Sublabial Approach for Symptomatic Basilar Impression

Abstract

To the Editor: We read with great interest the article by Dr Bettegowda and colleagues entitled “Sublabial Approach for the Treatment of Symptomatic Basilar Impression in a Patient With Klippel-Feil Syndrome.”1 In this report, the authors provide a detailed description of the sublabial approach to the anterior spine for basilar impression. They also provide a comparison with alternative approaches such as the transoral and transcervical approaches. However, we would like to highlight the existence of another direct route for resection of the odontoid process: the expanded endoscopic endonasal approach (EEA).2-5 The caudal angle of exposure with EEA is limited by the nasal bones anteriorly and the hard palate posteriorly. The line connecting these 2 points, defined as the nasopalatine line, accurately predicts the most inferior extent of surgical dissection. As previously published, we were able to demonstrate that the base of the odontoid process and the inferior extent of surgical dissection were always above this line in patients with basilar invagination.3 We favor the EEA route for cases of basilar invagination because of the cranial ascension of C1-C2, which makes a transoral approach less direct and often with the need for soft palate split.2 We believe that a pure EEA requires less manipulation of the facial structures compared with the sublabial approach and avoids contamination with oral flora. As an illustration, the Figure presents preoperative and postoperative imaging demonstrating the extent of anterior decompression possible with an EEA. Potential advantages of EEA to the clivus and anterior spine include improved visualization, limited morbidity, decreased pain, and faster recovery than with traditional approaches.1FIGURE: A, preoperative computed tomography (CT.) B, postoperative CT. C, preoperative magnetic resonance image (MRI). D, postoperative MRI.Disclosure The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.