Sat., Dec.

6, 2008, 8:39 8:46 AM CSRS-2008

Paper #36

Endoscopic Transcervical Ventral Decompression of Craniocervical Deformities

Jean-Paul Wolinsky, MD, Baltimore, MD, USA (n);
Matthew J McGirt, MD, Baltimore, MD, USA (e-Intrinsics Therapeutics);
Ziya L Gokaslan, MD, Baltimore, MD, USA (a-AO North America, Medtronic, DePuy,
Integra; b-AO North America; d-US Spine, Spinal Kinetics)

Introduction: A variety of cranio-cervical deformities can result in brainstem and/or spinal

cord compression. Irreducible pathology is approached ventrally followed by posterior
stabilization. Approaches traditionally are based on the transoral route with a transmandibular
or transmaxillary extension. The morbidity of these approaches include: meningitis due to
traversing the oral cavity, prolonged intubation, need for tracheostomy, the need to avoid oral
intake, and gastrostomy feeding. We have developed a minimally invasive technique for ventral
decompression of the craniocervical junction utilizing an endoscopic transcervical approach
(ETA).1,2 Presented are 12 patients that have undergone the ETA, and their outcomes.

Methods: Twelve patients have undergone the endoscopic transcervical approach for
decompression of the cranio-cervical junction in symptomatic patients with irreducible
pathology at our institution since May of 2006. We reviewed the patients age, sex, preoperative
and postoperative modified Ranawat (0-4, rather than 0,1,2,3a, 3b) scores and Japanese
Orthopedic Association myelopathy (JOA) scores, total blood loss (combined anterior and
posterior operations), length of postoperative hospital stay, and complications. We have also
tabulated (Table 1) the specific pathology, the degree of basilar invagination (as measured by
mm of the dens above the McGregor line), the anterior atlanto-dental interval (AADI), and the
posterior atlanto-dental interval (PADI).

Results: Our series includes seven females and five males. Ages ranged from 11 to 73 years. The
median preoperative modified Ranawat score was 3 (range 2-4), and the median preoperative
JOA score was 10 (range 3-16). The median postoperative modified Ranawat score was 0
(range 0-3), and the median postoperative JOA score was 17 (range 13-17). Improvement of the
median modified Ranawat score and the median JOA score was statistically significant with a
p<0.001 for both scoring methods. The mean blood loss for both the anterior decompression and
posterior stabilization was 355 +/-250cc (range 50 - 600cc). The mean length of postoperative
hospital stay was 10 +/-5 days (range 2 - 20 days). Complications included OC instrumentation
failure (1 after trauma 5 months postop), intraoperative CSF leak (2 without postop sequelae).
No patient required tracheostomy or developed significant dysphagia.

Conclusion: The ETA is a novel minimally invasive endoscopic approach and effective method
of ventral decompression of cranio-cervical deformities with a low complication profile.

If noted, the author indicates something of value received. The codes are identified as a-research or insti-
tutional support; b-miscellaneous non-income support/miscellaneous funding; c-royalties; d-stock or stock
options; e-consultant or employee; n-nothing of value received, and *disclosure not available at time of
printing. For full information refer to inside back cover.

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Table 1: Irreducible pathology of the cranio-cervical junction and corresponding measurement
of the anterior atlanto-dental interval (AADI), posterior atlanto-dental interval (PADI), and
degree of basilar invagination measured as the number of millimeters the top of the dens lies
above the McGregor line (mm BI). BI = basilar invagination; CS = cranial settling; RA =
rheumatoid arthritis; SAH = subarachnoid hemorrhage.

mm mm mm
Age/Sex Preoperative Diagnosis AADI PADI BI
42F BI, Occ - C1 Assimilation,
C2-3 Autofusion 3 15 8
69F BI, RA, C1-C2 Instability 5 14 14
73M BI, RA, C1-C2 Instability 6 10 11
63F BI, RA, C1-C2 Instability 3 10 14.8
49M BI, Failed OC Fusion, C1 fracture,
Syrinx, Gr 5 Aneurysmal SAH 3 8 14
14F CS, Platybasia, Osteogenesis
Imperfecta, Cranial Settling, Syrinx 1 8 35
11M BI, Downs Syndrome, Failed
OC Fusion 3 7 7.6
13M BI, Occ - C1 Assimilation,
C2-3 Autofusion, Syrinx 5 7 5
18F BI, Platybasia, Chiari Malformation,
C2-3 Autofusion, Syrinx 5 20 3
72F C2 Pannus, RA, C1-C2 Instability,
C5-6 and C6-7 subaxial instability
and spinal cord compression 1 2 0
11F BI, Failed OC Fusion, Failed Transoral
Odontoidectomy 7.4 12 0
51M BI, Occ - C1 Assimilation,
C2-3 Autofusion 5.5 12 11

The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug
or medical device is being discussed for an off label use). See inside back cover for full information.

128
Figure 1: Preoperative sagital and axial CT (A&B); Postoperative sagital and axial CT
(C&D)

References:

1. Wolinsky JP, Sciubba DM, Suk I, Gokaslan ZL. Endoscopic image-guided odontoidectomy
for decompression of basilar invagination via a standard anterior cervical approach.
J Neurosurg Spine 2007; 6: 184-191.

2. McGirt MJ, Attenello FJ, Sciubba DM, Gokaslan ZL, Wolinsky JP. Endoscopic
transcervical odontoidectomy for pediatric basilar invagination and cranial settling.
J Neurosurg Pediatrics 2008; 1: 337-342.

If noted, the author indicates something of value received. The codes are identified as a-research or insti-
tutional support; b-miscellaneous non-income support/miscellaneous funding; c-royalties; d-stock or stock
options; e-consultant or employee; n-nothing of value received, and *disclosure not available at time of
printing. For full information refer to inside back cover.

129