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Table of Contents    
Year : 2013  |  Volume : 61  |  Issue : 1  |  Page : 69-72

Endoscopic transnasal odontoidectomy using ultrasonic bone curette: Technical case report

1 Department of Neurosurgery, University of Torino, Torino, Italy
2 Department of Otolaryngology, University of Brescia, Brescia, Italy
3 Department of Neurosurgery, University of Brescia, Brescia, Italy

Date of Submission06-Nov-2012
Date of Decision25-Nov-2012
Date of Acceptance21-Jan-2013
Date of Web Publication4-Mar-2013

Correspondence Address:
Francesco Zenga
Department of Neurosurgery, University of Torino, Torino
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.108015

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 » Abstract 

A 65-year-old woman, a case of cranio-vertebral junction anomaly, presented with a sudden onset of quadriparesis, dysphagia, and breathing difficulty and required emergency surgery. She underwent image-guided endoscopic transnasal odontoidectomy followed by occipito-cervical decompression and stabilization. She recovered well, with immediate improvement of respiratory function. Burning paresthesias disappeared and the upper limbs function normalized.

Keywords: Cervical spine, craniovertebral junction anomaly, odontoidectomy, skull base, transnasal endoscopy, ultrasonic bone curette

How to cite this article:
Zenga F, Villaret AB, Fontanella MM, Nicolai P. Endoscopic transnasal odontoidectomy using ultrasonic bone curette: Technical case report. Neurol India 2013;61:69-72

How to cite this URL:
Zenga F, Villaret AB, Fontanella MM, Nicolai P. Endoscopic transnasal odontoidectomy using ultrasonic bone curette: Technical case report. Neurol India [serial online] 2013 [cited 2023 Feb 6];61:69-72. Available from: https://www.neurologyindia.com/text.asp?2013/61/1/69/108015

 » Introduction Top

Ventral compression due to craniovertebral junction (CVJ) anomalies has been traditionally accessed through a transoral approach. Since 2002 several anatomic studies emphasized the possibility to access this region through a transnasal corridor. [1],[2],[3] In 2005, Kassam's group underlined the feasibility of an endoscopic transnasal odontoidectomy. [4],[5],[6] Cooperation between otolaryngologists and neurosurgeons, technological improvements, and design of dedicated instruments greatly contributed to the reproducibility and success of the technique and several case reports yielded highly promising results. [7],[8],[9],[10],[11],[12],[13],[14] In 2010, Cappabianca et al. highlighted the value of an ultrasonic bone curette (UBC) as an ancillary device in both standard and extended transplanum approaches. [15] In this technical report, we present a patient who underwent emergency image guided endoscopic endonasal decompression of the CVJ by UBC followed by occipito-cervical decompression and stabilization.

 » Case Report Top

The patient was a 65-year-old woman with a long history of gait disturbances associated with progressive increasing paresthesias of four limbs refractory to all kind of opioid medication and selective serotonin reuptake inhibitors. Because of progressive worsening of symptoms, the patient was referred to the emergency. Magnetic resonance imaging (MRI) and computed tomography (CT) scans demonstrated a severe stenosis of the CVJ [Figure 1] b-c.

Due to sudden onset of quadriparesis, absolute dysphagia, and breathing difficulty, a naso-gastric feeding tube was positioned, a tracheostomy was performed, and she was admitted to the Intensive Care Unit for acute respiratory distress. Endoscopic transnasal odontoidectomy followed by occipito-cervical decompression and stabilization was scheduled as an emergency. Intraoperative neurophysiological monitoring was used. Extra-long high-speed microdrill (Anspach Effort, Palm Beach Gardens, FL, USA) and Sonopet Omni Ultrasonic Surgical System (Styker, Inc., Kalamazoo, MI, USA) were adopted. We used two disposable tips: The Payner 360 (model N 817-25) [Figure 2]a and the Spetzler Microclaw™ (model N 808-25) [Figure 2]b. This device allows selective bone emulsification based on longitudinal and torsional oscillation of the tip with a frequency of 25 kHz. CT-MRI fusion image guidance registration was undertaken (BrainLAB AG, Heimstetten, Germany). The ventral aspect of the foramen magnum and the anterior arch of C1 were identified [Figure 3] and drilled away starting from the midline. After image guided confirmation of the odontoid, a 2 mm coarse diamond burr was used to enter its anterior cortex [Figure 4]. The use of the UBC was reserved to removal of the tip of the dens, the base and the interface between the posterior cortex of the dens, and the soft tissues covering the spinal dura.
Figure 1: (a) Intraoperative picture showing the posterior portion of the right nasal cavity and the nasopharynx at the beginning of the procedure, (b) axial and, (c) sagittal preoperative MRI show upper cord compression, (d) 1-month postoperative endoscopic control highlights a well-healed nasopharyngeal mucosa and sphenoid sinus opened on its floor, (e) early postoperative sagittal CT reconstruction, and (f) 6-month postoperative MRI show successful odontoidectomy, occipito-cervical decompression and stabilization TT - Torus tubarius; V - Vomer; SP - Soft palate; LPM - Lateral pterygoid muscle; NF - Nasopharynx; O - Odontoid; SS - Sphenoid sinus; PE - Posterior ethmoid

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Figure 2: (a) Intraoperative pictures showing ultrasound-assisted odontoidectomy with Payner 360 and (b) Spetzler Claw tips

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Figure 3: Image guided localization of the midline and corresponding endonasal view. Note the rostro-caudal endonasal route toward the odontoid through the lower clivus P - Probe

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Figure 4: Image guided localization during microdrill-assisted odontoid cavitation and corresponding endonasal view P - Probe; ST - Suction tube

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After surgery the patient was followed in the Intensive Care Unit for 4 days with an improvement of respiratory drive and resolution of upper limbs paresis. Postoperative CT scan and MRI confirmed complete CVJ decompression [Figure 1]e-f. The nasogastric tube and tracheostomy were removed after 2-3 weeks with normal diet intake and normal respiratory function. Paresthesias disappeared within 1 month. The upper limbs function is normalizing. She is actually followed in a rehabilitation center to properly restore the lower limbs function. The patient underwent follow-up nasal endoscopy at 1 and 6 months postoperative period [Figure 1]d and [Figure 5]. Compared to the preoperative endoscopic view [Figure 1]a, the resection of the posterior third of the nasal septum and drilling of the sphenoid floor provided a direct midline exposure of the CVJ area.
Figure 5: Six-month postoperative endoscopic control. 70-degree view. Complete healing and remucosalization of the residual sphenoid floor. Physiologic mucus drainage (asterisk) from the natural sphenoid ostium (arrow head) to the spheno-ethmoid recess is visible NS - Nasal septum; R - Rostrum; SS - Sphenoid sinus; ST - Superior turbinate; MT - Middle turbinate

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 » Discussion Top

The endonasal technique provides an inside view of the CVJ and allows a less invasive decompression in selected cases. The inferior limit of the exposure is underlined by the Kassam's line (aka nasopalatine line). [16] Relative contraindications to the transoral odontoidectomy (i.e., retropharyngeal medialization of internal carotid artery, micrognathia, macroglossia, etc.,) can be addressed with the endonasal approach. Since 2005, surgical experiences reported in the literature underlined the need of dedicated instruments, state-of-the-art endoscopic equipment and image guidance. [4],[5],[6],[11]

Several factors contribute to the adaptability of the UBC to the transnasal approach to the CVJ: It provides a bone emulsification-irrigation-suction mechanism in single-hand, the thermal damage is minimal, dedicated tips are available, and the cost of the main unit can be shared between different departments of the hospital. This device allows selective bone emulsification based on longitudinal and torsional oscillation with minimal termal damage, which, combined with a meticulous respect for the sphenoid ostia, resulted in complete healing and remucosalization of the residual sphenoid floor [Figure 5].

A case of supposed UBC vibration-related spinal cord injury has been reported in the literature. [17] We used the UBC in about 10 endoscopic skull base procedures (unpublished data) and we never experienced related complications. The UBC is safe and effective; it contributes to reduce soft tissue manipulation and to optimize the surgical time. Larger series and follow-up validation studies should compare this emerging technique with the transoral approach.

 » References Top

1.Alfieri A, Jho HD, Tschabitscher M. Endoscopic endonasal approach to the ventral cranio-cervical junction: Anatomical study. Acta Neurochir (Wien) 2002;144:219-25.  Back to cited text no. 1
2.Cavallo LM, Cappabianca P, Messina A, Esposito F, Stella L, de Divitiis E, et al. The extended endoscopic endonasal approach to the clivus and cranio-vertebral junction: Anatomical study. Childs Nerv Syst 2007;23:665-71.  Back to cited text no. 2
3.Messina A, Bruno MC, Decq P, Coste A, Carvallo LM, de Diivittis E, et al. Pure endoscopic endonasal odontoidectomy: Anatomical study. Neurosurg Rev 2007;30:189-94.  Back to cited text no. 3
4.Kassam A, Abla A, Snyderman C, Carrau R, Spiro R. An endoscopic transnasal odontoidectomy to treat cervicomedullary compression with basilar invagination. Oper Tech Neurosurg 2005;8:198-204.  Back to cited text no. 4
5.Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: A fully endoscopic transnasal approach and resection of the odontoid process: Technical case report. Neurosurgery 2005;57:E213.  Back to cited text no. 5
6.Nayak JV, Gardner PA, Vescan AD, Carrau RL, Kassam AB, Snyderman CH. Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease. Am J Rhinol 2007;21:601-6.  Back to cited text no. 6
7.Magrini S, Pasquini E, Mazzatenta D, Mascari C, Galassi E, Frank G. Endoscopic endonasal odontoidectomy in a patient affected by Down syndrome: Technical case report. Neurosurgery 2008;63:E373-4.  Back to cited text no. 7
8.Wu JC, Huang WC, Cheng H, Liang ML, Ho CY, Wong TT, et al. Endoscopic transnasal transclival odontoidectomy: A new approach to decompression: Technical case report. Neurosurgery 2008;63:ONSE92-4.  Back to cited text no. 8
9.Fraser JF, Anand VK, Schwartz TH. Endoscopic biopsy sampling of tophaceous gout of the odontoid process. Case report and review of the literature. J Neurosurg Spine 2007;7:61-4.  Back to cited text no. 9
10.Hansen MA, da Cruz MJ, Owler BK. Endoscopic transnasal decompression for management of basilar invagination in osteogenesis imperfecta. J Neurosurg Spine 2008;9:354-7.  Back to cited text no. 10
11.Laufer I, Greenfield JP, Anand VK, Härtl R, Schwartz TH. Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: Feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report. J Neurosurg Spine 2008;8:376-80.  Back to cited text no. 11
12.Leng LZ, Anand VK, Hartl R, Schwartz TH. Endonasal endoscopic resection of an os odontoideum to decompress the cervicomedullary junction: A minimal access surgical technique. Spine (Philla Pa 1976) 2009;34:E139-43.  Back to cited text no. 12
13.Hankinson TC, Grunstein E, Gardner P, Spinks TJ, Anderson RC. Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression. J Neurosurg Pediatr 2010;5:549-53.  Back to cited text no. 13
14.Cornelius JF, Kania R, Bostelmann R, Herman P, George B. Transnasal endoscopic odontoidectomy after occipito-cervical fusion during the same operative setting-technical note. Neurosurg Rev 2011;34:115-21.  Back to cited text no. 14
15.Cappabianca P, Cavallo LM, Esposito I, Barakat M, Esposito F. Bone removal with a new ultrasonic bone curette during endoscopic endonasal approach to the sellar-suprasellar area: Technical note. Neurosurgery 2010;66:E118.  Back to cited text no. 15
16.de Almeida JR, Zanation AM, Snyderman CH, Carrau RL, Prevedello DM, Gardner PA, et al. Defining the nasopalatine line: The limit for endonasal surgery of the spine. Laryngoscope 2009;119:239-44.  Back to cited text no. 16
17.Kim K, Isu T, Matsumoto R, Isobe M, Kogure K. Surgical pitfalls of an ultrasonic bone curette (SONOPET) in spinal surgery. Neurosurgery 2006;59:ONS390-3.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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