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Endoscopic Endonasal Approach to the Upper Cervical Spine for Decompression of the Cervicomedullary Junction Following Occipitocervical Fusion.

TitleEndoscopic Endonasal Approach to the Upper Cervical Spine for Decompression of the Cervicomedullary Junction Following Occipitocervical Fusion.
Publication TypeJournal Article
Year of Publication2018
AuthorsHussain I, Schwartz TH, Greenfield JP
JournalClin Spine Surg
Volume31
Issue7
Pagination285-292
Date Published2018 08
ISSN2380-0194
KeywordsCervical Vertebrae, Decompression, Surgical, Endoscopy, Humans, Image Processing, Computer-Assisted, Magnetic Resonance Imaging, Occipital Bone, Operating Rooms, Patient Positioning, Postoperative Complications
Abstract

Basilar invagination is defined as abnormal upward and/or posterior displacement of the odontoid leading to ventral compression of the cervicomedullary junction. This condition leads to lower cranial neuropathies, sensorimotor deficits, and myelopathy. These symptoms can persist even after posterior decompression, which is an indication for ventral decompression. Transoral approaches to the upper cervical spine carry significant morbidity, limiting their utility. The endonasal approach to the upper cervical spine presents an alternative for patients with amenable anatomy. In this report, we present a case of a patient with type 1 Chiari malformation with persistent symptoms despite adequate posterior decompression through suboccipital craniectomy and C1 laminectomy. A retroflexed odontoid and dorsal clival bone lip contributed to persistent cervicomedullary compression. To address this, we performed a 2-stage procedure: an occiput-to-C4 fusion followed by endoscopic endonasal approach for dorsal clivusectomy, C1 anterior arch resection, and odontoidectomy. In the associated video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A52), we demonstrate the step-by-step approach for this anterior approach including positioning, dissection through the nasopharyngeal fascia, identification of bony landmarks using an intraoperative CT scanner with 3-dimensional navigation guidance, and drilling/bony decompression of the dorsal clivus, C1, and C2. We also discuss key pearls, pitfalls, and preoperative/postoperative considerations critical to successful outcomes.

DOI10.1097/BSD.0000000000000620
Alternate JournalClin Spine Surg
PubMed ID29538039