C1 anterior arch preservation in transnasal odontoidectomy using three-dimensional endoscope: A case report

BACKGROUND: The transoral ventral corridor is the most common approach used to reach the craniovertebral junction (CVJ). Over the last decade, many case reports have demonstrated the transnasal corridor to the odontoid peg represents a practicable route to remove the tip of the odontoid process. The biomechanical consequences of the traditional odontoidectomy led to the necessity of a cervical spine stabilization. Preserving the inferior portion of the C1 anterior arch should prevent instability. CASE DESCRIPTION: This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope. A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation. The upper-medial portion of the C1 anterior arch was removed preserving its continuity, and the odontoidectomy was performed. After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one. CONCLUSIONS: The stereoscopic perception augmented the precision of the surgical gesture in the deep field. The importance of a 3D view relates to the depth of field, which a two-dimensional endoscopy cannot provide. This affects the preservation of the C1 anterior arch because of the presence of critical structures that are exposed to potential damage if not displayed

Nanofibrous Synthetic Dural Patch for Skull Base Defects: Preliminary Experience for Reconstruction after Extended Endonasal Approaches

Setting One of the consequences of the widespread use of endoscopic endonasal approaches (EEA) to skull base pathologies is the management of complex skull base defects. Nowadays, the gold standard is a multilayer closure that reproduces the physiological tissue barriers. Several techniques have been described in the literature; however, skull base reconstruction after EEA still represents a matter of debate, especially after extended EEA. A watertight closure is paramount to prevent cerebrospinal fluid leak and meningitis. Design Regarding this issue, we present our experience with a new synthetic dural patch, ReDura (Medprin Biotech, La Mirada, California, United States), as a subdural inlay in three patients who underwent endoscopic endonasal removal of sellar and suprasellar lesions. Conclusions ReDura patch showed the same versatility of autologous iliotibial tract. A dural patch that easily adapts to all defects, revealed to be a useful tool for performing watertight closure, possibly in a short operative time, after endoscopic approaches

The Political Economy of the 2014-2020 Common Agricultural Policy: An Imperfect Storm. CEPS Paperback, 17 August 2015

After five years of debates, consultations and negotiations, the European institutions reached an agreement in 2013 on the Common Agricultural Policy (CAP) for the 2014-2020 period. The outcome has major implications for the EU’s budget and farmers’ incomes but also for Europe’s environment, its contribution to global climate change and to food security in the EU and in the world. It was decided to spend more than €400 billion during the rest of the decade on the CAP.The official claims are that the new CAP will take better account of society's expectations and lead to far-reaching changes by making subsidies fairer and ‘greener’ and making the CAP more efficient. It is also asserted that the CAP will play a key part in achieving the overall objective of promoting smart, sustainable and inclusive growth. However, there is significant scepticism about these claims and disappointment with the outcome of the decision-making, the first in which the European Parliament was involved under the co-decision procedure. In contrast to earlier reforms where more substantive changes were made to the CAP, the factors that induced the policy discussions in 2008-13 and those that influenced the decision-making did not reinforce each other. On the contrary, they sometimes counteracted one another, yielding an ‘imperfect storm’ as it were, resulting in more status quo and fewer changes. This book discusses the outcome of the decision-making and the factors that influenced the policy choices and decisions. It brings together contributions from leading academics from various disciplines and policy-makers, and key participants in the process from the European Commission and the European Parliament

Craniovertebral junction 360°: A combined microscopic and endoscopic anatomical study

Objectives: Craniovertebral junction (CVJ) can be approached from various corridors depending on the location and extent of disease. A three dimensional understanding of anatomy of CVJ is paramount for safe surgery in this region. Aim of this cadaveric study is to elucidate combined microscopic and endoscopic anatomy of critical neurovascular structures in this area in relation to bony and muscular landmarks. Materials and Methods: Eight fresh frozen cadaveric heads injected with color silicon were used for this study. A stepwise dissection was done from anterior, posterior, and lateral sides with reference to bony and muscular landmarks. Anterior approach was done endonasal endoscopically. Posterior and lateral approaches were done with a microscope. In two specimens, both anterior and posterior approaches were done to delineate the course of vertebral artery and lower cranial nerves from ventral and dorsal aspects. Results: CVJ can be accessed through three corridors, namely, anterior, posterior, and lateral. Access to clivus, foreman magnum, occipital cervical joint, odontoid, and atlantoaxial joint was studied anteriorly with an endoscope. Superior and inferior clival lines, supracondylar groove, hypoglossal canal, arch of atlas and body of axis, and occipitocervical joint act as useful bony landmarks whereas longus capitis and rectus capitis anterior are related muscles to this approach. In posterior approach, spinous process of axis, arch of atlas, C2 ganglion, and transverse process of atlas and axis are bony landmarks. Rectus capitis posterior major, superior oblique, inferior oblique, and rectus capitis lateralis (RCLa) are muscles related to this approach. Occipital condyles, transverse process of atlas, and jugular tubercle are main bony landmarks in lateral corridor whereas RCLa and posterior belly of digastric muscle are the main muscular landmarks. Conclusion: With advances in endoscopic and microscopic techniques, access to lesions and bony anomalies around CVJ is becoming easier and straightforward. A combination of microscopic and endoscopic techniques is more useful to understand this anatomy and may aid in the development of future combined approaches

Nanofibrous Synthetic Dural Patch for Skull Base Defects: Preliminary Experience for Reconstruction after Extended Endonasal Approaches

Setting One of the consequences of the widespread use of endoscopic endonasal approaches (EEA) to skull base pathologies is the management of complex skull base defects. Nowadays, the gold standard is a multilayer closure that reproduces the physiological tissue barriers. Several techniques have been described in the literature; however, skull base reconstruction after EEA still represents a matter of debate, especially after extended EEA. A watertight closure is paramount to prevent cerebrospinal fluid leak and meningitis. Design Regarding this issue, we present our experience with a new synthetic dural patch, ReDura (Medprin Biotech, La Mirada, California, United States), as a subdural inlay in three patients who underwent endoscopic endonasal removal of sellar and suprasellar lesions. Conclusions ReDura patch showed the same versatility of autologous iliotibial tract. A dural patch that easily adapts to all defects, revealed to be a useful tool for performing watertight closure, possibly in a short operative time, after endoscopic approaches