Odontoid-sparing transnasal approach for drainage of craniocervical epidural abscess; a novel technique and review of the literature

Background Context Surgical approaches to the craniovertebral junction (CVJ) are challenging. Available approaches include posterior, transoral, endonasal, and anterior extended retropharyngeal approach. Resection of the odontoid process is necessary to gain access to the pathology posterior to it. The resultant cranio-atlanto-axial instability usually necessitates subsequent posterior stabilization. Purpose To describe a new odontoid-sparing approach to the spinal canal at the CVJ. This dens-sparing approach preserves occipito-atlanto-axial stability and avoids the need for occipitocervical stabilization that adds to the extent of surgery and its associated morbidity and mortality. Study Design Describing a novel technique and reporting two cases. Patient Sample Two patients that presented with infection at the CVJ with a retro-odontoid epidural abscess were operated on. Outcome Measures Self-reported measures: visual analog scale for neck pain. Physiologic measures: plain x-rays (anteroposterior and lateral views), magnetic resonance imaging with contrast, computed tomography scan, C-reactive protein, and leukocytic count. Functional measures: dynamic flexion-extension views of the cervical spine. Methods Two patients were operated on using a combined endoscopic transnasal-transoral approach for drainage of a retro-odontoid epidural abscess and debridement without dens resection. A 4-mm, 30-degree rigid endoscope was used. Preoperative clinical and neurologic status was evaluated. The follow-up period was 12 months. The study received no funding from any organization. None of the authors has any relevant financial disclosures or conflict of interest. Results Both patients improved clinically after the endonasal transoral abscess drainage. Follow-up contrast magnetic resonance imaging showed complete resolution of the abscess after 3 weeks. Culture-sensitivity tests were positive for Staphylococcus aureus in one patient. Antibiotic therapy with clindamycin and flucloxacillin was continued for 12 weeks postoperatively. There were no intraoperative or postoperative complications. There was no need for posterior occipitocervical stabilization in both cases. Conclusion This represents the first clinical report of accessing the spinal canal at the CVJ without resection of the odontoid or the anterior arch of the atlas. The addition of endoscopic-assisted supra-dental approach to the transoral one improved visibility, and allowed access to the most cranial part of spinal canal without the need for dens resection, a procedure that significantly compromises C0-1-2 stability necessitating stabilization. This novel odontoid-sparing approach showed a favorable outcome in our first two cases with retro-odontoid abscess; however, it would likely pose a high risk in other pathologies including tumors.