The Naso-Axial Line: A New Method of Accurately Predicting the Inferior Limit of the Endoscopic Endonasal Approach to the Craniocervical Junction

Objective This study was aimed to achieve gross-total removal of a chordoma of the craniocervical junction via an endonasal approach (Fig. 1). Design The present study is a case report. Setting The study was conducted at neurosurgical clinic of university hospital. Participant A 40-year-old male, with normal neurologic exam and no prior medical history, presented with a 2-year history of cervicalgia. On preoperative imaging, a midline lesion, with image characteristics of chordoma, was seen in the lower clivus and odontoid. It had limited lateral extension. Main Outcome Measures This study measures postoperative neurological deficits and postoperative tumor volume on magnetic resonance imaging (MRI). Results A binostril approach to the upper nasopharynx was performed using endoscope at 30- and 45-degree angles. Subsequently, a heart-shaped mucosal flap was made and the clivus was drilled to expose the lesion (Fig. 2). After initial debulking, the ring of C1 was slightly drilled to reach the tumor in and around the odontoid. Postoperative MRI showed that a gross-total resection was achieved. The patient had no neurologic deficits postoperatively. Pathologic examination revealed a chordoma of the classical type. Conclusion An endoscopic endonasal approach, utilizing the heart-shaped flap and angled endoscopes and instruments, can be considered for resection of select cases of craniocervical junction chordoma with limited lateral expansion.The link to the video can be found at: https://youtu.be/rwVoZJRBIEo.

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Endoscopic Endonasal Approach to Foramen Magnum Meningioma—Technical Note and Case Example

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1673428 ◽

2018 ◽

Vol 37 (04) ◽

pp. 362-366

Author(s):

Flavio Romero ◽

Rodolfo Vieira ◽

Bruno Ancheschi

Keyword(s):

Cranial Nerves ◽

Craniocervical Junction ◽

Foramen Magnum ◽

Technical Note ◽

Open Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Midline Approach ◽

Lower Cranial Nerves

AbstractForamen magnum (FM) tumors represent one of the most complex cases for the neurosurgeon, due to their location in a very anatomically complex region surrounded by the brainstem and the lower cranial nerves, by bony elements of the craniocervical junction, and by the vertebrobasilar vessels. Currently, the open approach of choice is a lateral extension of the posterior midline approach including far lateral, and extreme lateral routes. However, the transoraltranspharyngeal approach remains the treatment of choice in cases of diseases affecting the craniocervical junction. For very selective cases, the endoscopic endonasal route to this region is another option. We present a case of a ventral FM meningioma treated exclusively with the endoscopic endonasal approach.

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Endoscopic Endonasal Approach to the Odontoid and Craniocervical Junction

Progress in Neurological Surgery - Endoscopic Approaches to the Skull Base ◽

10.1159/000329227 ◽

2012 ◽

pp. 152-167

Author(s):

Paul A. Gardner ◽

Matthew J. Tormenti ◽

Amin B. Kassam ◽

Richard M. Spiro ◽

Daniel M. Prevedello ◽

...

Keyword(s):

Craniocervical Junction ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

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Sixth Cranial Nerve Palsy and Craniocervical Junction Instability due to Metastatic Urothelial Bladder Carcinoma

Case Reports in Neurology ◽

10.1159/000496419 ◽

2019 ◽

Vol 11 (1) ◽

pp. 24-31 ◽

Cited By ~ 1

Author(s):

Davide Nasi ◽

Mauro Dobran ◽

Lucia di Somma ◽

Alfredo Santinelli ◽

Maurizio Iacoangeli

Keyword(s):

Neck Pain ◽

Bladder Carcinoma ◽

Cranial Nerve ◽

Cranial Nerve Palsy ◽

Nerve Palsy ◽

Craniocervical Junction ◽

Spinal Instability ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal

Metastases involving the clivus and craniocervical junction (CCJ) are extremely rare. Skull base involvement can result in cranial nerve palsies, while an extensive CCJ involvement can lead to spinal instability. We describe an unusual case of clival and CCJ metastases presenting with VI cranial nerve palsy and neck pain secondary to CCJ instability from metastatic bladder urothelial carcinoma. The patient was first treated with an endoscopic endonasal approach to the clivus for decompression of the VI cranial nerve and then with occipitocervical fixation and fusion to treat CCJ instability. At the 6-month follow-up, the patient experienced complete recovery of VI cranial nerve palsy. To the best of our knowledge, the simultaneous involvement of the clivus and the CCJ due to metastatic bladder carcinoma has never been reported in the literature. Another peculiarity of this case was the presence of both VI cranial nerve deficit and spinal instability. For this reason, the choice of treatment and timing were challenging. In fact, in case of no neurological deficit and spinal stability, palliative chemo- and radiotherapy are usually indicated. In our patient, the presence of progressive diplopia due to VI cranial nerve palsy required an emergent surgical decompression. In this scenario, the extended endoscopic endonasal approach was chosen as a minimally invasive approach to decompress the VI cranial nerve. Posterior occipitocervical stabilization is highly effective in avoiding patient’s neck pain and spinal instability, representing the approach of choice.

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A Staged Strategy for Craniocervical Junction Chordoma with Combination of Endoscopic Endonasal Approach and Far Lateral Approach with Endoscopic Assistance: Case Report

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1667018 ◽

2018 ◽

Vol 79 (S 04) ◽

pp. S371-S377 ◽

Cited By ~ 2

Author(s):

Shunya Hanakita ◽

Moujahed Labidi ◽

Kentaro Watanabe ◽

Sebastien Froelich

Keyword(s):

Treatment Strategy ◽

Treatment Plan ◽

Craniocervical Junction ◽

Lateral Approach ◽

Endoscopic Endonasal Approach ◽

Endonasal Approach ◽

Endoscopic Endonasal ◽

Far Lateral Approach ◽

Endoscopic Assistance ◽

Far Lateral

Objective While the endoscopic endonasal approach (EEA) has gained widespread acceptance for the resection of clivus chordomas, conventional transcranial approaches still have a crucial role in craniocervical junction (CCJ) chordoma surgery. In repeat surgery, a carefully planned treatment strategy is needed. We present a surgical treatment plan combining an EEA and a far-lateral craniotomy with endoscopic assistance (EA) in the salvage surgery of a recurrent CCJ chordoma. Case Presentation A 37-year-old woman who had undergone partial resection of a chordoma extending from the mid-clivus to the CCJ. Technique A two-stage surgical intervention was planned. First, we opted for an EEA with the intention of removing only the extradural and medial compartments of the lesion. The rationale was to avoid intradural dissection of possibly adherent tissues from the previous procedures and to minimize the cerebrospinal fluid leak risk. One month after the first endonasal stage, a far lateral craniotomy was performed. After removal of the lateral mass and pedicle of C1, a large surgical corridor to the tumor was obtained. Tumor loculations disseminated in and around the CCJ and located in the areas blind to microscopic examination were then successfully resected with EA. An occipito-cervical fusion was then performed during the same procedure. Conclusion In addition to the exact location and morphology of the tumor, history of previous surgery was an important factor in devising a treatment strategy in this case of clivus chordoma. EA was also found to be instrumental in improving the reach of the far lateral approach.

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