J Neurol Surg B Skull Base 2021; 82(S 02): S65-S270

DOI: 10.1055/s-0041-1725319

Presentation Abstracts
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An Institutional Evolution of Endoscopic Endonasal Odontoidectomy: From Occipito-

Cervical Fusion to Atlanto-Axial Fusion to Partial Anterior Arch of C1 Resection, and
Utilization of a Retropharyngeal Vascularized Flap
Hanna Algattas , David McCarthy , David K. Hamilton , David O. Okonkwo , Eric W. Wang , Carl H. Snyderman , Paul A. Gardner , Georgios A. Zenonos

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Background: Posterior fixation practices after endonasal odontoidectomy have moved away from occipitocervical fixations
(OCF) to atlantoaxial fusions (AAF), and endonasal decompressions have transitioned from complete anterior C1 arch
resections, to partial resections, preserving atlas' structural integrity. Furthermore, complete resection of the
retropharyngeal soft tissues has evolved to vascularized rhinopharyngeal (RP) flap reconstructions.

Objective: We sought to evaluate the impact this transition in practices had on clinical outcomes, based on our institutional
experience.

Methods: Retrospective review of endoscopic endonasal odontoidectomy cases with instrumented fusion between 2008 and
2020. Electronic medical records were queried for demographic, operative, and follow-up data. Pre- and postoperative CT
and MR images were evaluated and ventral triangular area of decompression calculated ([Fig. 1]).

Results: Thirty-four patients underwent endonasal odontoidectomy and fusion for basilar invagination (n = 12) or
rheumatoid pannus (n = 22); 19 received OCF and 15 AAF, with average follow-up of 34 months. Myelopathy was the most
common presenting feature, 23/34 (68%), followed by dysphagia, 14/34 (41%). A rhinopharyngeal flap was used in 12/34
(35%). Of RP patients, 3/12 had preexisting dysphagia none of which worsened postoperatively. Rates of infection were
similar with or without RP. Rates of CSF leak, wound complications, and chronic neck pain were similar between OCF and
AAF. There was no increased risk of hardware failure, deformity, adjacent segment disease (ASD), or redo cervical operation
with AAF compared with OCF. There was an increased risk of postop dysphagia in patients with OCF (8/19; 2/8 had pre-op
dysphagia) compared with AAF (1/15; the one had pre-op dysphagia; 42 vs. 7%; p = 0.047). Risk of tracheostomy was
26% among the OCF cohort versus 7% in AAF patients (p = 0.13). Twenty-four patients had complete C1 arch resection
while 10 were incomplete. There was no difference in degree of ventral decompression of the cervicomedullary junction with
complete versus incomplete arch of C1 resection. The average ventral triangular area of compression pre- and
postoperatively among patients with complete arch removal was 2.65 and 1.24 cm2, respectively, whereas in patients with
incomplete removal the values were 3.00 and 1.49 cm2, respectively. Within our follow-up period was no significant
difference between rates of hardware failure, deformity, ASD, or redo cervical operation between OCF and AAF with or
without complete resection of the anterior arch of C1.

Conclusion: AAF does not confer increased risk of hardware failure, deformity, ASD, or revision compared with OCF, while
the latter is associated with increased risk for dysphagia. AAF should therefore be performed preferentially over OCF when
feasible. Partial resections of the anterior arch of C1 did not lessen degree of decompression and may help maintain atlas
structural integrity. These changes combined with use of an RP flap represent an evolution of the overall management of
irreducible odontoid disease.

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 (https://www.thieme-connect.de/media/jnlsb/2021S02/10-1055-s-0041-1725319-od035-
1.jpg)
Fig. 1 Ventral triangular compression calculation.

No conflict of interest has been declared by the author(s).

Publication History

Publication Date:
12 February 2021 (online)

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