- Email: [email protected]
Endoscopic repair technique for traumatic penetrating injuries of the clivus
Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Endoscopic repair technique for traumatic penetrating injuries of the clivus Brandon D. Liebelt a,⇑, Zain Boghani a, Ali S. Haider a, Masayoshi Takashima b a b
Department of Neurological Surgery, Houston Methodist Neurological Institute, 6560 Fannin Street, #944, Houston, TX 77030, USA Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
a r t i c l e
i n f o
Article history: Received 22 September 2015 Accepted 11 October 2015 Available online xxxx Keywords: Clivus CSF fistula Endoscopic Skull base repair Trauma
a b s t r a c t Unlike basilar skull fractures, penetrating traumatic injuries to the clivus are uncommon. We present two novel and interesting cases of traumatic crossbow arrow injury and penetrating screwdriver injury to the clivus. A review of the literature describing methods to repair these injuries was performed. A careful, systematic approach is required when working up and treating these injuries, as airway preservation is critical. An adaptation to the previously described ‘‘gasket-seal” method for skull base repair was utilized to repair the traumatic cerebrospinal fluid (CSF) fistulas. This repair technique is unique in that it is tailored to a much smaller defect than typical post-surgical defects. Two patients are presented, one with a post-traumatic CSF fistula after penetrating crossbow injury to the clivus and one with a penetrating screwdriver injury to the clivus. The patients were treated successfully with transnasal endoscopic repair with fascia lata graft and a nasoseptal flap, a novel adaptation to the previously described ‘‘gasket-seal” technique of skull base repair. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Penetrating injuries to the clivus represent a rare and unique medical emergency due to the nature of the objects used and the delicate anatomical regions affected with the possibility of devastating neurological sequelae. Cerebrospinal fluid (CSF) leakage at any location has the potential to lead to meningeal infection with subsequent morbidity and mortality. Fractures at the skull base are potentially devastating pathologies not only because of the vital structures which are in close proximity but also because there is a potential for tears in the dura mater and subsequent CSF leak [1]. By far, trauma is the most common cause of CSF rhinorrhea [2]. Here we present two cases of penetrating trauma to the clivus and subsequent management and reconstruction of the defects.
2. Case presentations 2.1. Patient 1 A 50-year-old man presented to the emergency center with a crossbow arrow impaled intraorally after an unsuccessful suicide ⇑ Corresponding author. Tel.: +1 713 441 3800. E-mail address: [email protected] (B.D. Liebelt).
attempt. He was neurologically and hemodynamically stable but very agitated and combative. Prior to removal of the arrow, the patient was taken for CT angiogram to evaluate for vascular injury. The arrow was found to have passed just inferomedial to the junction of the petrous and lacerum segment of the right internal carotid artery (Fig. 1a). As the arrow coursed posteriorly, it penetrated the right clivus and the tip of the arrow came to rest just to the right of the vertebrobasilar junction (Fig. 1b). After determining that no significant vascular injury had occurred, the patient was transported to the operating room. As the arrow was protruding several inches from the mouth (Fig. 1c), there were several logistical concerns to address regarding safe removal while protecting the airway. A multidisciplinary effort to protect the airway involved anesthesiology, neurosurgery, and otolaryngology. It was not possible to introduce an endotracheal or nasotracheal tube without first removing the arrow. Likewise, there was no way to use bag-valve-mask ventilation should the patient’s respiratory drive diminish with administration of intravenous sedation. Preparation for an emergency tracheotomy was necessary in the event the airway was compromised at any point during the removal of the arrow. While there was no major vascular injury present, there was still concern about bleeding obstructing the upper airway after the arrow was removed. With these precautions in mind, the arrow was removed with the aid of intravenous sedation. An endotracheal tube was then placed and the
http://dx.doi.org/10.1016/j.jocn.2015.10.031 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
2
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
c
a
b
Fig. 1. Coronal CT angiogram shows the hyperdense arrow and air present along the track, located just inferomedial to the junction of the petrous and lacerum segments of the internal carotid artery (a). Coronal CT angiogram showing the arrow with adjacent intracranial air. The tip of the arrow seen here is just lateral to the vertebrobasilar junction (b). Sagittal CT scan showing the trajectory of the arrow with the tip piercing the clivus and entering the intracranial cavity. Of note, the arrow protrudes to a significant degree from the patient’s mouth (not fully visualized on this image) (c).
Fig. 2. Mucosa overlying the clivus with defect arising from prior crossbow arrow (a) is seen. Mucosal defect is more easily appreciated after debridement of surrounding mucosa (b). Harvested fascia lata graft was cut to an appropriate size to ensure coverage of the defect (c). A ball of Surgicel (Ethicon for Johnson & Johnson Medical, Piscataway, NJ, USA) was placed centrally within the fascia lata and pressed firmly into the defect. Redundant fascia lata is seen protruding from the previous skull base defect to ensure a watertight seal (d). A harvested pedicled nasoseptal flap is laid over the now secured fascia lata graft (e) and held in place with fibrin glue and nasal packing.
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
3
Fig. 3. Penetrating screwdriver injury to the midface is seen on a lateral radiograph (a). The screwdriver is demonstrated traversing the maxillary sinus en route to the clivus, penetrating just inferior to the sphenoid sinus floor shown on a noncontrast axial (b), sagittal (b), and coronal (d–f) CT scans of the head.
patient was placed under general anesthesia. The area was closely inspected from a transnasal, endoscopic approach and no CSF leak was apparent at the time of surgery. Therefore, only a local debridement was performed initially. On postoperative day 2 the patient was then taken back to the OR to repair the defect, as CSF rhinorrhea and pneumocephalus were noted. An endoscopic transnasal approach was once again used to expose the traumatic defect (Fig. 2a), after harvesting a fascia lata graft. An oscillating debrider was used to remove surrounding mucosa, fascia, and muscle to expose bone circumferentially around the clival defect. The defect was noted to be small, round, and cylindrical (Fig. 2b), making initial attempts to plug the hole difficult. Attempts to plug the hole with fascia lata were initially unsuccessful as the graft would not stay in place and was being extruded by pulsating CSF. The fascia lata was laid flat over the defect (Fig. 2c) and a plug of Surgicel (Ethicon for Johnson & Johnson Medical, Piscataway, NJ, USA) was placed centrally in the graft. Pressure was then placed centrally over the Surgicel and the fascia lata was pushed into the defect until the graft was flush with the bony edges superficially (Fig. 2d). A vascularized pedicled nasoseptal flap (PNSF) was then harvested based on the sphenopalatine artery and laid over this repair (Fig. 2e). Duraseal fibrin glue (Covidien, Dublin, Ireland) was applied next and absorbable, porous
nasal packing was utilized to maintain pressure of the nasoseptal flap against the clival defect. The patient did well postoperatively without any further evidence of CSF leak and complete resolution of the pneumocephalus. 2.2. Patient 2 A 42-year-old man presented to the emergency center with a screwdriver penetration injury to the midface after he was the victim of an aggravated assault. The patient was hemodynamically and neurologically stable with a Glasgow Coma Scale score of 15. Prior to removal of the screwdriver, the patient was taken for a CT scan to evaluate the extent of the injury (Fig. 3). This revealed the screwdriver entering the midface, traversing the maxillary sinus, and penetrating the clivus without vascular injury. The patient underwent elective intubation in the operating room. Next, an endoscope was inserted to evaluate the extent of injury. The ethmoid and sphenoid sinuses were widely opened in order to evaluate the clival defect. A vascularized right-sided PNSF was harvested in preparation for reconstruction of the skull base defect. The screwdriver tip was seen and the adjacent clivus drilled in order to directly visualize the deepest portion of the screwdriver (Fig. 4). Fascia lata was harvested and used to seal the defect
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
4
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Fig. 4. Endoscopic images obtained at the time of surgery illustrating the screwdriver tip penetrating the skull base just inferior to the sphenoid floor (a). The sinuses have been opened to adequately expose the traumatic injury and expose the point of entry into the clivus (b–d).
utilizing a ‘‘gasket-seal” technique. The vascularized PNSF was then placed on top to further seal the defect. Postoperative CT scan confirmed removal of the screwdriver without complication (Fig. 5). Postoperative follow-up revealed a well-healed reconstruction with no evidence of CSF leak. 3. Discussion Although penetrating injuries to organs are frequently reported, penetrating injuries to the brain are rare due to the resistance of the cranium to objects commonly used as weapons such as knives and bottles [3]. While rarely used as weapons, crossbow arrows and screwdrivers have been reported in cases involving traumatic penetrating injuries to the skull [4,5]. Workup should include skull radiographs, CT scan, and CT angiogram to evaluate underlying fracture or vascular injury [3]. If the brainstem is involved, the effects are generally devastating due to life-threatening neurological injury, with a very low likelihood of surviving such injury [4,5]. Projectiles that penetrate an airway and the central nervous system represent unique challenges in airway management, and removal involves risk of further deficit or vascular compromise [5,6]. Furthermore, there is an increased risk of intracranial infection in patients with penetrating injuries to the cranium due to the presence of contaminated foreign objects driven into the brain along the projectile track. Broad-spectrum antibiotics have been administered and shown to improve outcomes [7]. Once the patient is stable and the proper imaging tests have been performed, surgical exploration and reconstruction of the wound can be performed. CSF leaks through the clivus are uncommon and are in a particularly challenging region for reconstruction [8]. It is generally
Fig. 5. Postoperative axial CT scan of the head illustrating the traumatic penetrating defect in the clivus into the posterior fossa as well as the drilling defect which aided in visualization of the distal screwdriver tip for safe removal.
accepted that clival defects require multilayer reconstruction with subdural inlay along with epidural onlay with a covering vascularized flap [9]. Reconstructive techniques utilizing the endoscopic approach have greatly advanced since non-vascularized free tissue grafting and synthetic materials [9,10]. These techniques were primarily suited for smaller sized CSF leaks, smaller than 1 cm [11]; however, utilizing a PNSF allows larger defects to be repaired
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
through an endoscopic approach [12]. Several studies have evaluated closure techniques involving the clivus, with success rates ranging from 60–100% [13–15]. However, it is apparent that the inclusion of a PNSF in a multilayer closure technique offers optimal results. A similar technique to the ‘‘gasket-seal” method previously described in the literature can be applied to small penetrating injuries of the skull base with a few notable exceptions. The ‘‘gasketseal” method has been described to repair larger anterior skull base defects following transsphenoidal, transtuberculum, and transplanum approaches [16,17]. Our cases were post-traumatic with a much smaller defect than a post-surgical defect. As such, use of autologous nasal bone or a synthetic implant would not have been an appropriate solution to repair the CSF fistula. The void created by the crossbow arrow required material small enough to fit through the void but with sufficient expansile properties to conform to the cavity and prevent egress of CSF. Surgicel is easily compressed but also expands, fitting the above stated criteria.
4. Conclusions Traumatic penetrating injuries to the clivus are rarely reported in the literature and present a complex scenario. Visualization of the defect, removal of the offending object, and endoscopic repair were instrumental in treating these two patients. We present two particularly challenging cases where a vascularized PNSF in conjunction with a modified ‘‘gasket-seal” technique consisting of Surgicel and fascia lata was used to reconstruct injuries to the clivus with concomitant CSF fistula.
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
5
References [1] Lin DT, Lin AC. Surgical treatment of traumatic injuries of the cranial base. Otolaryngol Clin North Am 2013;46:749–57. [2] Loew F, Pertuiset B, Chaumier EE, et al. Traumatic, spontaneous and postoperative CSF rhinorrhea. Adv Tech Stand Neurosurg 1984;11:169–207. [3] Tutton MG, Chitnavis B, Stell IM. Screwdriver assaults and intracranial injuries. J Accid Emerg Med 2000;17:225–6. [4] de Andrade AF, de Almeida AN, Muoio VM, et al. Penetrating screwdriver injury to the brainstem. Case illustration. J Neurosurg 2006;104:853. [5] Kaye K, Kilgore KP, Grorud C. Transoral crossbow injury: an unusual case of central nervous system foreign body. J Trauma 2004;57:653–5. [6] Franklin GA, Lukan JK. Self-inflicted crossbow injury to the head. J Trauma 2002;52:1009. [7] Hengzhu Z, Enxi X, Lei S, et al. A rare case of penetrating brain injury by crossbow in a 22-month-old child. Pediatr Emerg Care 2014;30:421–3. [8] Elrahman HA, Malinvaud D, Bonfils NA, et al. Endoscopic management of idiopathic spontaneous skull base fistula through the clivus. Arch Otolaryngol Head Neck Surg 2009;135:311–5. [9] Wei CC, Palmer JN. Planum, tubercular, sellar and clival defects. Adv Otorhinolaryngol 2013;74:119–29. [10] Gates GA, Sertl GO, Grubb RL, et al. Closure of clival cerebrospinal fluid fistula with biocompatible osteoconductive polymer. Arch Otolaryngol Head Neck Surg 1994;120:459–61. [11] Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116:1882–6. [12] Kassam AB, Thomas A, Carrau RL, et al. Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 2008;63: ONS44–52 [discussion ONS52-3]. [13] Iacoangeli M, Di Rienzo A, di Somma LG, et al. Improving the endoscopic endonasal transclival approach: the importance of a precise layer by layer reconstruction. Br J Neurosurg 2014;28:241–6. [14] Saito K, Toda M, Tomita T, et al. Surgical results of an endoscopic endonasal approach for clival chordomas. Acta Neurochir (Wien) 2012;154:879–86. [15] Soudry E, Turner JH, Nayak JV, et al. Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 2014;150:730–8. [16] Garcia-Navarro V, Anand VK, Schwartz TH. Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 2013;80:563–8. [17] Leng LZ, Greenfield JP, Souweidane MM, et al. Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery 2012;70:110–23 [discussion 123–4].
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Technical note
Endoscopic repair technique for traumatic penetrating injuries of the clivus Brandon D. Liebelt a,⇑, Zain Boghani a, Ali S. Haider a, Masayoshi Takashima b a b
Department of Neurological Surgery, Houston Methodist Neurological Institute, 6560 Fannin Street, #944, Houston, TX 77030, USA Bobby R. Alford Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
a r t i c l e
i n f o
Article history: Received 22 September 2015 Accepted 11 October 2015 Available online xxxx Keywords: Clivus CSF fistula Endoscopic Skull base repair Trauma
a b s t r a c t Unlike basilar skull fractures, penetrating traumatic injuries to the clivus are uncommon. We present two novel and interesting cases of traumatic crossbow arrow injury and penetrating screwdriver injury to the clivus. A review of the literature describing methods to repair these injuries was performed. A careful, systematic approach is required when working up and treating these injuries, as airway preservation is critical. An adaptation to the previously described ‘‘gasket-seal” method for skull base repair was utilized to repair the traumatic cerebrospinal fluid (CSF) fistulas. This repair technique is unique in that it is tailored to a much smaller defect than typical post-surgical defects. Two patients are presented, one with a post-traumatic CSF fistula after penetrating crossbow injury to the clivus and one with a penetrating screwdriver injury to the clivus. The patients were treated successfully with transnasal endoscopic repair with fascia lata graft and a nasoseptal flap, a novel adaptation to the previously described ‘‘gasket-seal” technique of skull base repair. Ó 2015 Elsevier Ltd. All rights reserved.
1. Introduction Penetrating injuries to the clivus represent a rare and unique medical emergency due to the nature of the objects used and the delicate anatomical regions affected with the possibility of devastating neurological sequelae. Cerebrospinal fluid (CSF) leakage at any location has the potential to lead to meningeal infection with subsequent morbidity and mortality. Fractures at the skull base are potentially devastating pathologies not only because of the vital structures which are in close proximity but also because there is a potential for tears in the dura mater and subsequent CSF leak [1]. By far, trauma is the most common cause of CSF rhinorrhea [2]. Here we present two cases of penetrating trauma to the clivus and subsequent management and reconstruction of the defects.
2. Case presentations 2.1. Patient 1 A 50-year-old man presented to the emergency center with a crossbow arrow impaled intraorally after an unsuccessful suicide ⇑ Corresponding author. Tel.: +1 713 441 3800. E-mail address: [email protected] (B.D. Liebelt).
attempt. He was neurologically and hemodynamically stable but very agitated and combative. Prior to removal of the arrow, the patient was taken for CT angiogram to evaluate for vascular injury. The arrow was found to have passed just inferomedial to the junction of the petrous and lacerum segment of the right internal carotid artery (Fig. 1a). As the arrow coursed posteriorly, it penetrated the right clivus and the tip of the arrow came to rest just to the right of the vertebrobasilar junction (Fig. 1b). After determining that no significant vascular injury had occurred, the patient was transported to the operating room. As the arrow was protruding several inches from the mouth (Fig. 1c), there were several logistical concerns to address regarding safe removal while protecting the airway. A multidisciplinary effort to protect the airway involved anesthesiology, neurosurgery, and otolaryngology. It was not possible to introduce an endotracheal or nasotracheal tube without first removing the arrow. Likewise, there was no way to use bag-valve-mask ventilation should the patient’s respiratory drive diminish with administration of intravenous sedation. Preparation for an emergency tracheotomy was necessary in the event the airway was compromised at any point during the removal of the arrow. While there was no major vascular injury present, there was still concern about bleeding obstructing the upper airway after the arrow was removed. With these precautions in mind, the arrow was removed with the aid of intravenous sedation. An endotracheal tube was then placed and the
http://dx.doi.org/10.1016/j.jocn.2015.10.031 0967-5868/Ó 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
2
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
c
a
b
Fig. 1. Coronal CT angiogram shows the hyperdense arrow and air present along the track, located just inferomedial to the junction of the petrous and lacerum segments of the internal carotid artery (a). Coronal CT angiogram showing the arrow with adjacent intracranial air. The tip of the arrow seen here is just lateral to the vertebrobasilar junction (b). Sagittal CT scan showing the trajectory of the arrow with the tip piercing the clivus and entering the intracranial cavity. Of note, the arrow protrudes to a significant degree from the patient’s mouth (not fully visualized on this image) (c).
Fig. 2. Mucosa overlying the clivus with defect arising from prior crossbow arrow (a) is seen. Mucosal defect is more easily appreciated after debridement of surrounding mucosa (b). Harvested fascia lata graft was cut to an appropriate size to ensure coverage of the defect (c). A ball of Surgicel (Ethicon for Johnson & Johnson Medical, Piscataway, NJ, USA) was placed centrally within the fascia lata and pressed firmly into the defect. Redundant fascia lata is seen protruding from the previous skull base defect to ensure a watertight seal (d). A harvested pedicled nasoseptal flap is laid over the now secured fascia lata graft (e) and held in place with fibrin glue and nasal packing.
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
3
Fig. 3. Penetrating screwdriver injury to the midface is seen on a lateral radiograph (a). The screwdriver is demonstrated traversing the maxillary sinus en route to the clivus, penetrating just inferior to the sphenoid sinus floor shown on a noncontrast axial (b), sagittal (b), and coronal (d–f) CT scans of the head.
patient was placed under general anesthesia. The area was closely inspected from a transnasal, endoscopic approach and no CSF leak was apparent at the time of surgery. Therefore, only a local debridement was performed initially. On postoperative day 2 the patient was then taken back to the OR to repair the defect, as CSF rhinorrhea and pneumocephalus were noted. An endoscopic transnasal approach was once again used to expose the traumatic defect (Fig. 2a), after harvesting a fascia lata graft. An oscillating debrider was used to remove surrounding mucosa, fascia, and muscle to expose bone circumferentially around the clival defect. The defect was noted to be small, round, and cylindrical (Fig. 2b), making initial attempts to plug the hole difficult. Attempts to plug the hole with fascia lata were initially unsuccessful as the graft would not stay in place and was being extruded by pulsating CSF. The fascia lata was laid flat over the defect (Fig. 2c) and a plug of Surgicel (Ethicon for Johnson & Johnson Medical, Piscataway, NJ, USA) was placed centrally in the graft. Pressure was then placed centrally over the Surgicel and the fascia lata was pushed into the defect until the graft was flush with the bony edges superficially (Fig. 2d). A vascularized pedicled nasoseptal flap (PNSF) was then harvested based on the sphenopalatine artery and laid over this repair (Fig. 2e). Duraseal fibrin glue (Covidien, Dublin, Ireland) was applied next and absorbable, porous
nasal packing was utilized to maintain pressure of the nasoseptal flap against the clival defect. The patient did well postoperatively without any further evidence of CSF leak and complete resolution of the pneumocephalus. 2.2. Patient 2 A 42-year-old man presented to the emergency center with a screwdriver penetration injury to the midface after he was the victim of an aggravated assault. The patient was hemodynamically and neurologically stable with a Glasgow Coma Scale score of 15. Prior to removal of the screwdriver, the patient was taken for a CT scan to evaluate the extent of the injury (Fig. 3). This revealed the screwdriver entering the midface, traversing the maxillary sinus, and penetrating the clivus without vascular injury. The patient underwent elective intubation in the operating room. Next, an endoscope was inserted to evaluate the extent of injury. The ethmoid and sphenoid sinuses were widely opened in order to evaluate the clival defect. A vascularized right-sided PNSF was harvested in preparation for reconstruction of the skull base defect. The screwdriver tip was seen and the adjacent clivus drilled in order to directly visualize the deepest portion of the screwdriver (Fig. 4). Fascia lata was harvested and used to seal the defect
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
4
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
Fig. 4. Endoscopic images obtained at the time of surgery illustrating the screwdriver tip penetrating the skull base just inferior to the sphenoid floor (a). The sinuses have been opened to adequately expose the traumatic injury and expose the point of entry into the clivus (b–d).
utilizing a ‘‘gasket-seal” technique. The vascularized PNSF was then placed on top to further seal the defect. Postoperative CT scan confirmed removal of the screwdriver without complication (Fig. 5). Postoperative follow-up revealed a well-healed reconstruction with no evidence of CSF leak. 3. Discussion Although penetrating injuries to organs are frequently reported, penetrating injuries to the brain are rare due to the resistance of the cranium to objects commonly used as weapons such as knives and bottles [3]. While rarely used as weapons, crossbow arrows and screwdrivers have been reported in cases involving traumatic penetrating injuries to the skull [4,5]. Workup should include skull radiographs, CT scan, and CT angiogram to evaluate underlying fracture or vascular injury [3]. If the brainstem is involved, the effects are generally devastating due to life-threatening neurological injury, with a very low likelihood of surviving such injury [4,5]. Projectiles that penetrate an airway and the central nervous system represent unique challenges in airway management, and removal involves risk of further deficit or vascular compromise [5,6]. Furthermore, there is an increased risk of intracranial infection in patients with penetrating injuries to the cranium due to the presence of contaminated foreign objects driven into the brain along the projectile track. Broad-spectrum antibiotics have been administered and shown to improve outcomes [7]. Once the patient is stable and the proper imaging tests have been performed, surgical exploration and reconstruction of the wound can be performed. CSF leaks through the clivus are uncommon and are in a particularly challenging region for reconstruction [8]. It is generally
Fig. 5. Postoperative axial CT scan of the head illustrating the traumatic penetrating defect in the clivus into the posterior fossa as well as the drilling defect which aided in visualization of the distal screwdriver tip for safe removal.
accepted that clival defects require multilayer reconstruction with subdural inlay along with epidural onlay with a covering vascularized flap [9]. Reconstructive techniques utilizing the endoscopic approach have greatly advanced since non-vascularized free tissue grafting and synthetic materials [9,10]. These techniques were primarily suited for smaller sized CSF leaks, smaller than 1 cm [11]; however, utilizing a PNSF allows larger defects to be repaired
Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031
B.D. Liebelt et al. / Journal of Clinical Neuroscience xxx (2016) xxx–xxx
through an endoscopic approach [12]. Several studies have evaluated closure techniques involving the clivus, with success rates ranging from 60–100% [13–15]. However, it is apparent that the inclusion of a PNSF in a multilayer closure technique offers optimal results. A similar technique to the ‘‘gasket-seal” method previously described in the literature can be applied to small penetrating injuries of the skull base with a few notable exceptions. The ‘‘gasketseal” method has been described to repair larger anterior skull base defects following transsphenoidal, transtuberculum, and transplanum approaches [16,17]. Our cases were post-traumatic with a much smaller defect than a post-surgical defect. As such, use of autologous nasal bone or a synthetic implant would not have been an appropriate solution to repair the CSF fistula. The void created by the crossbow arrow required material small enough to fit through the void but with sufficient expansile properties to conform to the cavity and prevent egress of CSF. Surgicel is easily compressed but also expands, fitting the above stated criteria.
4. Conclusions Traumatic penetrating injuries to the clivus are rarely reported in the literature and present a complex scenario. Visualization of the defect, removal of the offending object, and endoscopic repair were instrumental in treating these two patients. We present two particularly challenging cases where a vascularized PNSF in conjunction with a modified ‘‘gasket-seal” technique consisting of Surgicel and fascia lata was used to reconstruct injuries to the clivus with concomitant CSF fistula.
Conflicts of Interest/Disclosures The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication.
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Please cite this article in press as: Liebelt BD et al. Endoscopic repair technique for traumatic penetrating injuries of the clivus. J Clin Neurosci (2016), http://dx.doi.org/10.1016/j.jocn.2015.10.031