TECHNICAL CASE REPORT THE EXPANDED ENDONASAL APPROACH:AFULLY ENDOSCOPIC TRANSNASAL APPROACH AND RESECTION OF THE ODONTOID PROCESS:TECHNICAL CASE REPORT Amin B. Kassam, M.D. Departments of Neurological Surgery and Otolaryngology, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania Carl Snyderman, M.D. Department of Neurological Surgery and Otolaryngology, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania Paul Gardner, M.D. Department of Neurological Surgery, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania Ricardo Carrau, M.D. Department of Neurological Surgery and Otolaryngology, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania Richard Spiro, M.D. Department of Neurological Surgery, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, Pittsburgh, Pennsylvania Reprint requests: Amin Kassam, M.D., Department of Neurological Surgery, University of Pittsburgh and University of Pittsburgh Medical Center, Presbyterian University Hospital, 200 Lothrop Street, Pittsburgh, PA 15213. Email: kassamab@upmc.edu Received, November 1, 2004. Accepted, February 18, 2005. THE TRANSORAL APPROACH to the odontoid process is considered the “gold standard” for resection of extradural lesions at this location. A completely transnasal endoscopic approach is feasible based on anatomic studies and our experience with the expanded endonasal approach for neoplasms of the cranial base. An illustrative case is presented to demonstrate the technical details of a fully transnasal completely endoscopic approach for the resection of the odontoid process. A 73-year-old woman with a long-standing history of rheumatoid arthritis presented with progressive cervi- comedullary compression. Complete resection of the odontoid was achieved with no significant morbidity. This is the first reported case of a completely endoscopic resection of the odontoid using a fully transnasal route. The report demonstrates the feasibility of this approach and larger clinical series with long-term follow-up will be needed to determine the reproducibility and validation of any potential benefits. KEY WORDS: Basilar invagination, Cranial settling, Dens, Endonasal, Endoscopic, Odontoid, Rheumatoid arthritis, Spine, Transoral Neurosurgery 57[ONS Suppl 1]:ONS-213–ONS-214, 2005 DOI: 10.1227/01.NEU.0000163687.64774.E4 T he anterior approach to the rostral cervical spine and cervicomedullary junction has be- come a well-established route of access to the atlantoaxial region and was first explored in 1935 by German (9). Since then, the transoral ap- proach has been used extensively (2–6, 8–16, 18, 19, 21) for a wide range of pathological entities, in- cluding basilar invagination (8, 15), rheumatoid arthritis with craniocervical settling and/or pan- nus, odontoid fractures (6) or nonunion, tumor (both extradural and intradural) (3), and odontoid hypoplasia (9). In an effort to aid visualization during the transoral approach, endoscopic assistance has been introduced (7, 20). Based on our experi- ence with the expanded endonasal endoscopic approach (EEA), we describe a fully endo- scopic, completely transnasal approach to re- sect the odontoid process. The feasibility of this approach has been demonstrated in a ca- daveric study by Alfieri et al. (1). In this re- port, we provide a detailed description of our technique for the resection of the odontoid process and rheumatoid pannus in a patient with symptomatic craniocervical compression secondary to rheumatoid arthritis (Fig. 1). CASE REPORT A 73-year-old woman with a long- standing history of rheumatoid arthritis pre- sented with progressive neck pain and cer- vicomedullary junction compression. The patient had clinical findings of myelopathy. Motor power was found to be Grade 4/5 in the upper and lower extremities. Subjec- tively, the patient noted increasing difficulty with swallowing. Preoperative imaging re- vealed significant compression of the cervi- comedullary junction (Fig. 2). The patient underwent EEA with resection of the odontoid process and a posterior fusion (occiput to C3) during the same surgical epi- sode and was placed in a cervical collar post- operatively. She was transferred to the inten- sive care unit and was extubated the next morning. She was discharged to a rehabilita- tion facility 1 week postoperatively. At her 1-month postoperative visit, she had increas- ing motor strength of Grade 5/5 power and improved swallowing function. Postoperative imaging revealed a complete resection of the odontoid (Fig. 3). NEUROSURGERY VOLUME 57 | OPERATIVE NEUROSURGERY 1 | JULY 2005 | ONS-E213