Objective Lesions of the ventral craniovertebral junction are difficult to access owing to their deep location and proximity to critical neurovascular and pharyngeal structures. In this study, we aimed to describe the surgical technique and clinical outcomes of the endoscopic endonasal transnasopharyngeal approach for ventral craniovertebral junction lesions and highlight key considerations regarding approach selection, airway management, and occipitocervical stabilization.
Methods We retrospectively reviewed 7 patients who underwent the endoscopic endonasal transnasopharyngeal approach for ventral craniovertebral junction lesions. The analysis included preoperative planning for surgical access, intraoperative technique, postoperative management, airway and nutritional strategies, and the need for occipitocervical fixation. One representative case is presented to illustrate key technical steps.
Results Of the 7 patients, 6 had neoplastic lesions and 1 had basilar invagination. Despite a relatively large mean lesion size of 39.4 mm, subtotal or greater resection was achieved in 5 of the 6 tumor cases. Occipitocervical fixation was performed in 2 cases. Two patients underwent prophylactic tracheostomy because of anticipated airway compromise. Of the 5 orally intubated cases, 3 were extubated immediately and 2 by postoperative day 2. Oral feeding resumed by day 10 in 6 cases. No postoperative infections or cerebrospinal fluid leakage occurred. One patient experienced transient velopharyngeal insufficiency, which resolved spontaneously.
Conclusion The endoscopic endonasal transnasopharyngeal approach is a safe and effective option for ventral craniovertebral junction lesions when appropriately selected. Careful preoperative evaluation and individualized management of airway and spinal stability are essential for favorable outcomes.
Objective Spinal cord cavernous malformation (CM) is an intramedullary vascular lesion that may present with progressive symptoms. Surgery is recommended for symptomatic patients, but optimal timing of surgery is debatable. Some advocate waiting until plateau of neurological recovery and others support emergency surgery. There is no statistic on how commonly these strategies are utilized. We aimed to find contemporary practice pattern among neurosurgical spine centers in Japan.
Methods A database of intramedullary spinal cord tumors assembled by Neurospinal Society of Japan was surveyed and 160 patients with spinal cord CM were identified. Neurological function, disease duration, and number of days between presentation to hospitals and surgery were analyzed.
Results Duration of disease before presentation to hospitals ranged from 0 to 336 months (median, 4 months). Number of days between patients’ presentation and surgery ranged from 0 to 6,011 days (median, 32 days). Time from symptom onset to surgery ranged from 0 to 336.9 months (median, 6.6 months). Patients with severe preoperative neurological dysfunction had shorter duration of disease, fewer days between presentation and surgery, and shorter time between symptom onset and surgery. Patients with paraplegia or quadriplegia were more likely to improve when operated on within 3 months from onset.
Conclusion Timing of surgery for spinal cord CM in Japanese neurosurgical spine centers generally was early, with 50% of patients undergoing surgery within 32 days after presentation. Further study is needed to clarify optimal timing of surgery.
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Objective This study aimed to analyze the clinical characteristics, treatment strategies, and surgical outcomes of subependymoma patients from the 2022 Neurospinal Society of Japan multicenter intramedullary spinal cord tumor study.
Methods Twenty-six patients with spinal cord subependymoma who were included in the index study of 1,033 patients were retrospectively analyzed.
Results Mean patient age was 49.4 years. Seventeen patients were men and 9 were women. Sensory disturbance was reported in 22 patients and motor weakness in 18. Median duration of symptoms was 24 months. The tumor was eccentrically located in 19 patients (73.1%) and unilateral in 17 (65.4%). Gross total resection was achieved in 6 patients (23.1%). The same rate for ependymoma patients in the index study was significantly higher (74.8%). Median follow-up was 40.5 months (interquartile range, 18–68 months). In 2 patients who underwent only partial resection, reoperation was required owing to progression 68 and 90 months after surgery, respectively. No recurrence occurred in patients who underwent gross total resection. Five patients experienced neurological worsening after surgery.
Conclusion Although spinal cord subependymoma can be difficult to distinguish from other intramedullary spinal cord lesions before surgery, it is characterized by an indolent clinical course and eccentric location. Surgical treatment should prioritize functional preservation because the prognosis is good even after subtotal resection.
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Neurospine 2022;19(2):441-452. Published online June 30, 2022
Objective We performed a retrospective observational study to demonstrate the surgical risks and long-term prognoses of intramedullary tumors in Japan using a multicenter registry authorized by the Neurospinal Society of Japan.
Methods Data from 1,033 consecutive patients with intramedullary tumors, treated between 2009 and 2020, were collected from 58 centers. Patients with spinal lipomas or myxopapillary ependymomas were excluded. Patient characteristics, clinical presentations, imaging characteristics, treatments, and outcomes were analyzed. The modified McCormick scale was used to classify functional status. Survival was described using Kaplan-Meier curves, and multivariable logistic regression analyses were performed.
Results The mean age of the patients was 48.4 years. Data of 361 ependymomas, 196 hemangioblastomas, 168 astrocytic tumors, 160 cavernous malformations, and the remaining 126 cases including subependymomas, metastases, schwannomas, capillary hemangiomas, and intravascular B-cell lymphomas were analyzed. Twenty-two patients were undiagnosed. The mean follow-up duration was 46.1 ± 38.5 months. Gross total tumor removal was achieved in 672 tumors (65.1%). On the modified McCormick scale, 234 patients (22.7%) had worse postoperative grades at the time of discharge. However, neurological status gradually improved. At 6 months postoperatively, 251 (27.5%), 500 (54.9%), and 160 patients (17.6%) had improved, unchanged, and worsened grades, respectively. Preoperative functional status, gross total tumor removal, and histopathological type were significantly associated with mortality and functional outcomes.
Conclusion Our findings demonstrate better postoperative functional outcomes in patients with fewer preoperative neurological deficits. Degree of resection, postoperative treatments, and prognoses are closely related to the histology of intramedullary tumors.
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Objective When treating patients with cervical spondylotic myelopathy (CSM), we often note amelioration in concomitant hypertension after surgery. To assess the effects of surgery and the mechanisms thereof, blood pressure (BP) and parasympathetic nervous activity were monitored prospectively in CSM patients undergoing surgery.
Methods Sixty-eight consecutive CSM patients who underwent surgery with myoarchitectonic spinolaminoplasty were enrolled. BP and electrocardiography were recorded preoperatively and at 1, 3, and 6 months postoperatively. Forty-six patients completed the scheduled follow-ups and were analyzed. Preoperatively, 17 had a mean BP higher than 100 mmHg (the HT group) and 12 had hypertension despite taking medication (the HT-refractory group). To evaluate alterations in parasympathetic function, the coefficient of variation of the RR interval (CVRR) was evaluated.
Results A significant BP reduction was observed in the HT group 6 months after surgery, but not in the normotensive group (n=29). The effect was more remarkable in the HT-refractory group. A transient BP increase at 1 and 3 months after surgery was observed in all groups. Comparisons were made between groups classified by age (over 65 years or younger than 60 years) and the presence or absence of an intramedullary hyperintense T2 signal on magnetic resonance imaging, but no significant differences were detected. Measurements of CVRR did not significantly differ between the groups over the course of follow-up.
Conclusion Hypertension coexisting with CSM can be ameliorated after surgical treatment. The effect is likely to be mediated by moderation of sympathetic activity, rather than parasympathetic activation. We believe that a combination of adequate decompression of the spinal cord and relief from musculoskeletal stresses effectuate this moderation.
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