Veiceschi Pierlorenzo, Pozzi Fabio, Restelli Francesco, Alfiero Tommaso, Castelnuovo Paolo, Locatelli Davide
Department of Neurosurgery, Ospedale di Circolo Fondazione Macchi, Varese, Italy.
Department of Otorhinolaryngology, University of Insubria, Ospedale di Circolo Fondazione Macchi, Varese, Italy.
J Neurol Surg B Skull Base. 2021 Feb;82(Suppl 1):S2-S3. doi: 10.1055/s-0039-3402797. Epub 2020 Mar 4.
We illustrate endoscopic endonasal odontoidectomy for the Chiari-I malformation respecting craniovertebral junction (CVJ) stability. Case report of a 12-year-old girl affected by the Chiari-I malformation. Magnetic resonance imaging (MRI) showed tonsillar herniation, basilar invagination, and dental retroversion, causing angulation and compression of the bulbomedullary junction. Patient underwent endoscopic third ventriculostomy (ETV) with reduction of ventricular size and resolution of gait disturbances, but she complained the Valsalva-induced headaches, hiccup, and dysesthesias in the lower limbs. Endoscopic endonasal odontoidectomy was chosen to decompress the cervicomedullary junction. The research was conducted at University Hospital "Ospedale di Circolo," Department of Neurosurgery at Varese in Italy. Patients were from neurosurgical and ENT (ear, nose, and throat) skull base team. A bilateral paraseptal approach was performed, using a four-hand technique. After resection of posterior edge of the nasal septum, the choana is entered and a rhinopharynx muscle-mucosal flap is dissected subperiosteal and transposed in oral cavity. The CVJ is exposed and, using neuronavigation and neuromonitoring, odontoidectomy is fulfilled until dura is reached, preserving the anterior arch of C1. Reconstruction is obtained suturing the flap previously harvested. Postoperative course was unremarkable and the patient experienced improvement of symptoms. Postoperative MRI documented the appearance of tight cerebrospinal fluid (CSF) film anterior to bulbomedullary junction and in retrotonsillar spaces, opening of the bulbomedullary angle, and slight tonsils reduction. No CVJ instability was occurred with any need of posterior fixation. Endoscopic endonasal odontoidectomy is a feasible approach for CVJ malformation. In this case, bulbar decompression was achieved preserving CVJ stability and avoiding posterior fixation. The link to the video can be found at: https://youtu.be/VIobocHfCuc .
我们展示了在保留颅颈交界区（CVJ）稳定性的前提下，采用鼻内镜下经鼻齿状突切除术治疗Chiari-I畸形。
12岁Chiari-I畸形女童的病例报告。磁共振成像（MRI）显示扁桃体疝、基底凹陷和齿状突后倾，导致延髓球部夹角和受压。患者接受了内镜下第三脑室造瘘术（ETV），脑室大小减小，步态障碍得到缓解，但她仍主诉Valsalva动作诱发头痛、呃逆及下肢感觉异常。遂选择鼻内镜下经鼻齿状突切除术以减压颈髓交界处。
该研究在意大利瓦雷泽市“Circolo医院”大学医院神经外科进行。
患者来自神经外科和耳鼻喉（耳、鼻、喉）颅底团队。
采用双手操作技术，行双侧鼻中隔旁入路。切除鼻中隔后缘后，进入后鼻孔，在骨膜下分离鼻咽喉肌黏膜瓣并转移至口腔。暴露CVJ，使用神经导航和神经监测，完成齿状突切除直至硬膜，保留C1前弓。通过缝合先前采集的皮瓣进行重建。
术后过程顺利，患者症状改善。术后MRI显示延髓球部交界处前方及扁桃体后间隙出现紧密的脑脊液（CSF）薄膜，延髓球部夹角开放，扁桃体略有缩小。未发生CVJ不稳定，无需后路固定。
鼻内镜下经鼻齿状突切除术是治疗CVJ畸形的一种可行方法。在本病例中，实现了延髓减压，同时保留了CVJ稳定性并避免了后路固定。视频链接可在：https://youtu.be/VIobocHfCuc 查看。
