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Endoscopic Transnasal Approach for Urgent Decompression of the Craniocervical Junction in Acute Skull Base Osteomyelitis.

ABSTRACT: Ventral epidural abscess with osteomyelitis at the craniocervical junction is a rare occurrence that typically mandates spinal cord decompression via a transoral approach. However, given the potential for morbidity with transoral surgery, especially in the setting of immunosuppression, together with the advent of extended endonasal techniques, the transnasal approach could be attractive for selected patients. We present two cases of ventral epidural abscess and osteomyelitis at the craniocervical junction involving C1/C2 that were successfully treated via the endoscopic transnasal approach. Both were treated in staged procedures involving posterior cervical fusion followed by endoscopic transnasal resection of the ventral C1 arch and odontoid process for decompression of the ventral spinal cord and medulla. Dural repairs were successfully performed using multilayered, onlay techniques where required. Both patients tolerated surgery exceedingly well, had brief postoperative hospital stays, and recovered uneventfully to their neurologic baselines. Postoperative magnetic resonance imaging confirmed complete decompression of the foramen magnum and upper C-spine. These cases illustrate the advantages and low morbidity of the endonasal endoscopic approach to the craniocervical junction in the setting of frank skull base infection and immunosuppression, representing to our knowledge a unique application of this technique to osteomyelitis and epidural abscess at the craniocervical junction.

SUBMITTER: Burns TC

PROVIDER: S-EPMC4520966 | biostudies-other | 2015 Jul

REPOSITORIES: biostudies-other

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Forces Applied at the Skull Base during Transnasal Endoscopic Transsphenoidal Pituitary Tumor Excision.

Project description:Objectives Our laboratory is developing a surgical robotic system to further improve dexterity and visualization that will allow for broader application of transnasal skull base surgery. To optimize this system, intraoperative force data are required. Using a modified curette, force data were recorded and analyzed during pituitary tumor excision. Design A neurosurgical curette was modified by the addition of a force sensor. The instrument was validated in an in vitro model to measure forces during simulated pituitary tumor excision. Following this, intraoperative force data from three patients during transnasal endoscopic excision of pituitary tumors was obtained. Setting Academic medical center. Main Outcome Measures Forces applied at the skull base during surgical excision of pituitary tumors. Results Average forces applied during in vitro testing ranged from 0.1 to 0.15 N. Average forces recorded during in vivo testing ranged from 0.1 to 0.5 N. Maximal forces occurred with collisions of the bony sella. The average maximal force was 1.61 N. There were no complications related to the use of the modified curette. Conclusions Forces to remove pituitary tumor are small and are similar between patients. The in vitro model presented here is adequate for further testing of a robotic skull base surgery system.

| S-EPMC3836813 | biostudies-literature

Morphometric measurements of the anterior skull base for endoscopic transoral and transnasal approaches.

Project description:The objective of this study is to determine the bony limits of the transnasal and transoral approaches to the anterior skull base. The data we present are meant to assist surgeons in preoperative planning for lesions of the sella, clivus, foramen magnum, and odontoid. Using precise measurements undertaken on 41 high-resolution computed tomography scans from patients at the University of Pennsylvania without any history of sinus or sellar pathology, we sought to define the bony limits of transoral and transnasal approaches. Direct measurements and calculated angles were used to assess the dimensions of the anterior skull base. Using our measurements, a transnasal approach can reach an average of 22.5 mm below the plane of the hard palate to the body of C2, and a transoral route can reach 38 mm above the basion along the length of the clivus. Analysis of variance demonstrated no significant differences when subjects were grouped based on race or gender. The measurements outlined within this article help to define the relative dimensions necessary for adapted transoral and transnasal skull base surgeries.

| S-EPMC3312413 | biostudies-other

Modified endoscopic transnasal orbital apex decompression in dysthyroid optic neuropathy.

Project description:BackgroundTo describe the surgical technique and assess the clinical efficacy and safety of modified endoscopic transnasal orbital apex decompression in the treatment of dysthyroid optic neuropathy.MethodsIn this retrospective research, forty-two subjects (74 orbits) who underwent modified endoscopic transnasal orbital apex decompression for the treatment of dysthyroid optic neuropathy were enrolled. Preoperative and postoperative best-corrected visual acuity (BCVA), visual field mean deviation (MD), Hertel exophthalmometry, and new onset diplopia were assessed before and after the intervention. The Wilcoxon test was used for differential analysis. Linear mixed-models' analyses were conducted to assess the potential predictors for BCVA change.ResultsPostoperatively, the mean BCVA improved from 0.70 ± 0.62 logMAR to 0.22 ± 0.33 logMAR. BCVA significantly improved in 69 eyes (93%), remained stable in 4 eyes (5%) and deteriorated in 1 eye (1%). MD of visual fields improved from -13.73 ± 9.22 dB to -7.23 ± 7.04 dB. Proptosis decreased from 19.57 ± 3.38 mm to 16.35 ± 3.01 mm. Preoperative BCVA, MD of visual fields and medical rectus diameter were independent factors associated with improvements in BCVA (P < 0.05) by linear mixed-models' analyses. Eighteen patients (42.9%) developed new diplopia postoperatively.ConclusionModified endoscopic transnasal orbital apex decompression effectively restores vision in dysthyroid optic neuropathy.

| S-EPMC8080388 | biostudies-literature

Endoscopic transnasal surgery as a replacement for maxillotomy techniques to approach the central skull base: fewer complications and more acceptable to patients?

Project description:Objectives To compare the complication rates of endoscopic transnasal and open maxillotomy approaches for the central skull base. Design Retrospective review. Setting Single-center study, London, United Kingdom. Participants From 1992 to 2012, 81 patients underwent surgery for skull base lesions, 59 by maxillotomy and 22 by endoscopy. Main Outcome Measures Total time of surgical anesthesia, blood loss, complications, duration of tracheal intubation, duration of hospital stay, myelopathy score, and mortality rate. Results The surgical time, blood loss, and duration of the postoperative intubation period were significantly less with endoscopy (p < 0.001). Requirements for intensive care, ward stay, and total hospital stay were also significantly less in the endoscopic group (p = 0.01, p < 0.001, and p < 0.001, respectively). The complication rate was lower with transnasal endoscopic surgery. Conclusion In patients for whom open maxillotomy or endoscopic surgery are both feasible, the preference should be to perform endoscopic surgery, with better visualization and fewer complications.

| S-EPMC4078146 | biostudies-other

Perioperative Considerations in Endoscopic Skull Base Surgery.

Project description:Purpose of the Review:Present an overview of perioperative considerations specific to endoscopic skull base surgery necessary to maximize successful outcomes. Recent Findings:The majority of perioperative considerations for endoscopic skull base surgery lack strong supporting evidence and frequently have varied use or implementation amongst institutions. A notable exception comes from a recent randomized controlled trial demonstrating the benefit of lumbar drainage in high-risk cerebrospinal fluid leaks. Summary:Skull base surgeons must consider a multitude of perioperative factors. While many components of perioperative management are extrapolated from related fields such as endoscopic sinus surgery or open cranial base surgery, additional high-quality studies are needed to delineate best practices specific to endoscopic skull base surgery.

| S-EPMC7223122 | biostudies-literature

Intraoperative Vagus Nerve Monitoring: A Transnasal Technique during Skull Base Surgery.

Project description:Objectives Intraoperative vagus nerve monitoring during skull base surgery has been reported with the use of an oral nerve monitoring endotracheal tube. However, the intraoral presence of an endotracheal tube can limit exposure by its location in the operative field during transfacial approaches and by limiting superior mobilization of the mandible during transcervical approaches. We describe a transnasal vagus nerve monitoring technique. Design and Participants Ten patients underwent open skull base surgery. Surgical approaches included transcervical (five), transfacial/maxillary swing (three), and double mandibular osteotomy (two). The vagus nerve was identified, stimulated, and monitored in all cases. Main Outcome Measures Intraoperative nerve stimulation, pre- and postoperative vagus nerve function through the use of flexible laryngoscopy in conjunction with assessment of subjective symptoms of hoarseness, voice change, and swallowing difficulty. Results Three patients had extensive involvement of the nerve by tumor with complete postoperative nerve deficit, one patient had a transient deficit following dissection of tumor off of nerve with resolution, and the remaining patients had nerve preservation. One patient experienced minor epistaxis during monitor tube placement that was managed conservatively. Conclusions Transnasal vagal nerve monitoring is a simple method that allows for intraoperative monitoring during nerve preservation surgery without limiting surgical exposure.

| S-EPMC4375050 | biostudies-other

Toward Video-Based Navigation for Endoscopic Endonasal Skull Base Surgery.

Project description:Endoscopic endonasal skull base surgery (ESBS) requires high accuracy to ensure safe navigation of the critical anatomy at the anterior skull base. Current navigation systems provide approximately 2mm accuracy. This level of registration error is due in part from the indirect nature of tracking used. We propose a method to directly track the position of the endoscope using video data. Our method first reconstructs image feature points from video in 3D, and then registers the reconstructed point cloud to pre-operative data (e.g. CT/MRI). After the initial registration, the system tracks image features and maintains the 2D-3D correspondence of image features and 3D locations. These data are then used to update the current camera pose. We present registration results within 1mm, which matches the accuracy of our validation framework.

| S-EPMC2850286 | biostudies-literature

Does Endoscopic Transnasal Optic Nerve Decompression Followed by Radiosurgery Improve Outcomes in the Treatment of Parasellar Meningiomas?

Project description:IntroductionThe clinical management of parasellar meningiomas (PM) is challenging due to their intimate association with critical neurovascular structures. Consensus regarding the recommended treatment protocol is lacking. This study will evaluate patients' visual outcomes following endoscopic transnasal optic nerve decompression (ETOND) and will investigate the possibility of reducing the rate of complications associated with stereotactic radiosurgery (SRS).MethodsRetrospective analysis was conducted on all patients who underwent ETOND for PM between 2013 and 2020. The study comprised 12 patients (7 women and 5 men aged 36-75 years; mean, 55.2 years; median, 57.6 years) in which 14 optic nerve decompression procedures were carried out. Patients were followed up for 6 to 86 months (mean, 29.3 months; median, 25 months). There were five cases of spheno-orbital meningioma, four cases of cavernous sinus meningioma, and one case each of petro-clival meningioma, optic nerve sheath meningioma, and planum sphenoidale/tuberculum sellae meningioma. Visual outcome was evaluated and any postoperative complications noted.ResultsImprovements in visual acuity were noted in 10 of 14 eyes (71.4%) 3 to 6 months postoperation. Visual acuity remained stable in the remaining four eyes. No deterioration of visual acuity was noted during the follow-up period. In total, 9 of the 12 patients underwent SRS. No tumor growth was determined, while reduction in tumor volume was noted in five patients following SRS. No complications associated with SRS or the surgical procedure were noted.ConclusionsETOND appears to be a promising technique for increasing rates of improved visual function, while reducing the risk of post SRS-related complications. In combination with subsequent SRS, it is an ideal treatment modality in the management of parasellar meningiomas. Confirmation of our findings would require a larger, prospective multicenter study.

| S-EPMC9414861 | biostudies-literature

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis.

Project description:ObjectIn the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes.MethodsA systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values.ResultsOf 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results.ConclusionIn this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

| S-EPMC5735207 | biostudies-literature

Modifications to the endoscopic approach for anterior skull base lesions improve postoperative sinonasal symptoms.

Project description:Background/Objective Our institution previously showed that patients experience significant postoperative sinonasal symptoms for the first few months after endoscopic transnasal transsphenoidal skull base surgery (eTNTS). Since our initial study we have modified our technique, discontinuing routine resection of the middle turbinate, maxillary antrostomies, and nasoseptal flaps. In this study, we analyze whether these technical modifications decrease postoperative sinonasal morbidity after eTNTS. Methods A retrospective review was performed of 93 consecutive patients who underwent eTNTS at a tertiary academic medical center from August 2011 to August 2012. Main Outcome Measures Sino-Nasal Outcome Test (SNOT)-20 and SNOT-22 scores preoperatively and after surgery. Results Compared with our previous study, our new cohort experienced a significant improvement (p < 0.05) in SNOT scores for the need to blow nose, runny nose, postnasal discharge, thick nasal discharge, wake up at night, reduced concentration, and frustrated/restless/irritable. Within the new cohort, patients who did not have a nasoseptal flap or middle turbinate resection had less worsening and faster improvement of nasal symptom scores after surgery. Conclusions Preserving normal sinonasal physiology during eTNTS by limiting middle turbinate resections, avoiding unnecessary maxillary antrostomies, and reducing the use of nasoseptal flaps when feasible results in less sinonasal morbidity and more rapid recovery during the postoperative period.

| S-EPMC3912144 | biostudies-other

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