Relevance of Skull Base Surgery to Pediatric Neurosurgery: Pediatric...

The goal of surgery in craniopharyngioma in the pediatric population is sometimes biopsy followed by radiation, different from adult paradigms where gross total resection may be the goal.

Intraventricular endoscopy has limitations including subpar optics compared to air medium and issues with hemorrhage obscuring the view in a fluid medium.

Endoscopic-assisted approaches in an air medium provide much better optics and the ability to do bimanual manipulation of tissues compared to fluid-medium intraventricular approaches.

Pediatric skull base lesions can be categorized into four groups: benign neoplastic lesions, malignant neoplastic lesions, congenital malformations, and iatrogenic or traumatic defects.

Five key considerations for endoscopic cases in children are: nasal aperture size (can limit bimanual operation), pneumatization, skull maturation, intercarotid distance, and defect closure.

The pathology of craniopharyngioma in children is very different molecularly and genetically than it is in adults.

In pediatric skull base surgery, the goal is sometimes biopsy or subtotal resection rather than gross total resection, with the aim of decompression, preservation of function, and allowing normal development before other therapy.

The transclival transodontoid approach has transitioned from a traditional transoral approach to what is exclusively now an endoscopic endonasal approach in the speaker's practice.

Advantages of the endoscopic endonasal approach for odontoid resection include the ability to extubate early and begin feeding early, seen in both adult and pediatric populations.

Odontoid resections are almost always done in conjunction with posterior fossa decompression and cervical instrumentation because of the instability that ensues from odontoid resection.

A linear incision in the retropharyngeal fascia works well for transodontoid approach, as long as suction is used to retract contralateral soft tissue; this replaced an earlier U-shaped incision technique.

The closure for transodontoid approach is simple: flow seal in the cavity and re-approximation of retropharyngeal fascia with one or two single interrupted stitches through a single nasal approach.

In the speaker's series of 10 odontoid resection patients, all are extubated on day 0 or 1, with early extubation now attempted on the same day of surgery.

One early reintubation in the odontoid series was due to aspiration of a sealant, which is no longer used because it was redundant and unnecessary due to lack of CSF leak.

The odontoid resection patient population is very select: children with cervicomedullary angles approximating 100 degrees and Grabb-Oakes measurements in the 10-15 millimeter or larger range, representing significant brainstem compression and torque.

For right-handed surgeons coming from the right nare in odontoid resection, there is a tendency to leave the very tip of the odontoid or the left side of the dens because getting to the contralateral side is challenging.

Pre-operative CTA or MRA is sometimes part of the workup for odontoid resection to identify and navigate the carotid arteries throughout the case.

The practice initially performed staged odontoid resection and fusion procedures (instrumentation/decompression on Monday, endonasal resection on Wednesday) to avoid additive morbidity, then moved to one-day procedures, but now prefers staged procedures again because single-day cases become 10-12 hour days with equipment and flow challenges.

The practice has not yet incorporated a sublabial approach to the sphenoid sinus in pediatric cases.

There is a steep learning curve for endoscopic endonasal surgery in young children due to ergonomic challenges of getting the scope and two instruments working together in tight spaces.

Endonasal equipment and scopes are designed to work in very small spaces and work well in the pediatric nose; while it is a little tighter, it is not so tight that cases cannot be done, and the practice has never had to avoid using an instrument because the nose was too small.