Advancing Surgical Precision: Extended Endoscopic Endonasal Approach for C1–C2 Traumatic and Inflammatory Lesions

Introduction: Extended endoscopic endonasal approaches (EEA) have gained increasing popularity in addressing a variety of anterior cranio-vertebral junction (aCVJ) disorders. These include conditions such as rheumatoid arthritis-related bulbo-medullary compression, basilar invagination in complex CVJ malformations, and non-healed odontoid type CII fractures.

Materials and Methods: We conducted a retrospective analysis of 38 patients with aCVJ disorders who underwent EEA, either alone or in combination with conventional surgical approaches at our institution. Among these cases, 13 patients underwent a combined classical anterior transcervical and endoscopic endonasal C1–C2 endoscopic screw fixation approach for non-union of odontoid fractures. Five patients with CVJ malformations underwent a fully endoscopic endonasal decompression and C1–C2 fusion. Additionally, EEA was carried out in 20 patients with irreducible bulbo-medullary junction compression due to a migrated odontoid process and/or retro-periodontoid inflammatory process. Notably, endoscopic endonasal odontoidectomy was performed while preserving the anterior C1 arch, serving as a pivot point for anterior C1–C2 screw fixation. All patients underwent follow-up with MRI, CT scans, and dynamic X-rays.

Results: Improvement in the Nurick scale was observed in all cases. Radiologically, successful bulbo-medullary decompression was consistently achieved. However, two patients experienced delayed spine instability, necessitating posterior occipito-cervical fixation. Cases involving anterior endoscopic C1–C2 screw fixation demonstrated clear bone fusion. Two patients developed CSF leaks, while two others experienced mucosal incision dehiscence, both of which healed secondarily and were confirmed during endoscopic outpatient follow-up.

Conclusions: The EEA is a promising alternative to conventional open transcervical, posterolateral, or transoral approaches for addressing aCVJ disorders. Advantages of EEA include reduced invasiveness, enhanced maneuverability with a straightforward working angle, and improved potential for preserving the anterior C1 arch. Moreover, it allows for both decompression and anterior endoscopic C1–C2 fixation/fusion, thereby reducing the risk of cranial settling and the need for posterior fixation due to spine instability.

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Artikel online veröffentlicht:
05. Februar 2024