Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review

Abstract

<jats:p>The endoscopic transnasal approach to the rostral pediatric spine and craniovertebral junction is a relatively new technique that provides an alternative to the traditional transoral approach to the anterior pediatric spine. In this case series, the authors provide 2 additional examples of patients undergoing endoscopic transnasal odontoidectomies for ventral decompression of the spinal cord. Both patients would have required transection of the palate to undergo an effective transoral operation, which can be a cause of significant morbidity. In one case, transnasal decompression was initially incomplete, and decompression was successfully achieved via a second endoscopic transnasal operation. Both cases resulted in significant neurological recovery and stable long-term spinal alignment. The transnasal approach benefits from entering into the posterior pharynx at an angle that often reduces the length of postoperative intubation and may speed a patient's return to oral intake. Higher reoperation rates are a concern for many endoscopic approaches, but there are insufficient data to conclude if this is the case for this procedure. Further experience with this technique will provide a better understanding of the indications for which it is most effective. Transcervical and transoral endoscopic approaches have also been reported and provide additional options for pediatric anterior cervical spine surgery.</jats:p>

Evolution from microscopic transoral to endoscopic endonasal odontoidectomy

“…Serious complications documented in previous case reports and clinical series 3,[9][10][11][12]14,16,17,25,26,30,31,34 are infrequent. However, maintaining the integrity of the dura mater is crucial.…”

“…Previous studies 3,[9][10][11][12]14,16,17,22,25,26,30,31,34 have demonstrated the effectiveness and feasibility of an odontoidectomy performed using an EEA and suggest the possibility of less invasiveness than with the oral or cervical approaches. In our small series there is no evidence of different neurological functional outcomes between the techniques.…”

“…Nevertheless, accurate neuronavigation is an important adjunct for achieving a complete odontoidectomy. Hickman et al 12 reported a pediatric endonasal odontoidectomy that required a second intervention, and they explained that the main factor was the lack of accuracy of the navigation system because of the loosening of the head pins in the thin skull attributable to osteogenesis imperfecta. Gempt et al 9 performed a second surgery for a laterally and caudally expanded resection 5 days after the first surgery, due to persistent symptoms and brainstem compression.…”

“…1,22 In 2005, Kassam et al 14 documented an expanded endoscopic endonasal approach (EEA), which has since been used, modified, and reported by several authors. 9,11,12,[16][17][18]34,36 We present our experience with craniocervical pathological entities that required posterior instrumentation and odontoidectomy. Endoscopic endonasal odontoidectomy (EEO) and transoral microscopic odontoidectomy (TMO) are described, analyzed, and compared.…”

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

“…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.…”