Source: Peking University Third Hospital
Author: Tian Yinglun Wang Shenglin
Skull base depression is a bone deformity in the craniocervical junction area, which is a deformity in which the skull base is depressed into the skull from the foramen magnum centered on the occipital bone. Clinical manifestations may include dysphagia, blurred vision, weakness of the limbs, and in severe cases, death due to compression of the brainstem or spinal cord. The cranial vertebral group of Peking University Third Hospital (hereinafter referred to as the Third Hospital of Peking University) recently admitted a patient with difficult primary skull base depression, the patient is a 49-year-old woman, who was diagnosed in an external hospital for unclear vision 10 years ago, and the symptoms worsened 5 months ago and was accompanied by numbness and weakness of the limbs and difficulty in walking.
Different from the common case of skull base depression, the patient had severe deformity of skull base development, severe skull base inversion, and compression of the spinal cord in the craniocervical junction on both the ventral and dorsal sides, accompanied by Chiari malformation, low cranial neuropathy and high cervical myelopathy. During the preoperative CTA examination, we found that the internal carotid artery was tortuous in the surgical area. Conventional surgical methods such as posterior occipital foramen magnum decompression and anterior transoral odontodontic resection are not suitable. The reason is that the patient has undergone osteotomy with foramen magnum, which is difficult to perform and unpredictable results. However, if the anterior route is chosen, the odontoid process is too high and the mouth is no longer resectable, and the anterior route has a high risk of damaging the brainstem and internal carotid artery. After being admitted to the hospital, the patient was discussed by the Department of Neurosurgery, the Department of Otolaryngology, the Department of Ophthalmology, the Department of Critical Care Medicine, and the Department of Anesthesiology, and finally the treatment plan was to undergo the endoscopic odontosectomy with anterior transnasal approach with orthopedics and otolaryngology.
After sufficient preoperative preparation, with the precise assistance of otolaryngology endoscopy, intraoperative navigation and intraoperative CT, we successfully and completely removed the odontoid process that compressed the spinal cord, and the whole operation process was smooth and unimpeded, and the key nerves and blood vessels were effectively protected without any complications. The next day after the operation, the patient was successfully removed from the endotracheal tube and transferred to the general ward for further recovery. Postoperative evaluation showed that the patient's symptoms of choking on drinking water and difficulty swallowing were alleviated by more than 70%, the upper limbs moved freely, he could stand without support, his unsteady walking condition was also improved, and the numbness of the upper limbs and trunk was also significantly reduced. Patients report a return to clear vision, smoother swallowing, and increased strength in their limbs. After a week of meticulous care, the patient recovered well and was discharged from the hospital.
Compared with the traditional transoral approach, the endoscopic transnasal approach has shown significant advantages in the treatment of atlantoaxial disease and skull base depression. The endoscope not only provides a clearer and broader surgical field of view, making the operation more detailed and accurate, but also the operation space is no longer limited by the oral cavity, and there is no need to use an opener to open the oral cavity, thus avoiding the risk of airway edema and tooth damage caused by tongue swelling, and significantly shortening the intubation time. In addition, nasal surgery effectively reduces the risk of postoperative velopharyngeal insufficiency, and patients do not need to rely on gastric tube nasogastric feeding after surgery, and can quickly resume oral diet, thereby accelerating the postoperative recovery process. It is worth mentioning that the incision of transnasal surgery is located in the nasal cavity above the oropharynx, and the infection rate of this approach is significantly lower than that of the oral approach, which further improves the safety and reliability of the operation.
We have accumulated rich experience in the treatment of this difficult case, which fully confirms the clinical effectiveness of the transnasal approach in the treatment of difficult atlantoaxial disease and skull base depression. With the continuous improvement and expansion of cranial spine expertise, we are able to provide accurate and efficient diagnosis and treatment services for more patients. At the same time, we also welcome colleagues to introduce more patients with atlantoaxial spine disease and skull base deformity to the Cranial Spine Professional Group of the Third Hospital of Beijing Medical University for treatment, so as to jointly promote the progress and development of cranial spine disease diagnosis and treatment technology.
Operator's profile
Wang Shenglin
Chief physician of the Department of Orthopedics, Peking University Third Hospital, head of the cranial spine specialty, associate professor, doctoral supervisor.
Academic Appointments:
Full member and Committee member of the Asia-Pacific Chapter of the Society for the Study of Cervical Spine Surgery (CSRS), full member and Committee (member) of CSRS China Branch, corresponding member of CSRS North American Branch, AO Spine Lecturer, Vice Chairman of the Occipital and Cervical Surgery and Rehabilitation Group of the Bone and Joint Rehabilitation Professional Committee of the Chinese Association of Rehabilitation Medicine, Member of the Standing Committee of the Orthopedic Professional Committee of the Chinese Medical Education Association, Member of the Cervical Spine Group and Member of the Spinal Function Reconstruction Group of the Orthopaedic Branch of the Chinese Medical Doctor Association.
国内期刊《中华医学杂志》《北京大学学报（医学版）》《中国脊柱脊髓杂志》《中华临床医师杂志》杂志审稿人；国际期刊Spine， Spine Journal， American Journal of Neuroradiology（AJNR），Global Spine Journal等杂志审稿人。
Awards include:
"Outstanding Young Physician" of Peking University, "Top 100 Young Physicians of the Capital", "Young Scientist of the Third Hospital of Beijing Medical University", "Outstanding Young Physician of the Third Hospital of Peking Medical University", etc.
Research Achievements:
He has presided over a series of studies on diseases of the upper cervical spine and atlantoaxial joint, published more than 30 papers on the upper cervical spine, participated in the translation of "Rothman-Simone Spine Surgery-Sixth Edition", "Spine Surgical Techniques", "Spine Surgery Failure", "Trauma Orthopedics", etc., and presided over the general projects of the National Natural Science Foundation of China, the Beijing Natural Science Foundation of China, and the Capital Health Development Scientific Research Initial Fund Project. It has obtained 3 national invention patents and 5 utility model patents.
Zhang Yinghong
Doctor of Medicine, Deputy Chief Physician of the Department of Otolaryngology, Peking University Third Hospital.
Graduated from Peking University Health Science Center, in 2016~2017, he completed fellowship training at Professor Zhou Bing of the Department of Rhinology, Beijing Tongren Hospital, Capital Medical University (Rhinology Group Leader, Otolaryngology-Head and Neck Surgery Branch of the Chinese Medical Association), and systematically studied and mastered nasal-eye-related and nasocranial-related endoscopic surgery. He has been engaged in nasal endoscopic surgery and clinical and basic research on olfactory disorders for a long time, and has rich clinical experience in transnasal endoscopic complex sinus surgery, endoscopic treatment of benign and malignant tumors of nasal cavity and sinuses, nasal and eye-related, nasopranial-related and craniocervical related diseases. He is good at nasal endoscopic surgery, proficient in performing fourth-level surgeries such as anterior middle skull base and lateral skull base surgery, and carrying out new technologies for multimural orbital decompression, endoscopic tear duct tumor resection and transnasal endoscopic craniocervical junction surgery.
He is the vice chairman of the Hearing and Related Diseases Professional Committee of the China Hearing Medicine Development Foundation, and a member of the Skull Base Group of the Otolaryngology-Head and Neck Surgery Branch of Integrated Traditional Chinese and Western Medicine. In recent years, he has published a number of results in surgical and analytical chemistry journals such as The Analyst, International Forum of Allergy and Rhinology as the first author, and participated in the translation of "Transnasal Endoscopic Anatomy and Peripheral Anatomy Laboratory Anatomy and Image Atlas" by Professor Zhou Bing. In 2023, he won the second prize of technological innovation of the hospital, the third prize of diagnosis and treatment of difficult cases, the Beijing-Tianjin-Hebei difficult case award for many times in 2017~2023, and the surgical video display of the Otolaryngology-Head and Neck Surgery Branch of the Chinese Medical Association for many times, and won the first prize.
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