The endoscopic transnasal approach to the lesions of the craniocervical junction: two case reports

Abstract

The endoscopic endonasal approach (EEA) to the craniovertebral junction (CVJ) has recently been considered a safer alternative and less invasive approach than the traditional transoral approach because the complications associated with the latter are avoided or minimized. Here, we present two challenging cases of CVJ pathologies. The first case involved os odontoideum associated with anterior displacement of the occipitocervical junction where the EEA was used, followed by C0-C1-C2 fusion using a posterior approach to decompress the CVJ, and was complicated by rhinorrhea and Candida albicans meningitis. The second case involved basilar invagination with syringomyelia previously treated using a posterior approach, where aggravation of neuropathic symptoms required combined treatment with EEA and occipitocervical fusion of C0-C2-C3-C4, with the postoperative course challenged by operative site infection requiring drainage with debridement and antibiotic therapy. The EEA is an alternative approach for accessing the CVJ in well-selected patients. Knowledge of EEA complications is crucial for the optimal care of patients.

Keywords: Candida albicans; Endoscopy; Meningitis; Odontoid process; Postoperative complications.

Fig. 1.

(A) Sagittal, (B) axial T2 magnetic resonance imaging, and (C) sagittal computed tomography scan of the cervical spine show an os odontoideum associated with anterior displacement of the occipitocervical junction resulting in compression of the spinal cord at the level of the odontoid process tip marked by arrows.

Fig. 2.

(A) Sagittal computed tomography scan of the cervical spine performed after the second surgery showed the extent of decompression marked by an arrow; and reduction in displacement with (B) left and (C) right parasagittal views showed occipitocervical fusion of C0-C1-C2 by the posterior approach.

Fig. 3.

(A) Sagittal computed tomography (CT) scan and (B) magnetic resonance imaging of the craniocervical junction show the residual syringomyelic cavity from C4 to T1 with compression of the brainstem by the basilar impression marked by white stars. Postoperative (C) sagittal and (D) axial CT scans show the extent of resection of the C1 anterior arch and odontoid tip marked by an arrow.

Fig. 4.

Intraoperative photographs of the endoscopic approach showing (A) the initial exposure of the C1 anterior arch marked by a black star, (B) drilling of the C1 anterior arch marked by a black star, (C) drilling of the odontoid marked by a black star, and (D) extent of decompression at the end of drilling marked by a black star.