Median labiomandibular glossotomy approach to the craniocervical region

LABIOMANDIBULAR GLOSSOTOMY APPROACH FOR CRANIOCERVICAL PATHOLOGIES - SPINE RECONSTRUCTION

ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 – C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.

Full-Endoscopic Transcervical Ventral Decompression for Pathologies of Craniovertebral Junction: Case Series

Odontoidectomy is very effective for the decompression of the ventral craniovertebral junction (CVJ). Various approaches are available for the direct ventral decompression of the CVJ. Because there are many disadvantages of open transoral approach, endoscopic odontoidectomy was developed. There are 3 approaches in endoscopic odontoidectomy. We report transcervical retropharyngeal endoscopic approach for the ventral CVJ in this paper. Three patients with different pathologies received operations using this approach. The decompression was enough and surgical invasion was less in all patients. Each endoscopic approach has some advantages and different working regions due to their approach trajectories, but transcervical retropharyngeal approach is very familiar for our neurospinal surgeons and has a relatively large working area. This approach might have the chance to take the place of open transoral approach for endoscopic spinal surgeons.

Carbon Dioxide Laser Microsurgical Median Glossotomy for Resection of Lingual Dermoid Cysts

Dermoid cysts are epithelial-lined cavities with skin adnexae in the capsule. Only 7% is present in the head and neck. Between 2004 and 2013, four patients with a lingual dermoid cyst underwent a microsurgical carbon dioxide laser resection via a median sagittal glossotomy approach. This approach is an elegant technique combining superior visualization, hemostasis, and little postoperative edema with good wound healing, allowing for perfect function preservation of the tongue.

Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update

The craniovertebral junction (CVJ), or the craniocervical junction (CCJ) as it is otherwise known, houses the crossroads of the CNS and is composed of the occipital bone that surrounds the foramen magnum, the atlas vertebrae, the axis vertebrae, and their associated ligaments and musculature. The musculoskeletal organization of the CVJ is unique and complex, resulting in a wide range of congenital, developmental, and acquired pathology. The refinements of the transoral approach to the CVJ by the senior author (A.H.M.) in the late 1970s revolutionized the treatment of CVJ pathology. At the same time, a physiological approach to CVJ management was adopted at the University of Iowa Hospitals and Clinics in 1977 based on the stability and motion dynamics of the CVJ and the site of encroachment, incorporating the transoral approach for irreducible ventral CVJ pathology. Since then, approaches and techniques to treat ventral CVJ lesions have evolved. In the last 40 years at University of Iowa Hospitals and Clinics, multiple approaches to the CVJ have evolved and a better understanding of CVJ pathology has been established. In addition, new reduction strategies that have diminished the need to perform ventral decompressive approaches have been developed and implemented. In this era of surgical subspecialization, to properly treat complex CVJ pathology, the CVJ specialist must be trained in skull base transoral and endoscopic endonasal approaches, pediatric and adult CVJ spine surgery, and must understand and be able to treat the complex CSF dynamics present in CVJ pathology to provide the appropriate, optimal, and tailored treatment strategy for each individual patient, both child and adult. This is a comprehensive review of the history and evolution of the transoral approaches, extended transoral approaches, endoscopie assisted transoral approaches, endoscopie endonasal approaches, and CVJ reduction strategies. Incorporating these advancements, the authors update the initial algorithm for the treatment of CVJ abnormalities first published in 1980 by the senior author.

Comparison of extraoral and transoral approaches to the craniocervical junction: morphometric and quantitative analysis

BACKGROUND

The transoral (TO) approach to the craniocervical junction provides similar access to the periclival and subaxial spine compared with the extraoral anterolateral prevascular (EAP) approach, but the additional exposure gained by the EAP approach has not been quantified. This study quantitatively compared the two surgical exposures.

METHODS

Ten silicon-injected fixed cadaver heads were used for the TO approach and another 5 heads (10 sides) were dissected for the EAP approach. For the TO approach, mouth opening was standardized to 5.5 cm using a Spetzler-Sonntag retractor, and the soft palate was split 1.5 cm to access the periclival area. A frameless stereotactic device was used to calculate the lengths, angles, and areas of surgical exposure for different anatomic targets.

RESULTS

The vertical working length on the dura progressively increased 61% (336 ± 26 mm to 539 ± 16 mm [mean ± standard deviation]; P < 0.001), and the vertical working angle increased 23% (98 ± 3 degrees to 121 ± 5 degrees; P < 0.0) using the TO versus the EAP approach. In the TO approach, the bilateral average horizontal working length on the C1 arch was less on the ipsilateral side than for the EAP approach (11 ± 1 mm vs. 17 ± 1 mm, 61%; P < 0.01). The mean periclival and subaxial exposures were 546 ± 72 mm(2) and 932 ± 70 mm(2) with the TO approach and 874 ± 75 mm(2) and 1644 ± 107 mm(2) with the EAP approach (mean increases 62% and 77%, respectively; both P < 0.001).

CONCLUSIONS

Both the TO and EAP approaches improved surgical exposure, but the EAP approach provides more significant and consistent gains to the anterolateral periclival and subaxial areas.

Anterior Fixation of the Axis

BACKGROUND:

Although anterior fixation of the axis is not commonly performed, plate fixation of C2 is an important technique for treating select upper cervical traumatic injuries and is also useful in the surgical management of spondylosis.

OBJECTIVE:

To report the technique and outcomes of C2 anterior plate fixation for a series of patients in which the majority presented with symptomatic degenerative spondylosis.

METHODS:

Forty-six consecutive patients underwent single or multilevel fusions over a 7-year period; 30 of these had advanced degenerative disease manifested by myelopathy or deformity. Exposure was achieved with rostral extension of the standard anterior cervical exposure via careful soft tissue dissection, mobilization of the superior thyroid artery, and the use of a table-mounted retractor. It was not necessary to remove the submandibular gland, section the digastric muscle, or make additional skin incisions.

RESULTS:

Screws were placed an average of 4.6 mm (± 2.3 mm) from the inferior C2 endplate with a mean sagittal trajectory of 15.7° (± 7.6 °).

Short- and long-term procedure-related mortality was 4.4%, and perioperative morbidity was 8.9%. Patients remained intubated an average of 2.5 days following surgery. Dysphagia was initially reported by 15.2% of patients but resolved by the 8th postoperative week in all patients. Arthrodesis was achieved in all patients available for long-term follow-up. Multilevel fusions were not associated with longer hospitalization or morbidity.

CONCLUSION:

Anterior plate fixation of the axis for degenerative disease can be accomplished with acceptable morbidity employing an extension of the standard anterolateral route.

Management of congenital lingual dermoid cysts

BACKGROUND

Lingual dermoid cysts are squamous epithelial-lined cavities with variable numbers of skin adnexae in the capsule and are rare entities in the head and neck. We discuss the presentation, possible aetiologies and the surgical management of these lesions and report on the ninth lingual dermoid cyst as an illustrative example, the first to be excised by laser.

METHODS

An extensive literature search was undertaken. We present the case of a 4-month-old di-zygotic twin girl with a firm midline anterior tongue dermoid cyst. Its extent was defined by magnetic resonance imaging. The cyst was excised using the CO(2) laser via an extended median sagittal glossotomy approach.

RESULTS

Lingual dermoid cysts most commonly present in early childhood or adolescence and are located in the anterior two thirds of the tongue. Eight lingual dermoid cysts have been reported, all of which were surgically excised, using varying techniques, and no recurrences have been reported. Our patient recovered well and was extubated immediately post-operatively. However, feeding was delayed for 48h post-operatively due to pain, requiring opiate analgesia. The tongue healed completely with only a small indent in the tip.

CONCLUSIONS

Treatment of these lesions consists of complete surgical excision. We propose that the midline sagittal glossotomy incision using the CO(2) laser offers surgical precision, superior haemostasis and wound healing and minimal post-operative oedema. The involvement of the sensitive tongue tip in this approach may be its one drawback, however this may be compensated for with appropriate post-operative analgesia.