November 2022

NEUROSCIENCES

CASE REPORT: ENDOSCOPIC TRANSCERVICAL ODONTOIDECTOMY FOR BASILAR IMPRESSION

A 40-year-old man from North Carolina presented to the emergency room with symptoms of dizziness and blurred vision. The patient had a history of head and neck pain and myelopathy, and he was being treated for migraines. Magnetic resonance imaging (MRI) revealed severe compression of his brain stem and spinal cord. His local care team diagnosed him with basilar invagination — a rare condition which causes the spine to press into the brain stem. Without surgical intervention, the patient’s condition could eventually progress to paralysis. The patient was referred to Jean-Paul Wolinsky, MD, a neurosurgeon at Northwestern Medicine, in Chicago, Illinois.
 
Dr. Wolinsky evaluated the patient preoperatively with computed tomography (CT) and MRI to confirm the diagnosis and determine the appropriate treatment method. He determined that the patient had cranial settling (a form of basilar impression) secondary to assimilation of the occiput and C1 and a C2-C3 Klippel-Feil resulting in C1-2 instability and brain stem compression.
 
Given the degree of crainal settling and brain stem compression it was felt that a posterior approach alone would not be sufficient to decompress the brain stem. Dr. Wolinsky recommended an endoscopic transcervical odontoidectomy — a novel surgical approach he developed – and occipitocervical (OC) fusion. This innovative procedure allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. Traditional routes for irreducible basilar invagination or cranial settling all require traversing the oral cavity with either a trans-oral approach or a trans-oral approach with an extended manidulotomy, increasing the risk for potential complications and the recovery time.
Preoperative and postoperative MRI scans showing basilar invagination and decompression following surgery. The post-op scan (right) shows the instrumentation in the occiput, C2, C4 and C5 with C1 fused to the head and C2-C3 fused together.
During the eight-hour procedure, Dr. Wolinsky and the surgical team detached the patient’s skull from his spine and carefully drilled away at the odontoid — the part of the spine that was pressing into the brain stem. Then, they stabilized the cranio-cervical junction with an occipital cervical instrumented fusion. The team used a total of nine screws and two rods.
 
The endoscopic transcervical procedure resulted in complete decompression. The patient didn’t have any postoperative complications or require prolonged intubation, tracheostomy, or enteral tube feeding. He was discharged from the hospital within a couple of days and was fully recovered in two months.
 
This less-invasive alternative surgical approach for treating ventral compression of the brainstem and spinal cord is safe and effective for decompression, and it provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.
 
See how the patient’s surgical team worked together to rebuild his spine >
 
Learn more about the endoscopic transcervical approach >
Jean-Paul Wolinsky, MD, is a professor of Neurological Surgery and Orthopaedic Surgery, vice chair of Strategy and Operations in the Department of Neurological Surgery, and a member of Lou and Jean Malnati Brain Tumor Institute of Robert H. Lurie Comprehensive Cancer Center of Northwestern Medicine.

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