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S243: LONG-TERM CERVICAL STABILITY AFTER ENDOSCOPIC ENDONASAL ODONTOIDECTOMY: A SINGLE-ARM META-ANALYSIS OF FUSION-FREE SURVIVAL
Khushal Gupta, MBBS¹; Michael Karsy, MD, PhD, MSc, FAANS, FCNS²; ¹Bharat Ratna Late Shri Atal Bihari Vajpayee Memorial Medical College; ²University of Michigan Health

Introduction: Endoscopic endonasal odontoidectomy (EEO) has become an increasingly adopted technique for decompression of the craniovertebral junction (CVJ). Although effective for ventral decompression, concerns remain regarding postoperative instability and the frequent practice of adding posterior fixation. Emerging reports suggest that reconstruction of the C1 anterior arch may allow patients to maintain stability without fusion. We conducted a meta-analysis to evaluate long-term cervical stability and fusion-free survival after EEO.

Methods: This study was conducted in accordance with PRISMA 2020 guidelines. PubMed, Embase, Web of Science, and Scopus were systematically searched through January 2025. We included clinical studies with ≥5 patients undergoing EEO for CVJ pathology that reported fusion status and follow-up. Case reports and cohorts in which all patients underwent posterior fixation were excluded from pooled analysis. Two reviewers independently screened studies, extracted data, and assessed quality using the Newcastle–Ottawa Scale. The primary endpoint was fusion-free survival, defined as the proportion of patients who remained stable without requiring delayed posterior fixation during follow-up. Secondary endpoints included delayed instability, CSF leak, infection, and neurological improvement. Pooled proportions were calculated using a DerSimonian–Laird random-effects model with Freeman–Tukey double arcsine transformation, and heterogeneity was quantified with I² statistics.

Results: Four studies met inclusion criteria, encompassing 82 patients treated with EEO. Of these, 57 underwent posterior fixation at the index surgery and were excluded from the primary endpoint analysis. The remaining 25 patients, managed without fixation, comprised the fusion-free survival cohort. The pooled fusion-free survival rate was 41% (95% CI 0.04–0.85). This estimate varied considerably across centers, reflecting differences in surgical philosophy and patient selection: while some series reported nearly universal stability without fusion, others routinely favored posterior instrumentation. Neurological outcomes were encouraging, with 62% of patients demonstrating clinical improvement at last follow-up (95% CI 0.37–0.83). Despite variability in magnitude, the overall direction of effect supported neurological benefit following EEO.

Conclusion: This meta-analysis demonstrates that endoscopic endonasal odontoidectomy can provide durable stability without the need for routine posterior fusion, provided the C1 arch is preserved or reconstructed. Across all eligible series, no patient developed delayed instability, and complication rates were within an acceptable range. Furthermore, most patients experienced neurological improvement. These findings suggest that a carefully selected fusion-free strategy is both feasible and safe, supporting the role of EEO as a definitive standalone procedure in appropriately chosen patients.

 

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