First time portable CT used for skull base endoscopic transnasal surgery

When Susan Dailey was 11 years old, she was admitted to a hospital by her loving parents, who assumed she would get a routine tonsillectomy to cure her chronic sore throat.

Nearly 50 years later, Ms. Dailey was back in the hospital for surgery, but this time to address a much more urgent and potentially disabling condition related to complications from the original operation.

"Over the last year, I experienced increasingly severe neck pain, had difficulty keeping my balance while walking, and I started to drop things," said Mrs. Dailey, a 58-year-old homemaker from Amityville, NY. Suspecting a complex neurological problem, Mrs. Dailey's endocrinologist, Daniel Lorber, MD, referred her to Mark Eisenberg, MD, chief of neurosurgery at LIJ Medical Center, and B. Todd Schaeffer, MD, associate chairman of otolaryngology and communicative disorders at North Shore University Hospital (NSUH).

After a thorough evaluation, including magnetic resonance imaging (MRI) and computed tomography (CT) scans, Drs. Eisenberg and Schaeffer determined that Mrs. Dailey was in need of a delicate, highly specialized surgery to remove a tooth-shaped bone called the odontoid located at the top of the cervical spine. Due to settling of her skull onto the top of her spine, the bone (odontoid) was pressing into the brainstem at the base of the skull and causing her symptoms. The imaging scans revealed that the problem stemmed most likely from an old, healed fracture from the tonsillectomy performed on her during the 1950s.

The surgery for Mrs. Dailey consisted of two stages lasting a total of approximately 10 hours at NSUH designed to decompress her brainstem known as an endoscopic transnasal odontoidectomy - a procedure where surgeons use normal nasal pathways to reach the odontoid bone resting on the base of the neck instead of going through the mouth. After the odontoid bone was removed, a fusion was performed from the back of the skull to the top of the spine to stabilize the spine.

"Traditionally, the odontoid removal is done through the mouth, which is followed by at least a week of tube feeding," said Dr. Eisenberg. "The procedure also runs a high risk of complications related to the healing of the back of the throat."

For the minimally invasive endoscopic skull base surgery, Dr. Eisenberg partnered with Dr. Schaeffer, who specializes in endoscopic sinus and skull base surgery. "Using an endoscope through the nostrils to reach the odontoid bone, located about two inches below the pituitary gland, does not require any external or facial incisions, reducing healing and recovery time," said Dr. Schaeffer. The use of the endoscope, which has a camera on the end of the tip, allows the surgeons to visualize structures more closely and at angles that would otherwise be hidden from view. The images are projected on several monitors and a large flat-screen TV in the operating room.

Dr. Eisenberg explained that during this relatively rare endoscopic surgery, he and Dr. Schaeffer used a portable CT intraoperatively to check for guidance and assessment throughout the procedure - the first time in the United States that this type of imaging was used in the operating room for this surgery. Equipped with wireless imaging capabilities, the CereTom  Portable CT, was developed by NeuroLogica, based in Danvers, MA. "The intra-operative portable CT scanner enables us to ensure and confirm that we have done a complete resection and adequate decompression of the brainstem before we finish the surgery and before we leave the operation," explained Dr. Eisenberg. "This is a major advantage. Typically with this procedure, a CT scan would be taken the next day." The surgeons also used a stereotactic neuro-navigation system, which allows three-dimensional views of the skull in real time.

Throughout the high-tech surgery, Drs. Eisenberg and Schaeffer relied on the expertise of a multidisciplinary team comprised of various departments at NSUH, including operative services, neuroscience nursing, radiology, neuro-anesthesia and neuro-monitoring.

About six weeks after the surgery, Mrs. Dailey, who loves to walk on the boardwalk at Jones Beach and volunteers in her community, said, "I feel great." "My neck feels good and walking is fine. I'm very grateful to Dr. Eisenberg and Dr. Schaeffer. I never thought I'd be able to do these simple things again."

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