Minimally Invasive Surgery for Skull Base Tumors

The Jefferson Center for Minimally Invasive Cranial Base Surgery and Endoscopic Neurosurgery reflects three of the current evolutions in neurological surgery. The first of these is reflected in the name of the Center itself. Surgical Procedures, Minimally Invasive, a Medline Subject Heading since 1998, is defined as: Procedures that avoid use of open invasive surgery in favor of closed or local surgery. These generally involve use of laparoscopic devices and remote-control manipulation of instruments with indirect observation of the surgical field through an endoscope or similar device. With the reduced trauma associated with minimally invasive surgery, long hospital stays may be reduced with increased rates of short stay or day surgery. Traditionally, cranial base tumors have been removed by making craniotomies or cranial base ostomies, and possibly by removing facial bones. To access these areas, surgeons usually need to make potentially disfiguring incisions in the face and scalp. Sometimes the morbidity from the “open” cranial base approach alone could be significant, even with an uneventful removal of the tumor. At the Center, the endoscopic approaches are usually through the nose or nasal passages (Figure 1), however transoral endoscopic approaches to the cranial base and cervical spine are also performed. Because morbidity from the minimally invasive endoscopic approaches is so low, it becomes possible to treat patients with tumors that were previously considered non-resectable or as having too poor a prognosis for more invasive surgery. Even partial resection of such tumors can relieve pain, preserve function, and permit earlier adjuvant radiation and chemotherapy

Prevention and Management of Bleeding During Endoscopic Approaches to Skull Base Pathologies

The rate of serious permanent morbidity and mortality with endonasal approaches has declined secondary to increased knowledge of the pertinent anatomy, advanced neuroimaging and navigation techniques, better surgical instruments, and improved exposure and reconstruction strategies.1-3 Although rare, vascular injury remains a potentially serious complication. However, with limited systematically-collected and reported data, the exact incidence rate of vascular injuries is difficult to determine. In terms of arterial injuries, the incidence based on reported series likely ranges from 0.3%-9% (Table 1),4-11 with higher rates most commonly associated with chordomas and chondrosarcomas involving the clivus. Venous injury is comparatively less severe and easier to manage. As a result, there is a comparatively lower impetus to publish epidemiological data and management strategies for these injuries. The consequences of arterial injury include fatal hemorrhage, vessel occlusion or thromboembolism causing infarction, development of a pseudoaneurysm (PA), carotid-cavernous fistula (CCF), subarachnoid hemorrhage (SAH), and vasospasm.6,7,9 Surgical expertise and detailed knowledge of the neurovascular anatomy is critical to the avoidance and management of vascular injuries. Pages: 20-2

NUT Midline Carcinoma in a Pregnant Woman

NUT midline carcinoma is a rare, highly aggressive tumor that involves midline structures, particularly in the head, neck and mediastinum. It is characterized by NUT gene translocations on chromosome 15. It typically impacts teenagers or young adults, and has a fulminant course leading to death in less than a year in most cases despite aggressive chemoradiotherapy. Due to its location, this tumor is frequently considered inoperable. We present a case of a sinonasal NUT midline carcinoma with orbital invasion discovered during the workup of sinusitis in a young, pregnant woman. The tumor was managed with definitive excision to negative margins followed by aggressive chemoradiation, with no evidence of recurrence for 12 months. We propose that diagnosis of NUT midline carcinoma should prompt recognition of the limitations of current medical therapy and rapid surgical intervention should be undertaken when possible

Comprehensive Management of the Paranasal Sinuses in Patients Undergoing Endoscopic Endonasal Skull Base Surgery.

OBJECTIVE: The endonasal route often provides the most direct and safe approach to skull base pathology. In this article we review the literature with regard to management of the paranasal sinuses in the setting of skull base surgery. METHODS: We describe our institutional experience and review the literature of concurrent management of the sinusitis in patients undergoing endoscopic skull base surgery. RESULTS: Patients should be optimized preoperatively to ensure the endonasal route is a safe corridor to enter the intracranial cavity. Often the paranasal sinuses can be surgically addressed at the same time as endoscopic skull base surgery. We describe the technical details of management of the paranasal sinuses when addressing skull base pathology. CONCLUSIONS: Careful management of the paranasal sinuses throughout the peri-operative course is paramount to optimizing sinonasal function and safety

Endonasal Vascularized Flaps For Cranial Base Reconstruction

Since the introduction of extended endoscopic cranial base surgery, postoperative cerebrospinal fluid (CSF) leak has been a formidable and troublesome issue resulting in complications such meningitis, pneumocephalus, and the need for additional surgical interventions. Establishment of a watertight cranial base reconstruction is the most critical step in preventing postoperative CSF leakage. Historically, various free grafts, both synthetic and autologous, were utilized as repair materials for reconstruction of the cranial base defect often in combination with temporary CSF diversion. Free grafts are often sufficient for repair of small low flow, low pressure dural defects. High postoperative CSF leak rates reported in the initial endoscopic skull base literature are evidence that free grafts do not provide a reliably competent repair for large defects or direct high-flow CSF leaks. The introduction of the Hadad-Bassagasteguy vascularized nasoseptal flap has significantly reduced the reported CSF leak rate with a recent meta-analysis reporting that use of the vascularized flap is associated with a 7% rate of postoperative CSF leakage compared to 16% with free grafts alone for large dural defects.6 Since the initial description of the vascularized pedicled nasoseptal flap in 2006, many surgeons have developed a variety of alternative vascularized flaps for endonasal cranial base reconstruction. In this article, we summarize and compare several of the most clinically useful vascularized flaps including their harvest technique, indications and limitations, and potential complications. Pages: 28-3

Avoidance of Maxillary Swing for Nasopharyngectomy via Combined Open Lateral and Endoscopic Approach

Objectives: Nasopharyngectomy performed via a solely endoscopic approach has limitations in access and feasibility, particularly regarding management of the carotid artery. To address these limitations, we report three cases with one cadaver dissection where nasopharyngectomy was performed via a combined open lateral an endoscopic approach. We highlight the benefits and technical considerations for this operative technique. Study Design: Case Series Methods: Patients diagnosed with recurrent nasopharyngeal carcinoma (NPC) that underwent combined open lateral and endoscopic nasopharyngectomy from 2016-2020 were analyzed. A cadaver dissection was also performed. Results: We present the details of the approach and follow-up in three patients with recurrent nasopharyngeal carcinoma. Briefly, a preauricular incision is extended down to the neck. The zygoma and mandibular ramus can be removed and replaced if required. V3, the pterygoid plates and the eustachian tube can be resected or mobilized. The carotid artery may be identified proximally in the neck and traced to the skull base, where the carotid canal may be drilled to the level of the foramen lacerum and protected with a pledget. Then, tumor mucosal cuts are made via an endoscopic endonasal approach and connected to the lateral exposure. No carotid artery injuries occurred. Conclusion: The combined open lateral approach and endoscopic nasopharyngectomy technique is a useful technique in salvage patients. It provides excellent control of major vessels, adequate access to the carotid canal, V3, and remainder of the skull base, and cervical protection.https://jdc.jefferson.edu/otoposters/1009/thumbnail.jp

A Comparative Analysis of Anterior & Lateral Cranial Base CSF Leaks

Introduction The optimal strategy for management of Idiopathic Intracranial Hypertension (IIH) in anterior and lateral cranial base meningoencephaloceles remains debated. The purpose of this study is to present a comparison of the surgical management of anterior and lateral cranial base meningoencephalocele and a treatment algorithm for the diagnosis and management of IIH in this patient population. Methods Retrospective study of 109 patients who underwent anterior or lateral CSF leak repair at TJU from 2004-2020. Epic & RedCap were utilized to record data. Patient demographics, presenting symptoms, imaging, Beta-2 Transferring testing, surgery, repair, and post-op data were collected. Two-sided Chi-squared tests and Independent t-test were performed via SPSS Statistics 26. Results 49 anterior cranial base (ACB) and 60 lateral cranial base (LCB) defects were included. Anterior cohort had significantly more women (N=77, 85.7%, p=0.02). Anterior cohort presented with significantly higher multiple leak sites (24.5% vs 15.0%, p=0.036). Six patients, 3 in each cohort, none of whom received Ventriculoperitoneal shunts (VPS) developed recurrence. VPS were placed for long-term CSF diversion in 23 ACB cases (46.9%) and 10 LCB cases (16.7%), (p\u3c0.01). Discussion ACB cases had a higher incidence of females, multiple site leaks, and more likely to undergo VPS placement. No patients developed recurrence after placement of a VPS. Long-term CSF diversion via VPS, in addition to surgical repair, should be considered in patients with elevated intracranial pressure and other high-risk factors to prevent recurrence of CSF leaks

Clinical characteristics and prognosis of osteosarcoma in young children: a retrospective series of 15 cases

<p>Abstract</p> <p>Background</p> <p>Osteosarcoma is the most common primary bone malignancy in childhood and adolescence. However, it is very rare in children under 5 years of age. Although studies in young children are limited in number, they all underline the high rate of amputation in this population, with conflicting results being recently reported regarding their prognosis.</p> <p>Methods</p> <p>To enhance knowledge on the clinical characteristics and prognosis of osteosarcoma in young children, we reviewed the medical records and histology of all children diagnosed with osteosarcoma before the age of five years and treated in SFCE (Société Française des Cancers et leucémies de l'Enfant) centers between 1980 and 2007.</p> <p>Results</p> <p>Fifteen patients from 7 centers were studied. Long bones were involved in 14 cases. Metastases were present at diagnosis in 40% of cases. The histologic type was osteoblastic in 74% of cases. Two patients had a relevant history. One child developed a second malignancy 13 years after osteosarcoma diagnosis.</p> <p>Thirteen children received preoperative chemotherapy including high-dose methotrexate, but only 36% had a good histologic response. Chemotherapy was well tolerated, apart from a case of severe late convulsive encephalopathy in a one-year-old infant. Limb salvage surgery was performed in six cases, with frequent mechanical and infectious complications and variable functional outcomes.</p> <p>Complete remission was obtained in 12 children, six of whom relapsed. With a median follow-up of 5 years, six patients were alive in remission, seven died of their disease (45%), in a broad range of 2 months to 8 years after diagnosis, two were lost to follow-up.</p> <p>Conclusions</p> <p>Osteosarcoma seems to be more aggressive in children under five years of age, and surgical management remains a challange.</p

Overcoming Obstacles in Endoscopic Skull Base Surgery: Challenging Corridors, Cases and Defects

Objectives: Endoscopic cranial base surgery is a rapidly advancing field with new innovations leading to an expansion in surgical approaches. The aim of this lecture is to provide the audience with an overview of some common challenges and obstacles faced by the endoscopic skull base surgeon and provide algorithms for confronting some of these difficult cases. Presentation: 47 minute

An algorithm for sellar reconstruction following endoscopic transsphenoidal surgery for pituitary adenoma: A review of 582 cases.

BACKGROUND: Several sellar reconstruction algorithms stratify patients based on risk of postoperative cerebrospinal fluid (CSF) leak. Many proposed algorithms employ techniques that are overly complex and confer morbidity. We review our experience with sellar reconstruction following transsphenoidal pituitary surgery and propose a highly effective, yet simple and low morbidity, algorithm. METHODS: A retrospective review of 582 patients who underwent transsphenoidal surgery for pituitary adenoma by a single neurosurgeon between 2005 and 2020 was performed. Patients without an intraoperative CSF leak and without a patulous diaphragm were repaired with an oxidized cellulose onlay (group 1). Patients with a low-flow intraoperative CSF leak or a patulous diaphragm were repaired with a synthetic dural substitute inlay (group 2). Patients with a persistent leak around the inlay repair or a high-flow leak were reconstructed with a synthetic dural substitute inlay and a nasoseptal flap onlay (group 3). RESULTS: There was an overall leak rate of 1.5% (9/582) to 1.0% (2/197) in group 1, 1.7% (6/347) in group 2, and 2.6% (1/38) in group 3. Group 3 had the highest rate of postoperative morbidity, including sinusitis (23.7% vs. 8.6% and 15.0% in groups 1 and 2, p = 0.018) and crusting (42.1% vs. 4.6% and 6.3% in groups 1 and 2, p \u3c 0.001). All techniques healed equally well radiographically. CONCLUSION: The proposed algorithm for sellar reconstruction is highly effective and minimizes complexity and morbidity, primarily utilizing single-layer reconstructions without the addition of packing material or lumbar drainage