferior limit of the EEA to the craniovertebral junction more accurately than previously described lines. The use of the RPL may help surgeons in choosing suitable candidates for the EEA and in selecting those for whom surgery through the oropharynx or the facial bones is the better approach.

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“…16,30 In patients with rheumatoid arthritis, the compressive soft-tissue pannus will generally resolve after occipitocervical fusion. 14 If, however, the basilar invagination is irreducible and/ or there is persistent symptomatic ventral compression of the cervicomedullary junction by the odontoid process or soft-tissue pannus, an anterior odontoidectomy and decompression of the craniovertebral junction are warranted. In cases of irreducible basilar invagination, we generally prefer first to perform an endoscopic endonasal odontoidectomy, followed by posterior occipitocervical stabilization in a staged fashion (within 48 hours).…”

Section: Cervical Tractionmentioning

confidence: 99%

“…18,43,49 Postoperative recovery after endonasal skull base surgery is generally quicker, the hospital stays are shorter, and patients are fed orally and ambulate earlier in the postoperative period than patients who undergo transoral procedures. 6,14,18,43 The endoscopic endonasal approach for odontoidectomy has been investigated in cadaveric studies and in several clinical studies. 2,4,6,14,18,23,24,28,32,33,38,[40][41][42][43][44][45][46]48 Although several variations in technique exist in the literature, the aims of this report are to describe our method of the purely endoscopic endonasal transclival transodontoid approach for anterior decompression of the craniovertebral junction and to describe various operative pearls and nuances of the technique.…”

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confidence: 99%

Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances

Liu

Patel²,

Goldstein³

et al. 2015

FOC

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The transoral approach is considered the gold-standard surgical route for performing anterior odontoidectomy and ventral decompression of the craniovertebral junction for pathological conditions that result in symptomatic cervicomedullary compression, including basilar invagination, rheumatoid pannus, platybasia with retroflexed odontoid processes, and neoplasms. Extended modifications to increase the operative corridor and exposure include the transmaxillary, extended “open-door” maxillotomy, transpalatal, and transmandibular approaches. With the advent of extended endoscopic endonasal skull base techniques, there has been increased interest in the last decade in the endoscopic endonasal transclival transodontoid approach to the craniovertebral junction. The endonasal route represents an attractive minimally invasive surgical alternative, especially in cases of irreducible basilar invagination in which the pathology is situated well above the palatine line. Angled endoscopes and instrumentation can also be used for lower-lying pathology. By avoiding the oral cavity and subsequently using a transoral retractor, the endonasal route has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia. Postoperative recovery is quicker, and hospital stays are shorter. In this report, the authors describe and illustrate their method of purely endoscopic endonasal transclival odonotoidectomy for anterior decompression of the craniovertebral junction and describe various operative pearls and nuances of the technique for avoiding complications.

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Advantages and limitations of endoscopic endonasal odontoidectomy. A series of nine cases

Abstract: IV retrospective study.

Cited by 45 publications

References 15 publications

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

The rhinopalatine line as a reliable predictor of the inferior extent of endonasal odontoidectomies

Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances

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