Article
Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process and the retro-odontoid region in same sitting after occipitocervical fixation and decompression
Der posteriolaterale epidurale supra-C2-Nervenwurzel Zugang für Biopsien von Läsionen im und hinter dem Dens axis nach occipitozervikaler Fusion und Dekompression
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Authors
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Patrick Haas
- University of Tübingen, Department of Neurosurgery, Tübingen, Deutschland
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Till-Karsten Hauser
- University of Tübingen, Department of Neuroradiology, Tübingen, Deutschland
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Kosmas Kandilaris
- University of Tübingen, Department of Neuropathology, Tübingen, Deutschland
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Sebastian Schenk
- University of Tübingen, Department of Anesthesiology and Intensive Care Medicine, Tübingen, Deutschland
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Marcos Tatagiba
- University of Tübingen, Department of Neurosurgery, Tübingen, Deutschland
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Sasan Darius Adib
- University of Tübingen, Department of Neurosurgery, Tübingen, Deutschland
| Published: | June 4, 2021 |
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Outline
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Objective: This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of unusual lesions of the odontoid process (OP) and retro-odontoid region.
Methods: The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional-print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an x-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc).
The trajectory is immediately above the C2-root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants).
Results: We performed PESCA in two patients with unusual lesions of the odontoid process (patient 1: 72-year-old man) and the retro-odontoid region (patient 2: 70-year-old woman). Both patients recovered well from surgery. The pathological examination of the masses showed in the first case a very unusual spondylodiscitis of the OP (microbiological analysis of the probe revealed Corynebacterium striatum) and in the second case a crowned dens syndrome. The lesions were treated in the first case with vancomycine and in the second case with non-steroidal anti-inflammatory drugs.
Conclusion: In both of our patietns the pathological findings were the key to the successful treatment of two very rare diseases. PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.
