Suture Repair in Endoscopic Surgery for Craniovertebral Junction

다국어 초록 (Multilingual Abstract)

Objective: Endoscopic approaches to the craniovertebral junction (CVJ) have been established as viable and effective surgical treatments in the past decade. One of the major complications is leakage of the cerebrospinal fluid (CSF). This study aimed to investigate the efficacy and feasibility of suture closure at the nasopharyngeal mucosa upon durotomy.
Methods: A series of consecutive patients who underwent different endoscopic approaches to the CVJ were retrospectively reviewed. The pathologies, surgical corridors, neurological and functional outcomes, radiological evaluations, and complications were analyzed. Different strategies of repair for the intraoperative CSF leakage were described and compared.
Results: A total of 22 patients covering 13 years were analyzed. There were 12, 2, and 8 patients who underwent transnasal, transoral, and combined approaches, respectively. There were 8 patients (36.4%) who experienced intraoperative CSF leakage, and were grouped into 2: 4 in the nonsuture (NS) group and 4 in the suture-repaired (SR) group. The NS group had 3 (75%) persistent CSF leakages postoperation that caused 1 mortality, whereas patients of the SR group had only 1 minor CSF rhinorrhea that healed spontaneously within days.
Conclusion: In this series of 22 patients who required anterior endoscopic resection of pathologies at the CVJ, there was 1 (4.5%) serious complication related to CSF leakage. For patients who had no durotomy, the mucosal incision at the nasopharynx usually healed rapidly and there were few procedure-related complications. For patients with intraoperative CSF leakage, suture closure was technically challenging but could significantly lower the risks of postoperative complications.

참고문헌 (Reference)

1 Goel A, "Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation" 1 : 281-286, 2004

2 Taggard DA, "Treatment of Down syndrome-associated craniovertebral junction abnormalities" 93 (93): 205-213, 2000

3 Weissler MC, "Transoral approaches to the skull base" 70 : 587-592, 1991

4 Enepekides DJ, "Transoral approaches to the clivus and nasopharynx" 34 : 1105-1121, 2001

5 Hsu W, "Transoral approaches to the cervical spine" 66 (66): 119-125, 2010

6 Goel A, "Three-dimensional models : an emerging investigational revolution for craniovertebral junction surgery" 25 : 740-744, 2016

7 El-Sayed IH, "The importance of platybasia and the palatine line in patient selection for endonasal surgery of the craniocervical junction : a radiographic study of 12 patients" 76 : 183-188, 2011

8 Chang PY, "The importance of atlantoaxial fixation after odontoidectomy" 24 : 300-308, 2016

9 Menezes AH, "Surgical approaches : postoperative care and complications"transoral-transpalatopharyngeal approach to the craniocervical junction"" 24 : 1187-1193, 2008

10 Kuo CH, "Primary endoscopic transnasal transsphenoidal surgery for magnetic resonance imagepositive cushing disease : outcomes of a series over 14 years" 84 : 772-779, 2015

11 Kuo CH, "Primary endoscopic transnasal transsphenoidal surgery for giant pituitary adenoma" 91 : 121-128, 2016

12 Marda M, "Post-operative pulmonary complications in patients undergoing transoral odontoidectomy and posterior fixation for craniovertebral junction anomalies" 29 : 200-204, 2013

13 Laborde G, "Limits of the transoral approach in craniospinal malformations" 2 : 6-10, 1992

14 Chang CC, "Letter to the editor : endoscopic transsphenoidal pituitary surgery" 126 : 1022-1023, 2017

15 Goel A, "Is atlantoaxial instability the cause of Chiari malformation? Outcome analysis of 65 patients treated by atlantoaxial fixation" 22 : 116-127, 2015

16 Yu X, "Intraoperative computed tomography with an integrated navigation system in stabilization surgery for complex craniovertebral junction malformation" 27 : 245-252, 2014

17 Taggard DA, "Instability of the craniovertebral junction and treatment outcomes in patients with Down’s syndrome" 6 : e3-, 1999

18 Goel A, "Immediate postoperative regression of retroodontoid pannus after lateral mass reconstruction in a patient with rheumatoid disease of the craniovertebral junction. Case report" 9 : 273-276, 2008

19 Choi D, "Evolution of transoral surgery : three decades of change in patients, pathologies, and indications" 73 : 296-303, 2013

20 Dlouhy BJ, "Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology : a treatment algorithm update" 38 : E8-, 2015

21 Moshel YA, "Endoscopic transnasal versus transoral approaches to the craniovertebral junction" 74 : 568-569, 2010

22 Wu JC, "Endoscopic transnasal transclival odontoidectomy: a new approach to decompression:technical case report" 63 (63): ONSE92-ONSE94, 2008

23 Yen YS, "Endoscopic transnasal odontoidectomy without resection of nasal turbinates : clinical outcomes of 13 patients" 21 : 929-937, 2014

24 Zweig JL, "Endoscopic repair of cerebrospinal fluid leaks to the sinonasal tract: predictors of success" 123 : 195-201, 2000

25 Kassam AB, "Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap" 63 (63): ONS44-ONS52, 2008

26 Morales-Valero SF, "Endoscopic endonasal approach for craniovertebral junction pathology : a review of the literature" 38 : E15-, 2015

27 Tosun F, "Endonasal endoscopic repair of cerebrospinal fluid leaks of the sphenoid sinus" 129 : 576-580, 2003

28 Wu JC, "Diseases of the odontoid and craniovertebral junction with management by endoscopic approaches" 44 : 1029-1042, 2011

29 Goel A, "Craniovertebral junction instability-an overview" 110 : 515-516, 2018

30 Menezes AH, "Craniovertebral junction abnormalities with hindbrain herniation and syringomyelia : regression of syringomyelia after removal of ventral craniovertebral junction compression" 116 : 301-309, 2012

31 Agrawal A, "Comparison of extraoral and transoral approaches to the craniocervical junction : morphometric and quantitative analysis" 74 : 178-188, 2010

32 El-Sayed IH, "Combined transnasal and transoral endoscopic approaches to the craniovertebral junction" 1 : 44-48, 2010

33 Atul Goel, "Cervical Fusion as a Protective Response to Craniovertebral Junction Instability: A Novel Concept" 대한척추신경외과학회 15 (15): 323-328, 2018

34 Goel A, "Atlantoaxial facet locking: treatment by facet manipulation and fixation. Experience in 14 cases" 14 : 3-9, 2011