Troy D. Woodard

Transoral and transnasal odontoidectomy complications: A systematic review and meta-analysis

OBJECT The craniovertebral junction (CVJ) is a complex region of the spine with unique anatomical and functional relationships. To alleviate symptoms associated with pathological processes involving the odontoid process, decompression is often required, including odontoidectomy. Accurate knowledge of the complication rates following the transoral and transnasal techniques is essential for both patients and surgeons. METHODS We conducted MEDLINE, Scopus and Web of Science database searches for studies reporting complications associated with the transoral and transnasal techniques for odontoidectomy. Case series presenting data for less than three patients were excluded. Rates of complication and clinical outcomes were calculated and subsequently analyzed using a fixed-effects model to assess statistical significance. RESULTS Of 1288 articles retrieved from MEDLINE, Scopus, and Web of Science, twenty-six met inclusion criteria. Transoral and transnasal procedures resulted in the following respective complication rates: arterial injury 1.9% and 0.0%, intraoperative CSF leak 0.3% and 30.0%, postoperative CSF leak 0.8% and 5.2%, 30-day mortality 2.9% and 4.4%, medical complications 13.9% and 28.6%, meningitis 1.0% and 4.0%, pharyngeal wound dehiscence 1.7% (transnasal not reported), pneumonia 10.3% (transnasal not reported), prolonged or re-intubation 5.6% and 6.0%, reoperation 2.5% and 5.1%, sepsis 1.9% and 7.7%, tracheostomy 10.8% and 3.4%, velopharyngeal insufficiency 3.3% and 6.4% and wound infection 3.3% and 1.9%. None of these differences were statistically significant, except for postoperative tracheostomy, which was significantly higher after transoral odontoidectomy 8.4% (95% CI 4.9% -11.9%) compared to transnasal odontoidectomy 0.8% (95% CI -1.0% -2.9%). Neurologic outcome was improved in 90.0% and worse in 0.9% of patients after transoral compared to 94.0% and 0.0% after transnasal odontoidectomy (p=0.30). CONCLUSIONS This work presents a systematic review of complications reported for transoral or transnasal odontoidectomy across a heterogeneous group of surgeons and patients. Due to inconsistent reporting, statistical significance was only achieved for postoperative tracheostomy, which was significantly higher in the transoral group. This investigation sets the framework for further discussions regarding odontoidectomy approach options and their associated complications during the informed consent process.

The utility of lumbar drains in modern endoscopic skull base surgery.

Purpose of review Lumbar drains were once routinely used for cerebrospinal fluid (CSF) diversion in endoscopic skull base reconstruction. The vascularized pedicled nasoseptal flap has now become the reconstructive workhorse in the setting of high-flow leaks. High-flow CSF leaks occur when there is violation of a cistern or ventricle. As lumbar drains have the potential for significant complications and the rate of postoperative CSF leak has decreased with the use of vascularized flaps, lumbar drain use has been challenged. Recent findings Lumbar drains have a reported 3% major and 5% minor complication rates. Two recent studies reviewed their postoperative CSF leak rates after reconstruction of high-flow leaks. Garcia-Navarro described 46 cases in which a lumbar drain was placed in 67% of patients with two postoperative CSF leaks, one in each group. Eloy et al. described 59 patients without lumbar drain and reported no postoperative CSF leaks. Summary Lumbar drains are not necessary in the settings of low-flow CSF leaks or even in all high-flow leaks. We consider the use of a lumbar drain in settings wherein a high-flow leak is encountered or anticipated and the patient has other risk factors that may make the risk of postoperative CSF leak higher or closure of the leak more difficult.

Surgical outcomes after endoscopic management of cholesterol granulomas of the petrous apex: a systematic review

OBJECT Endoscopic endonasal treatment of petrous apex cholesterol granulomas allows for a natural drainage pathway into the nasopharynx. Because of the limited number of case series in the literature, there is limited evidence of recurrence rates and outcomes following endoscopic endonasal management. The purpose of this study was to determine the surgical outcomes of endoscopic endonasal approaches in the treatment of cholesterol granulomas of the petrous apex. METHODS A systematic literature review was performed using PubMed for articles published from January 1980 to April 2014 to identify all studies reporting outcomes for endoscopic endonasal surgical management of cholesterol granulomas of the petrous apex. Operative approach, use of a stent, symptom outcome, restenosis, cyst recurrence, reoperation, and complications were extracted from included studies. RESULTS A total of 53 patient cases were included from 22 relevant studies. The mean age was 41 years, and 26 patients (49%) were female. Stents were used in 45.1% of cases. Symptom resolution or improvement was seen in 98.6% of cases at follow-up (mean follow-up 20 months). Complications were reported in 13.2% of cases, with the most common complication being epistaxis. Restenosis on follow-up office endoscopic examination occurred in 9 of 45 cases (20.0%). Only 4 of these restenosis cases resulted in symptomatic cyst recurrence, resulting in an overall recurrence rate of 7.5%. The mean time from surgery to cyst recurrence was 13.5 months. The rate of symptomatic cyst recurrence was 10.7% in cases without the use of a stent compared with 4.3% in cases with stent placement (p = 0.6). CONCLUSIONS Based on current literature, endoscopic endonasal approaches result in a high rate of symptom improvement or resolution. Complication rates are lower than prior case series that have utilized open approaches. Asymptomatic restenosis can be managed conservatively, since it is associated with symptomatic cyst recurrence less than half of the time. This study revealed a nonsignificant trend toward a decrease in symptomatic cyst recurrence when a stent was used, but further work is needed to clarify its impact.

Multi-institutional study of risk factors for perioperative morbidity following transnasal endoscopic pituitary adenoma surgery

The goal of this study was to identify preoperative risk factors associated with increased perioperative morbidity after endoscopic pituitary surgery.

Epidemiologic factors affect surgical outcomes in allergic fungal sinusitis.

To evaluate discrepancies in presentation and postoperative outcomes in a population of allergic fungal sinusitis (AFS) patients.

Cerebrospinal Fluid Diversion in Endoscopic Skull Base Reconstruction: An Evidence-Based Approach to the Use of Lumbar Drains

Before the vascularized pedicled nasoseptal flap was popularized, lumbar drains (LDs) were routinely used for cerebral spinal fluid (CSF) diversion in endoscopic skull base reconstruction. LDs are not necessary in most CSF leaks encountered during skull base surgery. In this article, the use is considered of an LD in select high-risk settings in which a high-flow leak is anticipated and the patient has significant risk factors that make closure of the leak more challenging. Evidence for the use of LDs in preventing postoperative after endoscopic skull base reconstruction is reviewed and a rational framework for their use is proposed.

Endoscopic Skull Base Reconstruction: An Evolution of Materials and Methods

Endoscopic skull base surgery has developed rapidly over the last decade, in large part because of the expanding armamentarium of endoscopic repair techniques. This article reviews the available technologies and techniques, including vascularized and nonvascularized flaps, synthetic grafts, sealants and glues, and multilayer reconstruction. Understanding which of these repair methods is appropriate and under what circumstances is paramount to achieving success in this challenging but rewarding field. A graduated approach to skull base reconstruction is presented to provide a systematic framework to guide selection of repair technique to ensure a successful outcome while minimizing morbidity for the patient.

An Overview of Anterior Skull Base Meningiomas and the Endoscopic Endonasal Approach

Meningiomas represent 30% of all primary brain tumors. Anterior skull base meningiomas represent 8.8% of all meningiomas. Surgical resection is a main treatment option for tumors that are symptomatic and/or growing. Recurrence is directly related to the extent of resection of the tumor, the dural attachment, and pathologic bone. Endoscopic endonasal approaches represent an important addition to the treatment armamentarium for skull base meningiomas. This article provides an overview of meningiomas, with a focus on those of the anterior skull base and their management.

Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery

In patients undergoing transnasal endoscopic sellar surgery, an analysis of risk factors and predictors of intraoperative and postoperative cerebrospinal fluid leak (CSF) would provide important prognostic information.

Successful repair of intraoperative cerebrospinal fluid leaks improves outcomes in endoscopic skull base surgery

The impact of failed cerebrospinal fluid leak (CSF) leak repair in endoscopic skull base surgery has not been adequately studied.