Name:
10.3171/2024.1.FOCVID23176
Description:
10.3171/2024.1.FOCVID23176
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Duration:
T00H10M24S
Embed URL:
https://stream.cadmore.media/player/8440d898-9b44-4d01-b601-3e078118a8e0
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https://cadmoreoriginalmedia.blob.core.windows.net/8440d898-9b44-4d01-b601-3e078118a8e0/2. 23-176.mp4?sv=2019-02-02&sr=c&sig=DHoMUMePeSMAavVo6TJHl5qPCaBv%2FAb7pKRTC8I89T0%3D&st=2024-12-22T01%3A34%3A20Z&se=2024-12-22T03%3A39%3A20Z&sp=r
Upload Date:
2024-12-22T01:39:20.5399730Z
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: We are presenting the case of endoscopic endonasal approach for odontoidectomy and resection of odontoid pannus and anterior cervicomedullary junction decompression of the spinal cord. The patient is a 77-year-old female with a history of spinal stenosis with progressive myelopathy. She presented to our institution with 1 year of progressive hand and feet numbness and tingling.
SPEAKER: She also had worsening symptoms and weakness, particularly in the right upper extremity. She initially presented to an outside hospital where she was found to have a large pannus at C1–2. Over there they performed a posterior cervical fusion from C1 to C4, as well as C1–2 laminectomies. However, the patient failed to improve after this. In fact, she complained that her symptoms were worsening. Of note, she also had a prior C4–7 ACDF that was done in 2019 to treat cervical radiculopathy.
SPEAKER: Her physical exam was significant for bilateral upper- extremity weakness, right side worse than the left side. She was able to walk by herself. However, she did have some difficulty with her balance. Her preop MRI at our hospital showed significant compression of the spinal cord from an anterior vector coming from this odontoid pannus, as we can see here in the sagittal and axial images.
SPEAKER: We can also notice that she also has T2 changes already in the spinal cord. Her preop CT shows the hardware from the C1–4 posterior cervical fusion, as well as her prior anterior cervical decompression and fusion. We also obtained a preop CTA that we obtain routinely in our patients to evaluate the location of the bilateral internal carotid arteries.
SPEAKER: In this particular case, you can see that the intercarotid distance is narrow, which is a factor to consider when performing the rhinopharyngeal flap as we're going to discuss later. The patient is positioned supine on the operating table with the left shoulder bump to have the patient facing toward us. The head is fixed in a 3-pin Mayfield in neutral position to avoid C1 from rotating on top of C2, which could bring one of the lateral masses anteriorly, difficult in the resection of the interior arch of C1 and the odontoid.
SPEAKER: We decided to proceed with an odontoidectomy since the patient's symptoms actually got worse after 6 months from her prior surgery. Here we can see the surgical corridor. And also we can see the inferior extent for the limit of our resection of the odontoid, which is delineated by the nasopalatine line, which has been described in prior publications by our team. This line has been represented here with the yellow arrow.
SPEAKER: And the area that can be resected from the odontoid has been represented in red color. We performed the entire surgery in collaboration with the ENT team. We started injecting some epinephrine in the mucosa of the nasal septum on each side. They also perform lateralization of the inferior turbinate on both sides. This allows to have more space to pass the instruments through the nose.
SPEAKER: We then perform a posterior septectomy with a needle-tip electrocautery. These cuts are done at the level of the choana and bring anteriorly about an inch, and then is turned inferiorly to the junction of the septum with the nasal floor. The second cut with the needle-tip Bovie is done at the junction of the septum and the nasal floor. This is done bilaterally.
SPEAKER: Once the mucosa is cut, it's subsequently elevated with a Cottle dissector. It's really important to notice here that this septectomy is done posterior and inferior to avoid damage to the nasoseptal flap pedicle. We then perform two cuts with a back-biter in the posterior aspect of the septum to release the mucosa, which is then removed. The exposed bone from the septum is then fractured with a Cottle dissector.
SPEAKER: We then remove any bony spicules to have a smooth surface to work. We drill the maxillary crest with a 4-mm diamond burr. This creates a smooth surface to work and facilitates the binostril access to this area, also allows us to reach down to the area of interest. We use navigation to confirm that we can reach below the anterior arch of C1.
SPEAKER: We also use Doppler and image guidance to study the localization of the ICAs bilaterally. Once we know where the internal carotid arteries are, we then start performing our cut with a needle-tip cautery. We started, in this case, on the left side. And then we're going to perform the superior cut of the rhinopharyngeal flap. In this particular case, because the carotid arteries were close to each other, meaning that the intercarotid distance was narrow, we decided it was safer to perform a vertical split of the rhinopharyngeal flap in a T-shape instead of an inverted U-shape.
SPEAKER: The dissection of the rhinopharyngeal flap is done very carefully. We dissect this flap off the anterior surface of the inferior clivus, all the way down to the vertebral body of C2 and it is carried out as lateral as safe as possible. We use navigation to confirm the location of the lateral masses of C1. We can also see here very clearly the anterior tubercle of C1, which is a midline structure.
SPEAKER: A high-speed drill was then used to remove the anterior ring of C1 between both lateral masses. After this drilling is completed with the help of a Kerrison ronguer, we disconnect the soft tissue off the anterior ring of C1. And this part of the bone is then removed, exposing the odontoid process of C2. We then use a 4-0 Vicryl stitch non–pop-up to retract each side of the rhinopharyngeal flap, which you can see here.
SPEAKER: The thread from each stitch is pulled out of the nose through the respective nostril, and then is secured under tension to the patient's drape with a mosquito. We then remove all the pannus that is anterior to odontoid process. And we start drilling the dens from top to bottom to keep it from disconnecting from the vertebral body of C2, which will create a tip of the dens that is floating with significant ligamentous attachment.
SPEAKER: We continue to drill the dens all the way down to the vertebral body of C2. This drilling is also carried out posteriorly, until a very thin rim of C2 dense is left behind. We then remove this posterior cortex of the odontoid process with the help of a Kerrison ronguer. You can see here all this pannus that is posterior to the dens, which is the area that is compressing the spinal cord.
SPEAKER: We use a combination of Kerrison ronguers as well as pituitary and ENT ethmoidals to resect this pannus off the dura. We resect all this abnormal tissue very carefully off the dura to avoid causing a durotomy. We continue to remove this pannus all the way deep to the level of the dura, until the dura is free, is ballooning, and is pulsatile, as we can appreciate in this segment of the video.
SPEAKER: Hemostasis is easily achieved with a combination of bipolar electrocautery, Surgifoam, and warm irrigation. We then remove the stitches that were holding on each side the RP flap. We use a 4-0 V-Loc stitch to put together each piece of the retropharyngeal flap.
SPEAKER: Once the RP flap has been sutured we then proceed to cut the stitch. And then we keep the flap in place with the help of a Merocel packing that is placed by our ENT colleagues. The surgery duration was 3 hours and the blood loss was 200 cc. The patient tolerated the procedure well. She spent 1 night in the ICU.
SPEAKER: She subsequently was discharged to inpatient rehab where she spent 1 week. And then she went home. Her pathology report confirmed an odontoid pannus with fibroconnective tissue. Her upper-extremity strength improved as well as her gait postoperatively. Her postop CT shows complete resection of the odontoid process.
SPEAKER: On the axial sequences you can see the removal of the anterior ring of C1. Her MRI shows adequate decompression of the ventral aspect of the spinal cord at the craniocervical junction. This can be also seen here in this comparison between her preop and her postop images.
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