Atlanto-occipital Instability Following Endoscopic Endonasal Approach for Lower Clival Lesions

Neurosurgery ◽  
2015 ◽  
Vol 77 (6) ◽  
pp. 888-897 ◽  
Author(s):  
Ali Kooshkabadi ◽  
Phillip A. Choi ◽  
Maria Koutourousiou ◽  
Carl H. Snyderman ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Foramen Magnum ◽  
Open Approach ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Combined Approach ◽  
Endoscopic Endonasal ◽  
Primary Bone Tumors ◽  
Far Lateral Approach ◽  
Lower Clivus ◽  
Occipital Condyles

BACKGROUND: The endoscopic endonasal approach (EEA) for craniocervical lesions involving the lower clivus and occipital condyles carries an unclear risk of atlanto-occipital (AO) instability requiring arthrodesis. OBJECTIVE: Elucidate risk factors for AO instability following EEA for clival lesions. METHODS: We reviewed patients with clival tumors who underwent EEA at our institution between 2002 and 2012. Resection of the lower clivus, foramen magnum, AO joint, and occipital condyles were evaluated on fine-cut postoperative computed tomography. RESULTS: Two hundred twelve patients (mean age 47.9 years, 57.1% male) underwent transclival EEA for lower clival lesions. In addition to the lower clivus, resection involved the condyle in 14.2% of patients, the foramen magnum in 16.5%, and the AO joint in 1.4%. Quantification of condyle resection revealed complete resection in 3 cases, 75% resection in 8 cases, 50% resection in 6 cases, and 25% resection in 13 cases. Seven of these patients had EEA combined with an open, far-lateral approach. In total, 7 patients required arthrodesis following EEA (3.3%), 4 of them after a combined approach. All patients who underwent arthrodesis had primary bone tumors such as chordoma, chondrosarcoma, or osteosarcoma (P = .022). Degree of condyle resection was a significant factor predisposing to occipitocervical instability (P = .001 and P < .001 for 75% and 100% condyle resection, respectively). Use of a combined approach was significantly associated with arthrodesis (P < .001). CONCLUSION: EEA resection of the occipital condyles that results in greater than 75% condyle resection or EEA in combination with an open approach significantly increases the risk of AO instability and likely necessitates AO fixation.

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

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.

Endoscopic Endonasal Approaches to the Clivus with No Violation of the Nasopharynx: Surgical Anatomy and Clinical Illustration

2021 ◽  
Author(s):  
Carlos D. Pinheiro-Neto ◽  
Laura Salgado-Lopez ◽  
Luciano C.P.C. Leonel ◽  
Serdar O. Aydin ◽  
Maria Peris-Celda
Keyword(s):  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Surgical Anatomy ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

Abstract Background Despite the use of vascularized intranasal flaps, endoscopic endonasal posterior fossa defects remain surgically challenging with high rates of postoperative cerebrospinal fluid leak. Objective The aim of the study is to describe a novel surgical technique that allows complete drilling of the clivus and exposure of the craniovertebral junction with preservation of the nasopharynx. Methods Two formalin-fixed latex-injected anatomical specimens were used to confirm feasibility of the technique. Two surgical approaches were used: sole endoscopic endonasal approach and transnasion approach. The sole endonasal approach was used in a patient with a petroclival meningioma. Results In both anatomical dissections, the inferior clivectomy with exposure of the foramen magnum was achieved with a sole endoscopic endonasal approach. The addition of the transnasion approach helped to complete drilling of the inferior border of the foramen magnum and exposure of the arch of C1. Conclusion This study shows the anatomical feasibility of total clivectomy and exposure of the craniovertebral junction with preservation of the nasopharynx. A more favorable anatomical posterior fossa defect for the reconstruction is achieved with this technique. Further clinical studies are needed to assess if this change would impact the postoperative CSF leak rate.

Endoscopic Endonasal Approach to Foramen Magnum Meningioma: Two-Dimensional Surgical Video

2020 ◽  
Vol 137 ◽  
pp. 362
Author(s):  
Raíssa Mansilla ◽  
Daniel Monte Serrat Prevedello ◽  
Lázaro de Lima ◽  
Ricardo L. Carrau ◽  
José Alberto Landeiro
Keyword(s):  
Foramen Magnum ◽  
Two Dimensional ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Surgical Video

scholarly journals Chordoma of the Craniocervical Junction: Endoscopic Endonasal Approach

2019 ◽  
Vol 80 (S 04) ◽  
pp. S372-S374
Author(s):  
Eduard H. Voormolen ◽  
Pierre Olivier Champagne ◽  
Sebastien Froelich
Keyword(s):  
Craniocervical Junction ◽  
University Hospital ◽  
Neurological Deficits ◽  
Preoperative Imaging ◽  
Classical Type ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
Postoperative Mri ◽  
Lower Clivus

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.

scholarly journals The Tough Fibrous Tissue of The Supracondylar Groove As A Useful Landmark Via The Endoscopic Endonasal Approach To The Lower Clivus

2021 ◽  
Author(s):  
Changchen Hu ◽  
Liyuan Zhou ◽  
Hongming Ji ◽  
Gangli Zhang ◽  
Shengli Chen ◽  
...  
Keyword(s):  
Connective Tissue ◽  
Fibrous Tissue ◽  
Craniovertebral Junction ◽  
Fibrous Connective Tissue ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal ◽  
External Orifice ◽  
Surgical Corridor ◽  
Lower Clivus

Abstract Background: The hypoglossal canal (HGC) is the most important structural landmark for the endoscopic endonasal approach to access the lower clivus (LC). We explored the feasibility of using the tough fibrous tissue covering the supracondylar groove (SCG) as a useful landmark to identify the location of the HGC. Methods: Four cadaveric specimens were dissected and analyzed. The craniovertebral junction (CVJ) region was accessed utilizing 4-mm endoscope with either 0° or 30° lenses. CVJ exposure and the surgical corridor areas were measured. The relationship between the tough fibrous tissue covering the SCG and the HGC was analyzed.Results: Tough fibrous connective tissue was tightly attached the SCG and ran superomedially to inferolaterally. The angle between the horizontal plane and the long axis of the SCG was 30°. Separating the tough tissue inferolaterally, we could locate the external orifice (EO) of the HGC to further accurately isolate the hypoglossal nerve. Conclusion: The tough fibrous connective tissue covered the SCG to the upper part of the HGC EO. The course of the tough fibrous connective tissue was superomedial to inferolateral. Using the tough fibrous connective tissue covering the SCG as a landmark, it was possible to accurately locate the HGC EO via the endoscopic endonasal approach to access the LC.

The Anterior (Endoscopic Endonasal) Approach and Outcomes for Foramen Magnum Tumors

2019 ◽  
pp. 395-402
Author(s):  
Nathan T. Zwagerman ◽  
Juan C. Fernandez-Miranda ◽  
Eric W. Wang ◽  
Carl H. Snyderman ◽  
Paul A. Gardner
Keyword(s):  
Foramen Magnum ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

The Endoscopic Endonasal Approach to the Inferior Clivus and Foramen Magnum: Anatomical Landmarks in the Surgical Window

2015 ◽  
Vol 76 (S 01) ◽  
Author(s):  
Satyan Sreenath ◽  
Benjamin McClintock ◽  
Benjamin Huang ◽  
Kibwei McKinney ◽  
Brian Thorp ◽  
...  
Keyword(s):  
Foramen Magnum ◽  
Anatomical Landmarks ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

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

2018 ◽  
Vol 79 (S 04) ◽  
pp. S371-S377 ◽  
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.

scholarly journals Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations

2005 ◽  
Vol 19 (1) ◽  
pp. 1-14 ◽  
Author(s):  
Luigi M. Cavallo ◽  
Andrea Messina ◽  
Paolo Cappabianca ◽  
Felice Esposito ◽  
Enrico de Divitiis ◽  
...  
Keyword(s):  
Skull Base ◽  
Dura Mater ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Lateral Direction ◽  
Endoscopic Endonasal ◽  
Fresh Cadaver ◽  
Csf Leakage

Object The midline skull base is an anatomical area that extends from the anterior limit of the cranial fossa down to the anterior border of the foramen magnum. Resection of lesions involving this area requires a variety of innovative skull base approaches. These include anterior, anterolateral, and posterolateral routes, performed either alone or in combination, and resection via these routes often requires extensive neurovascular manipulation. The goals in this study were to define the application of the endoscopic endonasal approach and to become more familiar with the views and skills associated with the technique by using cadaveric specimens. Methods To assess the feasibility of the endonasal route for the surgical management of lesions in the midline skull base, five fresh cadaver heads injected with colored latex were dissected using a modified endoscopic endonasal approach. Full access to the skull base and the cisternal space around it is possible with this route. From the crista galli to the spinomedullary junction, with incision of the dura mater, a complete visualization of the carotid and vertebrobasilar arterial systems and of all 12 of the cranial nerves is obtainable. Conclusions The major potential advantage of the endoscopic endonasal approach to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, obviating brain retraction. Many tumors grow in a medial-to-lateral direction, displacing structures laterally as they expand, creating natural corridors for their resection via an anteromedial approach. Potential disadvantages of this procedure include the relatively restricted working space and the danger of an inadequate dural repair with cerebrospinal fluid (CSF) leakage and potential for meningitis resulting. These approaches often require a large opening of the dura mater over the tuberculum sellae and posterior planum sphenoidale, or retroclival space. In addition, they typically involve large intraoperative CSF leaks, which necessitate precise and effective dural closure.

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