Transoral-transpharyngeal approach to the upper cervical vertebrae

Transcervical, retropharyngeal odontoidectomy - Anatomical considerations

Context

Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications.

Aims

This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process.

Methods and Surgical Technique

To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach.

Results

The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas.

Conclusions

For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.

Full-endoscopic uniportal retropharyngeal odontoidectomy: A preliminary case report

Summary of background data

Odontoidectomy aims to decompress the medulla oblongata and is usually performed through the classical transoral approach, which affects oropharynx and accompanied with high rate of complications comprising swallowing and respiratory tract. We have developed a minimal invasive method via a standard cervical anterior approach: full-endoscopic trans-cervical odontoidectomy, which provides an alternative access for the resection of odontoid process and medulla oblongata decompression without traversing potentially contaminated cavities.

Methods

From 2018 to 2020, three patients with either odontoid process lesion or basilar invagination underwent full-endoscopic uniportal trans-cervical odontoidectomy with/without combining the posterior instrumentation. With fluoroscopic guidance, a uniportal endoscope sleeve was placed inside of the odontoid process; then odontoid process was gradually resected from the inside to outside under endoscopic monitoring. Postoperative images and clinical data were collected during post-op follow-up.

Result

Patients were soon extubated after surgery when patients wake up from general anesthesia. There were no severely perioperative complications, especially dysphagia and airway obstruction, and the symptoms and neurological function was improved immediately after surgery. The final pathology of one patient with odontoid osteolytic lesion was confirmed as plasmacytoma. The postoperative CT scans proved that the range of odontoid process resection was consistent with the preoperative expectation.

Conclusion

In summary, our proposed endoscopic trans-cervical odontoidectomy provides a valid choice for non-oral approach, which would reduce postoperative approach related complications and accelerate postoperative recovery.

The endoscopic transnasal approach to the lesions of the craniocervical junction: two case reports

The endoscopic endonasal approach (EEA) to the craniovertebral junction (CVJ) has recently been considered a safer alternative and less invasive approach than the traditional transoral approach because the complications associated with the latter are avoided or minimized. Here, we present two challenging cases of CVJ pathologies. The first case involved os odontoideum associated with anterior displacement of the occipitocervical junction where the EEA was used, followed by C0-C1-C2 fusion using a posterior approach to decompress the CVJ, and was complicated by rhinorrhea and Candida albicans meningitis. The second case involved basilar invagination with syringomyelia previously treated using a posterior approach, where aggravation of neuropathic symptoms required combined treatment with EEA and occipitocervical fusion of C0-C2-C3-C4, with the postoperative course challenged by operative site infection requiring drainage with debridement and antibiotic therapy. The EEA is an alternative approach for accessing the CVJ in well-selected patients. Knowledge of EEA complications is crucial for the optimal care of patients.

Preoperative management and postoperative complications associated with transoral decompression for the upper cervical spine

Purpose

This review aimed to describe the preoperative management and postoperative complications associated with transoral decompression of the upper cervical spine, and to clarify the risk factors, related issues and complication management.

Methods

Studies on transoral decompression for the upper cervical spine were reviewed systematically. The preoperative management and postoperative complications associated with transoral decompression for upper cervical deformities were analyzed.

Results

Evidence suggests that preoperative management in patients undergoing transoral decompression for the upper cervical spine is closely related to the occurrence of postoperative complications. Hence, preoperative surgical planning, preoperative preparation, and oral nursing care should be seriously considered in these patients. Moreover, while being established as an effective and safe method, transoral decompression is associated with several postoperative complications, which could be prevented by elaborate preoperative management, improved surgical skills, and appropriate precautionary measures.

Conclusions

The effectiveness and safety of transoral decompression has been improved by the constant development of operative techniques and advanced auxiliary diagnostic and therapeutic methods, with the understanding of the anatomical structure of the craniocervical joint. Therefore, the incidence rates of postoperative complications have decreased. The application of individualized anterior implants and less-invasive endoscopic endonasal approach has improved the effectiveness of transoral decompression and reduced the associated complications.

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.

Posterior transdural approach for odontoidectomy in a child: case report

The transoral transpharyngeal approach is the standard approach to resect the odontoid process and decompress the cervicomedullary spinal cord. There are some significant risks associated with this approach, however, including infection, CSF leak, prolonged intubation or tracheostomy, need for nasogastric tube feeding, extended hospitalization, and possible effects of phonation. Other ventral approaches, such as transmandibular and circumglossal, endoscopic transcervical, and endoscopic transnasal, are also viable alternatives but are technically challenging or may still traverse the nasopharyngeal cavity. Far-lateral and posterior extradural approaches to the craniocervical junction require extensive soft-tissue dissection. Recently, a posterior transdural approach was used to resect retro-odontoid cysts in 3 adult patients. The authors present the case of a 12-year-old girl with Down syndrome and significant spinal cord compression due to basilar invagination and a retro-flexed odontoid process. A posterior transdural odontoidectomy prior to occiptocervical fusion was performed. At 12 months after surgery, the authors report satisfactory clinical and radiographic outcomes with this approach.

The Endonasal Endoscopic Approach to Pathologies of the Anterior Craniocervical Junction: Analytical Review of Cases Treated at Four European Neurosurgical Centres

Supported by preliminary anatomical and clinical studies exploring the feasibility and usefulness of approaching many ventral pathologies of the craniocervical junction (CCJ) using the endoscopic endonasal approach, four European centres have joined forces to accumulate and share their growing surgical experience of this advanced technique. By describing the steps that led to the development and continuous refinement of this approach to the CCJ, this article delves deeply into an analysis of the cases operated on since 2010 at these four institutions, and discusses in detail the operative nuances that so far have allowed achievement of successful outcomes with excellent perioperative patient comfort and satisfactory long-term quality of life.

Endonasal Endoscopic Odontoidectomy in Ventral Diseases of the Craniocervical Junction: Results of a Multicenter Experience

BACKGROUND

Over the past decades, supported by preliminary anatomic and clinical studies exploring its feasibility and safety, experience has increased of the use of the endoscopic endonasal approach (EEA) to ventral diseases at the craniocervical junction (CCJ).

METHODS

A multicenter study was carried out over a 4-year period of 14 patients managed by EEA odontoidectomy for CCJ diseases causing irreducible atlantoaxial dislocation. The surgical setup included an IGS system based on computed tomography and magnetic resonance images fusion, and 0° and 30° angled endoscopes with dedicated endoscopic tools.

RESULTS

Nine men and 5 women, with a mean age of 60.7 years, were included. The mean follow-up was 28.5 months; 9 patients had basilar impression, whereas 5 had a degenerative pannus. The quality of anterior decompression was excellent in all cases; nonetheless, a posterior stabilization was deemed necessary in 13 patients, and no external orthosis was used during the postoperative course. No tracheostomy or gastrostomy was required after surgery; no deaths, no new neurologic deficits/complications, and no postoperative cerebrospinal fluid leak were recorded. At follow-up, the neurologic status assessed with Frankel grade did not deteriorate in any of the patients but improved in 13 of them; and no new listhesis was shown on neuroradiologic follow-up.

CONCLUSIONS

The results show that EEA provides a direct surgical corridor to the CCJ, allowing an adequate decompression as with the more invasive transoral route. Morbidity is less than with a transoral approach, resulting in higher patient comfort and faster recovery.

Single-stage Anterior Release and Sequential Posterior Fusion for Irreducible Atlantoaxial Dislocation

STUDY DESIGN

A retrospective study.

OBJECTIVE

To introduce the method of single-stage anterior release and reduction with posterior fusion in irreducible atlantoaxial dislocation (IAAD) and to evaluate the clinical effects of this surgery.

SUMMARY OF BACKGROUND DATA

In previous clinical studies, several techniques have been introduced to manage IAAD. But all these treatments have intrinsic disadvantages. A single-stage anterior release and reduction with posterior fusion can offer a new alternative which can avoid these disadvantages.

METHODS

From January 2003 to January 2009, 22 cases of IAAD were diagnosed consecutively. Anterior atlantoaxial release was performed through anterior retropharyngeal approach, after traction reduction conducted on the monitoring of C-arm fluoroscopy. C1-C2 were then fixed posteriorly and fused by single stage. Neurological status was evaluated using the Japanese Orthopaedic Association scoring system.

RESULTS

All patients were observed for an average of 32 months, ranging from 15 to 40 months. All cases achieved anatomic reduction and solid fusion. The Japanese Orthopaedic Association score of 12 patients with myelopathy improved from 8.3 to 13.9, 6 months postoperatively, and the mean improving rate was 87.5%. No graft or implant-related complications were observed in any patient during the entire follow-up period.

CONCLUSIONS

The method of single-stage anterior release and reduction with posterior fusion is an effective method for management of IAAD, proving its value as a technique for achieving complete reduction with solid bony fusion.

Variations of mucosal-sparing septectomy for endonasal approach to the craniocervical junction

OBJECTIVES/HYPOTHESIS

Recent advances in surgical techniques have rendered the craniocervical junction (CCJ) accessible transnasally. Endoscopic endonasal transclival and transodontoid approaches are routinely performed in leading skull base centers. Usually, these approaches involve a posterior bony and mucosal septectomy, which may compromise the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option for repair of large skull base defects. With the possibility of an intraoperative cerebrospinal fluid leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. We describe three new variations/refinements of the endoscopic endonasal approach to the CCJ that preserve the mucosal integrity of the posterior nasal septum and PNSF.

METHODS

Photo and video documentation of cadaveric dissections.

RESULTS

The steps required for the different variations in approaching the CCJ are demonstrated. These three options are: 1) nonopposing Killian incisions with submucosal elevation of PNSFs laterally under the inferior turbinates (the PNSFs are retracted laterally and left attached superiorly onto the nasal septum and laterally under the inferior turbinate); 2) bilateral non-opposing PNSFs tucked beneath their respective middle turbinate or into the sphenoid sinus; and 3) a hybrid approach combining option 1 performed on one side and option 2 on the contralateral side. All three options allowed for a mucosal-sparing septectomy to provide ample access to the CCJ.

CONCLUSION

These variations/refinements of the mucosal-sparing approach to the CCJ allowed adequate surgical access with sufficient maneuverability while preserving both PNSFs.

LEVEL OF EVIDENCE

NA. Laryngoscope, 126:2220-2225, 2016.

C1 anterior arch preservation in transnasal odontoidectomy using three-dimensional endoscope: A case report

BACKGROUND

The transoral ventral corridor is the most common approach used to reach the craniovertebral junction (CVJ). Over the last decade, many case reports have demonstrated the transnasal corridor to the odontoid peg represents a practicable route to remove the tip of the odontoid process. The biomechanical consequences of the traditional odontoidectomy led to the necessity of a cervical spine stabilization. Preserving the inferior portion of the C1 anterior arch should prevent instability.

CASE DESCRIPTION

This is the first report in which the technique to remove the tip of the odontoid while preserving the C1 anterior arch is described by means of a three-dimensional (3D) endoscope. A 53-year-old man underwent a transnasal 3D endoscopic approach because of a complex CVJ malformation. The upper-medial portion of the C1 anterior arch was removed preserving its continuity, and the odontoidectomy was performed. After surgery, a dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative one.

CONCLUSIONS

The stereoscopic perception augmented the precision of the surgical gesture in the deep field. The importance of a 3D view relates to the depth of field, which a two-dimensional endoscopy cannot provide. This affects the preservation of the C1 anterior arch because of the presence of critical structures that are exposed to potential damage if not displayed.

Mucosal-sparing posterior septectomy for endoscopic endonasal approach to the craniocervical junction

Recent technological advances and developments in surgical technique have made the craniocervical junction (CCJ) accessible through the transnasal surgical corridor. Endoscopic endonasal transclival and transodontoid approaches have been previously described in the literature. Traditionally, these approaches entail a posterior bony and mucosal septectomy. This posterior bony and mucosal septectomy can compromise the integrity of the posterior septum and damage the vascularized pedicled nasoseptal flap (PNSF), a robust reconstructive option. With the possibility of an intraoperative cerebrospinal fluid (CSF) leak and the reported success of the PNSF for repair of these defects, preserving the integrity of the PNSF is beneficial during the endoscopic endonasal approach to the CCJ. Here, we present a new variation which preserves the mucosal integrity of the posterior nasal septum and PNSF. This mucosal-sparing variation of the traditional endoscopic endonasal transclival and transodontoid approaches allows for the preservation of posterior mucosal nasoseptal integrity, and salvages a reconstructive option for future usage. This is accomplished at no expense to visualization, surgical access, or maneuverability.

Infection rate after transoral approach for the upper cervical spine

STUDY DESIGN

A retrospective review of prospectively collected databases of 139 consecutive patients who underwent transoral surgery for lesions of the upper cervical spine.

OBJECTIVE

To analyze the incidence and risk factors of local infection after transoral surgery for the craniocervical junction in a single institution and to compare the findings with the literature.

SUMMARY OF BACKGROUND DATA

One of the primary risks associated with transoral approach for lesions in the upper cervical spine is postoperative surgical wound infection.

METHODS

From April 1994 to December 2012, 139 consecutive transoral surgical procedures were performed at a single referral center. The mean age at presentation was 53.6 years (range: 5-87 yr), and more than half of the patients were males (58.3%). The majority of cases were experiencing rheumatic diseases (43.9%), whereas tumor destruction was the indication for surgery in 23.7% of the cases. A total of 23% had fracture of the upper cervical spine and primary infection was found in 7 patients (5%). The mean follow-up period was 4.5 years.

RESULTS

Infection of the pharyngeal wound occurred in 5 patients (3.6%), solely in the rheumatic and tumor groups. The presentation was mostly in the first 4 months. A single patient with cage reconstruction after giant cell tumor C2 presented with a late infection 5 years postoperatively. Debridement and primary closure was possible in 2 patients, whereas flap coverage of the pharyngeal wall was necessary in 3 patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage.

CONCLUSION

The transoral route has proved to be an invaluable method of approaching pathological lesions in the upper cervical spine. The infection rate in this work was 3.6%. Patients with rheumatic diseases and patients presenting with tumors were more susceptible to postoperative surgical wound infection.

LEVEL OF EVIDENCE

4.

Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis

BACKGROUND CONTEXT

Rheumatoid arthritis is the most common inflammatory disease involving the spine with predilection for the craniovertebral segment. Surgery is usually reserved to patients with symptomatic craniovertebral junction (CVJ) instability, basilar invagination, or upper spinal cord compression by rheumatoid pannus. Anterior approaches are indicated in cases of irreducible ventral bulbo-medullary compression. Classically performed through the transoral approach, the exposure of this region can be now achieved by a minimally invasive endonasal endoscopic approach (EEA).

PURPOSE

The aim of this article is to demonstrate the feasibility of performing an odontoidectomy and a rheumatoid pannus removal by a minimally invasive EEA, preserving the anterior C1 arch continuity and avoiding a posterior fixation procedure.

STUDY DESIGN

Technical description and cohort report.

METHODS

We report three cases of elderly patients with a long history of rheumatoid arthritis and irreducible anterior bulbo-medullary compression secondary to basilar invagination and/or rheumatoid pannus. Anterior decompression was achieved by an endonasal image-guided fully endoscopic approach.

RESULTS

Neurological improvement and adequate bulbo-medullary decompression were obtained in all cases. The anterior C1 arch continuity was preserved, and none of the patients required a subsequent posterior fixation.

CONCLUSIONS

Anterior decompression by a minimally invasive EEA could represent an innovative option for the treatment of irreducible ventral CVJ lesions in elderly patients with rheumatoid arthritis. This approach permits the preservation of the anterior C1 arch and the avoidance of a posterior fixation, thus preserving the rotational movement at C0-C2 segment and reducing the risk of a subaxial instability development.

Endonasal access to the upper cervical spine, part one: radiographic morphometric analysis

Objectives To determine the anatomical relationships that may influence endonasal access to the upper cervical spine. Setting We retrospectively analyzed computed tomography of 100 patients at a single institution. Participants Participants included adults with imaging of the hard palate, clivus, and cervical spine without evidence of fracture, severe spondylosis, or previous instrumentation. Main Outcome Measures Morphometric analyses of hard palate length and both distance and angle between the hard palate and odontoid process were based on radiographic measurements. Descriptive zones were assigned to cervical spine levels, and endoscopic visualization was simulated with projected lines at 0, 30, and 45 degrees from the hard palate to the cervical spine. Results We found an inverse relationship between hard palate length and the lowest zone of the cervical spine potentially visualized by nasal endoscopy. The distance between the posterior tip of the hard palate and the odontoid tip, and the angle formed between the two, directly influenced the lowest possible cervical exposure. Conclusions Radiographic relationships between hard palate length, distance to the odontoid, and the angle formed between the two predict the limits of endonasal access to the cervical spine. These results are supported by cadaveric data in Part Two of this study.

Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: case report and literature review

INTRODUCTION

Although the transoral transpharyngeal approach has been the standard approach to decompress the odontoid process, it bears some disadvantages including risk of infection, prolonged intubation or tracheostomy, need for nasogastric tube feeding, extended hospitalization, and possible effects of phonation. The endoscopic transnasal approach is a viable alternative, managing to avoid some of the pitfalls of the more accepted transoral transpharyngeal approach. However, there have only been a handful of adult cases and only three pediatric cases.

CASE REPORT

We present the case of a 10-year-old girl with a chronic type 3 atlantoaxial rotator fixation and significant spinal cord compression from basilar invagination and a displaced odontoid process. We performed an endoscopic endonasal odontoidectomy prior to posterior occiptocervical fusion on the patient. She was neurologically intact with a well-healed wound at 7-month follow-up.

Anterior approach to cervical spine

STUDY DESIGN

Review of surgical technique.

OBJECTIVE

To provide accounts of the authors' preferred methods for performing anterior cervical surgery with personal tips and pearls.

SUMMARY OF BACKGROUND DATA

Many have described the various anterior surgical approaches to the cervical spine, and in this review, we hope to describe our preferences, highlighted with some tips and pearls.

METHODS

Various accounts of the transoral, the anterolateral (Smith-Robinson), and the split manubrium approaches were reviewed and used as the basis of the review. Additional notes with regard to the authors' preferences were noted to provide further guidance. The descriptions were delineated from the most cephalad to the most caudal.

RESULTS

The transoral, the anterolateral (Smith-Robinson), and the manubriotomy approaches were described. Each account starts with the basic preoperative considerations, then describes the incision and the main anatomical landmarks, and finally concludes with closure and main complications to monitor for. A brief description of the main pathologies that each approach may address is also provided.

CONCLUSION

The 3 anterior approaches to the cervical spine are direct and elegant solutions to pathologies arising from the anterior column. They supplement the more commonly used posterior approaches, which provide stronger multilevel fixation, and thus provide an essential tool in the armamentarium of spine surgeons.

Diseases of the odontoid and craniovertebral junction with management by endoscopic approaches

Surgical approaches to the craniovertebral junction (CVJ) can result in dysfunction of the upper aerodigestive tract. However, few data are available regarding the incidence of complications after such surgery. Evaluation of a CVJ lesion for treatment must establish the biology, transverse and longitudinal extent of the lesion, and the preoperative and postoperative stability of the spine. Endoscopic approaches to the CVJ, which should reduce the expected morbidity of an open transoral approach, have been described recently. This article reviews common pathologies of the CVJ and surgical approaches, and provides an evidence-based analysis of whether endoscopic approaches reduce velopharyngeal insufficiency.

Transoral approach and extended modifications for lesions of the ventral foramen magnum and craniovertebral junction

OBJECTIVES

To describe our method of performing the transoral approach and the extended approaches to the ventral foramen magnum and craniovertebral junction and review the technical aspects and operative nuances.

DESIGN

Review.

RESULTS

The transoral approach provides direct midline exposure to access extradural disease located at the craniovertebral junction and ventral foramen magnum. The corridor of exposure is generally limited by the extent to which the patient can open his or her mouth. The location of the hard palate relative to the craniovertebral junction limits superior exposure, whereas the mandible and base of the tongue limit the inferior exposure. In most cases, exposure can be obtained from the inferior clivus to the middle to lower C2 vertebral body. Extended transoral approaches can be performed to increase exposure if necessary. These approaches include transmaxillary (Le Fort I maxillotomy), transmaxillary with a midline palatal split (extended "open-door" maxillotomy), transpalatal, and median labiomandibular glossotomy (transmandibular split).

CONCLUSIONS

The transoral approach effectively provides direct access to extradural midline lesions of the craniovertebral junction. A specialized retractor system can expose the inferior clivus to the C2 body. Extended approaches as described can access lesions that extend beyond these limits.

Sublabial approach for the treatment of symptomatic basilar impression in a patient with Klippel-Feil syndrome

BACKGROUND

Basilar impression (BI) is an uncommon condition in which there is upward displacement of the elements forming the foramen magnum, causing translocation of vertebral elements into the brainstem. Most commonly a developmental anomaly, BI is often associated with congenital conditions such as Down syndrome. Symptomatic BI is often difficult to treat surgically secondary to the anatomic variants associated with many of the coinciding congenital syndromes.

OBJECTIVE

To present a feasible approach for the treatment of BI.

METHODS

We present an alternative surgical approach for the treatment of symptomatic BI in a 37-year-old woman with Klippel-Feil syndrome. Because of the altered anatomy, traditional approaches such as the transoral-transpharyngeal, transmandibular circumglossal, and transcervical endoscopic routes were not feasible.

RESULTS

We chose a staged sublabial, transnasal, transpalatal route for the anterior brainstem decompression followed by posterior fixation. The patient tolerated the procedures well and at last follow-up had nearly complete resolution of symptoms.

CONCLUSION

The sublabial route is an alternative approach for anterior decompression in patients with symptomatic basilar impression and altered anatomic circumstances such as that caused by Klippel-Feil syndrome.

Combined pre- and retrovascular extraoral approach for tumors at lateral mass of the atlas

STUDY DESIGN

a series of 9 patients surgically treated with a novel combined pre-and retrovascular extraoral approach to lateral mass of the atlas (LMA) is examined.

OBJECTIVE

to describe the efficacy of combined pre- and retrovascular extraoral approach in achieving a wide exposure and aggressive resection of tumors at the LMA.

SUMMARY OF BACKGROUND DATA

the anatomic complexity and closeness to vital neurovascular structures raise technical difficulties in the surgical access to the LMA. Although various approaches, such as transoral approach, high anterior cervical approach, anterior lateral approach, and far lateral approach, have been reported in literature, wide exposure for the tumors at the LMA remains a unique challenge.

METHODS

for our experience in the surgical exposure of the upper cervical spine, we have developed a combined pre- and retrovascular extraoral approach to the atlas since 2001. Nine patients with neoplastic lesions at the LMA were surgically treated through this combined approach. Reconstruction of stability was achieved by a posterior occipitocervical fusion through a posterior approach under the same anesthesia.

RESULTS

this combined approach provided an excellent surgical field exposure to ensure the successful tumor resection while preventing the vertebral artery or nerve from injury. There was no operative mortality or severe morbidity in this series. Complications included 1 instance of transient dysphagia and 2 instances of transient trouble swallowing liquids. The symptoms of local pain and pharyngeal discomfort relieved, and patients suffering from spinal cord compression recovered well with 1 level of the Frankel scale when reevaluated 3 months after operation. With a follow-up period of 16 to 100 months, 1 patient with chondrosarcoma developed local recurrence at the 14th month of postoperation and died of respiratory and circulatory failure 39 months after surgery. No evidence of local recurrence was found in other patients.

CONCLUSION

the combined pre- and retrovascular extraoral approach provides an advantageous alternative to previous reported approaches. For selected cases with tumor lesions at the LMA, this combined approach offers more benefits, through which a wide exposure with well-protected vertebral artery favoring radical excision could be achieved without complications normally associated with transoral surgery.

Video-assisted anterior transcervical approach for the reduction of irreducible atlantoaxial dislocation

STUDY DESIGN

Technique note.

OBJECTIVE

To describe a modified minimally invasive approach for the treatment of irreducible atlantoaxial dislocation (IAAD).

SUMMARY OF THE BACKGROUND DATA

Currently, the most frequently used route for the treatment of symptomatic IAAD is transoral-transpharyngeal approach. Although it provides the most direct route to the atlantoaxial joint, potential problems may arise because of traverse oral cavity, such as the potential risks of infection, postoperative disturbances of breathing, and swallowing. The aim of this study was to describe a less-invasive approach for IAAD.

METHODS

Four consecutive patients with IAAD underwent the combined video-assisted atlantoaxial transcervical release (VAAT) procedure and posterior occipital-cervical fusion or C1-C2 screw fixation at Tongji Hospital. Clinical characteristics, images data, operative variables, and follow-up data were recorded.

RESULTS

Four cases presented with signs and symptoms of spinal cord dysfunction caused by IAAD underwent 1-stage anterior release, reduction, and posterior fixation. Three cases received C1-C2 screw fixation, and 1 case with occipitocervical fixation. Postoperative imaging studies showed that complete decompression was achieved in all the cases. No systemic infections, cerebrospinal fluid leaks, or adverse neurologic sequelae were found. None of the patients required prolonged intubation, tracheostomy, or enteral tube feeding. All patients started to oral intake after anesthesia. Neurologic status in 1 case remained at baseline whereas it improved in the others. The mean follow-up period was 9 months (6 approximately 12 months). All cases achieved solid fusion, without implants failure.

CONCLUSION

Our initial experience showed that the VAAT procedure for IAAD is a safe supplement and alternative to conventional and transcervical procedures.

Radiographic and anatomic basis of endoscopic anterior craniocervical decompression: a comparison of endonasal, transoral, and transcervical approaches

OBJECTIVE

To evaluate surgical access to the craniocervical junction using 3 endoscopic approaches: endonasal, transoral, and transcervical.

METHODS

Nine cadaveric specimens were used. Image guidance was used in 1 specimen for each approach; fluoroscopy was used in every case. The Vitrea imaging station (Vital Images Inc., Minnetonka, MN) was used to evaluate the angles and distances to the target of the approach, centered on the tip of the odontoid. The entry site was defined as: 1) the endonasal approach (inferior midline of the nasal bone), 2) the transoral approach (the tip of the upper incisor), and 3) the transcervical approach (the skin at the C4-C5 level).

RESULTS

Adequate lower clivus and craniocervical decompression was achieved using the endonasal and transoral approaches. Lower clivus decompression was not achieved with the transcervical approach. The average distance to the surgical target was as follows: endonasal (94 mm), transoral (102 mm), and transcervical (100 mm). The angle of attack was as follows: endonasal (28 degrees), transoral (30 degrees), and transcervical (15 degrees). The working area at the base of the field was as follows: endonasal (1305 mm2), transoral (1406 mm2), and transcervical (743 mm2).

CONCLUSION

The endonasal and transoral approaches allow wide exposure with large working angles to the craniocervical junction. The transcervical approach accesses the odontoid for resection from the body of C2 to the lip of the basion. The angles of attack in the transcervical approach when centered on the surgical target are limited, but this approach offers a clean, sterile operative field. Clinical investigation will be required to determine the optimal indications for each approach.

Extended Transoral Approaches

BACKGROUND

The transoral approach provides the most direct exposure to extradural lesions of the ventral craniovertebral junction. Lesions that extend beyond the exposure provided by the standard transoral approach require an extended transoral modification. The exposure can be expanded in the sagittal and axial planes by adding mandibulotomy, mandibuloglossotomy, palatotomy, and transmaxillary approaches to the standard transoral approach. Extended transoral approaches increase the surgical complexity and the risk of cosmetic and functional complications. Until recently, selection of an extended approach has been arbitrary and dependent on the surgeon's familiarity with the surgical approach.

OBJECTIVE

We review the literature of extended transoral approaches and analyze the different modifications in terms of the technical aspects, added exposure, and complications.

METHODS

Classic approaches and recently published morphometric studies that objectively document the gain in exposure provided by several modifications were analyzed and tabulated to outline the limits of exposure and risk of complications associated with the various modifications.

RESULTS

Transmaxillary approaches expand the exposure to include the sphenoid sinus and upper lateral clivus. To expand the exposure more inferiorly to C4–C5, mandibulotomy or mandibuloglossotomy can be applied. Mandibuloglossotomy increases the rostral exposure as well to the upper third of the clivus. Palatotomy increases rostral exposure without requiring a facial incision or perioperative tracheostomy, but is associated with a significant risk of velopharyngeal insufficiency.

CONCLUSION

Surgical decisions can be based on comprehensive preoperative evaluation of anatomy, pathology, and radiographic studies to maximize exposure while minimizing complications.

Median labiomandibular glossotomy approach to the craniocervical region

INTRODUCTION

In children as well as adults, adequate access to the craniocervical junction and upper cervical vertebra can usually be achieved with a transoral-transpalatopharyngeal route. However, when access is necessary to achieve the C5 level and the upper cervical spine in children, this is very difficult. This is particularly so when the incisor opening is less than 2.5 cm. The median labiomandibular glossotomy provides such an approach.

MATERIALS AND METHODS

Our experience with five children is presented in a representative case: a 4-year-old male with a family history of spondyloepiphyseal dysplasia presented with mild quadriparesis, 2 years earlier. This had rapid progression with severe upper cervical kyphosis. A standard transoral-transpalatopharyngeal approach or a lateral extrapharyngeal approach would not achieve exposure of the pathology. Hence, a median labiomandibular glossotomy was utilized for ventral decompression with an anterior interbody fusion between C2 and C4. Crown halo cervical traction was placed intraoperatively before a tracheostomy and tonsillectomy. A median labiomandibular glossotomy was then made with resection of the displaced odontoid process and the vertebral bodies of C3 and C4. This was followed by an anterior interbody fusion between the C2 and C4 vertebrae with costal rib grafts.

RESULT AND CONCLUSION

He was successfully decannulated during the second postoperative week upon resolution of lingual edema. A planned staged dorsal occipitocervical fusion was performed 6 months later, at which time the ventral fusion was quite solid. He had full neurological recovery.

Endoscopic Transnasal Transclival Odontoidectomy: A New Approach to Decompression: Technical Case Report

Objective:

Endoscopic transnasal transclival resection of the odontoid process is less invasive than the standard transoral odontoidectomy. In this article, we describe our techniques, which are less invasive but provide successful decompression.

Clinical Presentation:

From September 2004 to April 2007, three consecutive patients with basilar invagination and instability in the craniovertebral junction were enrolled. The causes for the invagination and instability included rheumatoid arthritis in two patients and trauma in one patient, and all patients presented with myelopathy and quadriparesis before intervention.

Intervention:

All three patients underwent an endoscopic transnasal transclival approach for anterior decompression and resection of the displaced odontoid process and pannus to decompress the underlying medulla. Subsequently, they received occipitocervical fixation by lateral mass screws and bone fusion to ensure stability. Remarkable neurological recovery was observed after surgery in all patients, and no adverse effects were noted.

Conclusion:

Compared with the standard transoral approach, the transnasal transclival endoscopic approach for decompressing basilar invagination is a feasible and effective alternative that avoids common disadvantages like prolonged intubation, excessive tongue retraction, and the need for palatal incision.

Modifications of the transoral approach to the craniovertebral junction: anatomic study and clinical correlations

OBJECTIVE

This study was designed to more precisely characterize the changes in exposure achieved by modifying the standard transoral approach by sequential mandibulotomy and mandibuloglossotomy with or without palatotomy.

METHODS

A series of cadaveric dissections was performed and the operative distance and angle of exposure in both axial and sagittal planes was evaluated for each approach, with and without palatotomy. Intraoperative measurements were made in patients undergoing transoral approaches to assess the validity of the anatomic model. The use of this model was then assessed by a retrospective analysis of a group of 19 patients operated on through transoral approaches between 1991 and 2006.

RESULTS

The simple transoral approach exposed the region from the lower third of the clivus to the middle of the C2 vertebral body at an operative distance of 12.9 +/- 1.0 cm from the dura. The axial and sagittal angles of exposure were 39.4 +/- 3.5 degrees and 36.8 +/- 3.5 degrees, respectively. Mandibulotomy significantly increased the sagittal exposure to 59.0 +/- 1.0 degrees (P < 0.001), exposing the area from the midclivus to the C2-C3 interspace while simultaneously increasing the axial angle of exposure to 51.9 +/- 7.4 degrees (P < 0.01) and decreasing the operative distance to the dura to 10.7 +/- 1.7 cm (P < 0.05). Mandibuloglossotomy augmented sagittal exposure to 85.3 +/- 0.3 degrees (P < 0.001), revealing the region between the upper one-third of the clivus and the C4-C5 interspace (P < 0.001) while decreasing the operative distance to the dura to 8.7 +/- 0.3 cm (P < 0.05). Palatotomy significantly increased the rostral exposure achieved by each approach by 8.5 to 12.3 degrees (P < 0.01) without altering caudal or axial exposure or the operative distance.

CONCLUSION

The cadaveric data correlated well with intraoperative measurements and the need for modifications of the transoral approach in 15 of the 16 adult patients (93.8%). Pediatric patients, patients with limited mouth opening, elevated craniovertebral junctions, and particularly deep lesions required more extensive exposure. This analysis may be useful for determining the optimal approach for patients undergoing transoral surgery.

Endoscopic transcervical odontoidectomy for pediatric basilar invagination and cranial settling. Report of 4 cases

Pediatric basilar invagination and cranial settling have traditionally been approached through a transoral-transpharyngeal route with or without extended maxillotomy or mandibulotomy for resection of the anterior portion of C-1 and the odontoid. The authors hypothesize that application of a recently described endoscopic transcervical odontoidectomy (ETO) technique would allow an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients. The authors performed ETO in a consecutive series of pediatric patients presenting with myelopathy or bulbar dysfunction resulting from basilar invagination or cranial settling. All clinical, radiographic, surgical, and follow-up data were prospectively collected. The initial experience with ETO in the pediatric population is analyzed and outcomes are reported. Three patients required ETO for basilar invagination and 1 required ETO with anterior C-1 arch and distal clivus resection for cranial settling. All patients presented with myelopathy. One patient was wheelchair bound with severe quadriparesis. The mean age was 14 +/- 3 years (mean +/- standard deviation [SD]) in the 2 male and 2 female patients. The ETO and posterior fusion were performed as a 2-stage procedure in 2 (50%) and as a single-stage procedure in 2 (50%) cases. Prolonged intubation or postoperative placement of a gastrostomy tube was not needed in any case. The postoperative hospitalization lasted 9 +/- 4 days (mean +/- SD). At last follow-up (mean 5 months), head and neck pain had resolved and motor strength had improved or stabilized in all cases. All 4 children were independently functioning and ambulatory at the last follow-up. In the authors' initial experience, ETO has allowed ventral brainstem decompression without the need for prolonged intubation, worsening dysphagia requiring enteral tube feeding, or prolonged hospitalization, and has resulted in cosmetically appealing results. The ETO technique allows an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.

Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note

Chordomas are locally invasive, malignant bone tumors that rarely occur in the cervical spine. En bloc resection or even fully resecting the tumor along its margin offers improved patient survival and a potential disease cure. Complete resection of tumors involving the upper cervical vertebrae requires a combined anterior-posterior approach but is complicated by the presence of vertebral arteries (VAs). In addition, reconstruction of the postresection defect may be prone to failure. The authors present a case of a chordoma involving the axis that was treated using a single-stage total intralesional C-2 spondylectomy with preservation of both VAs because the patient did not tolerate a preoperative occlusion test. A three-column reconstruction technique is also presented.

Anterior fracture dislocation of the odontoid peg in ankylosing spondylitis as a cause for rhinolalia clausa: a case study

We present an unusual cause of rhinolalia clausa secondary to an oropharyngeal mass. A 69-year-old male presented to the otorhinolaryngology clinic with a one year history of a ‘plummy’ voice. He had a longstanding history of severe ankylosing spondylitis. Examination revealed an obvious hyponasal voice and a smooth hard mass in the midline of the posterior nasopharyngeal and oropharyngeal walls. Subsequent computed tomography scans and lateral plain neck X-ray showed a fracture dislocation of the odontoid peg, secondary to ankylosing spondylitis, which had eroded through the body of the C1 vertebra to lie anteriorly, resulting in the aforementioned impression into the pharyngeal mucosa. The radiological images, the role of the nasal airways in phonation and the causes of hyponasal speech are discussed.

Anatomical analysis of transoral surgical approaches to the clivus

OBJECT

The authors conducted a cadaveric anatomical study to quantify and compare the area of surgical exposure and the freedom available for instrument manipulation provided by the following four surgical approaches to the extracranial periclival region: simple transoral (STO), transoral with a palate split (TOPS), Le Fort I osteotomy (LFO), and median labioglossomandibulotomy (MLM).

METHODS

Twelve unembalmed cadaveric heads with normal mouth opening capacity were serially dissected. For each approach, quantitation of extracranial periclival exposure and freedom for instrument manipulation (known here as surgical freedom) was accomplished by stereotactic localization. To quantify the extent of extracranial clival exposure obtained, anatomical measurements of the extracranial clivus were performed on 17 dry skull bases. The values (means +/- standard deviations in mm2) for periclival exposure and surgical freedom, respectively, for the surgical approaches studied were as follows: STO = 492 +/- 229 and 3164 +/- 1900; TOPS = 743 +/- 319 and 3478 +/- 2363; LFO = 689 +/- 248 and 2760 +/- 1922; and MLM 1312 +/- 384 and 8074 +/- 6451. The extent of linear midline clival exposure and the percentage of linear midline clival exposure relative to the total linear midline exposure were as follows, respectively: STO = 0.6 +/- 4.9 mm and 7.8 +/- 11%; TOPS = 8.9 +/- 5.5 mm and 24.2 +/- 16.7%; LFO = 32.9 +/- 10.2 mm and 85.0 +/- 18.7%; and MLM = 2.1 +/- 4.4 mm and 6.7 +/- 11.1%.

CONCLUSIONS

The choice of approach and the resulting degree of complexity and associated morbidity depends on the location of the pathological entity. The authors found that the MLM approach, like the STO approach, provided good exposure of the craniocervical junction but limited exposure of the clivus. The TOPS approach, an approach attended by a lesser risk of morbidity, provided adequate exposure of the extracranial inferior clivus. Maximal exposure of the extracranial clivus proper was provided by the LFO approach.

Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach

✓Symptomatic irreducible basilar invagination has traditionally been approached through a transoral–transpharyngeal route with resection of the anterior portion of C-1 and the odontoid. Modification of this exposure with either a Le Fort osteotomy or a transmandibular osteotomy and circumglossal approach has increased the access to pathological conditions in this region. These traditional routes all require traversing the oral cavity and accepting the associated potential complications. The authors have developed a novel surgical approach, an endoscopic transcervical odontoidectomy, which allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. In this paper they describe the technique and its advantages and present three cases in which patients underwent the endoscopic transcervical odontoidectomy for basilar invagination.

Three consecutive patients (age range 42–74 years) who had irreducible basilar invagination underwent the endoscopic transcervical odontoidectomy. All were symptomatic and had neck pain and myelopathy. All were evaluated preoperatively and postoperatively with computed tomography and magnetic resonance imaging. In all cases the procedure resulted in complete decompression. There were no serious complications. No patient required prolonged intubation, tracheostomy, or enteral tube feeding. One patient had an intraoperative cerebrospinal fluid leak, which had no postoperative sequelae.

The authors present an alternative surgical approach for treating ventral compression of the brainstem and spinal cord. The technique is safe and effective for decompression and provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.

Treatment of lesions involving both the infratemporal fossa and middle skull base

BACKGROUND

Communicating occupying lesions of the intratemporal fossa and mid-cranial fossa represent challenges for neurosurgeons and maxillofacial surgeons. Lesions of the skull base, with complex anatomy, are extremely varied in their histopathology. They often spread via normal anatomic pathways or bony destruction to involve adjacent structures, especially in the case of malignant neoplasms. However, with the development of operative skills and reconstruction techniques, total or near total resection of many such lesions can be accomplished with a low morbidity rate.

METHODS

The combined frontotemporal-preauricular infratemporal approach, frontotemporal-orbitozygomatic approach, combined frontotemporal and transmandibular approach, transmandibular approach, and transmaxillary approach were used to resect the lesions using microsurgical skills. The plastic reconstruction included reconstruction of the dura defects, osteosynthesis, and obliteration of the operative cavity.

RESULTS

Thirty-three patients with communicating lesions invading both the infratemporal fossa and the middle skull base underwent microsurgery. Among them, lesions were totally resected in 23, subtotally resected in 6, and partially resected in 4. In 29 patients, clinical status improved significantly. Complications were encountered in 7 cases, and morbidity was not remarkable.

CONCLUSION

The surgical approach should be selected depending on the size, location, histopathology, and invading extension of the lesion, which can provide excellent visualization and allow for an aggressive and safe resection of lesions involving this region. Familiarity with skull base anatomy, careful microsurgical manipulation, protection of vital structures, reliable plastic reconstruction, intraoperative nerve monitoring, as well as consideration of functional and esthetic outcomes, will all contribute to successful surgery and satisfactory results.

Endoscopic transoral surgery for craniovertebral junction anomalies

✓Craniovertebral junction (CVJ) anomalies continue to be challenging for neurosurgeons because of the complex anatomy of this region. To date, microsurgical decompression via a transoral route is the standard treatment for anteriorly located compressive lesions of the cervicomedullary junction (CMJ). The results obtained by minimizing surgical trauma are fewer complications, shorter hospital stays, and reduced overall psychological burden. Endoscopic surgery is becoming a leading modality in minimally invasive neurosurgical treatment.

The authors performed surgery in 11 patients with irreducible osseous dislocations resulting from CVJ abnormality during a 2-year period. Anterior CMJ decompression was achieved in all patients by performing neuroendoscopically controlled transoral excision of bone and soft tissues. The surgical technique and results will be discussed. The use of the endoscope offers several advantages in cases requiring a transoral approach to the lower clivus and atlantoaxial region. The use of minimally invasive endoscopic techniques has the potential to reduce the need for a wider cranial base opening and to decrease postoperative complications.

The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report

The transoral approach to the odontoid process is considered the "gold standard" for resection of extradural lesions at this location. A completely transnasal endoscopic approach is feasible based on anatomic studies and our experience with the expanded endonasal approach for neoplasms of the cranial base. An illustrative case is presented to demonstrate the technical details of a fully transnasal completely endoscopic approach for the resection of the odontoid process. A 73-year-old woman with a long-standing history of rheumatoid arthritis presented with progressive cervicomedullary compression. Complete resection of the odontoid was achieved with no significant morbidity. This is the first reported case of a completely endoscopic resection of the odontoid using a fully transnasal route. The report demonstrates the feasibility of this approach and larger clinical series with long-term follow-up will be needed to determine the reproducibility and validation of any potential benefits.

Transoral anterior approach for extensive anterior decompression at the C3 vertebra level in a patient with severe atlantoaxial vertical subluxation and rheumatoid arthritis

STUDY DESIGN

We report a successful extensive transoral anterior decompression for an elderly patient with myelopathy and occipitalgia due to severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with rheumatoid arthritis (RA).

OBJECTIVE

To describe the treatment of an exceptional pathological condition involving severe vertical subluxation.

SETTING

University-affiliated hospital in Gifu, Japan.

METHODS

A 73-year-old woman was referred to our clinic because of myelopathy and occipitalgia due to severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with RA. Plain radiographs revealed severe atlantoaxial vertical subluxation and sagittal magnetic resonance (MR) imaging revealed severe compression of the spinal cord at the level of the C2/3 disc space due to both posterior subluxation of C2 and rheumatoid pannus at the C2/3 disc space. As MR images demonstrated that the C2/3 disc space was located just behind the retropharyngeal wall, we performed successful anterior decompression from C2 to C3 via the standard transoral approach without mandibular osteotomy.

RESULTS

The patient has been followed for 4 years and her symptoms are currently much improved without further surgical treatment.

CONCLUSIONS

The present case illustrates that severe atlantoaxial vertical subluxation and posterior subluxation of the axis associated with RA can be treated successfully by anterior decompression of C2 and C3 via the standard transoral approach.

Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction

OBJECTIVE

We describe a series of seven consecutive patients treated with endoscopically assisted transoral surgery for decompression of high cervical and clival abnormalities.

METHODS

Seven endoscopically assisted transoral procedures were performed at the University of Florida from September 1999 to April 2000 for irreducible compression at the cervicomedullary junction. The abnormalities encountered were primary basilar invagination from congenital craniovertebral junction malformation (two cases), irreducible rheumatoid cranial settling (one case), secondary basilar invagination caused by migration of odontoid fracture fragments (one case), pseudogout granulation mass (one case), clivus chordoma (one case), and Chiari malformation with associated basilar invagination (one case).

RESULTS

Successful decompression was achieved in all seven patients. There were no adverse neurological sequelae. One patient died from a perioperative myocardial infarction. At a mean clinical follow-up of 6.16 months, neurological status was noted to be stable or improved in all remaining patients.

CONCLUSION

Endoscopically assisted transoral surgery represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior cervicomedullary junction. Used in conjunction with intraoperative fluoroscopy, it provides a safe method for anterior decompression of the cervicomedullary junction without the need for extensive soft palate splitting, hard palate resection, or extended maxillotomy. Experience is required with greater numbers of patients and long-term follow-up to further validate this promising technique.

Transoral resection and reconstruction for primary osteogenic sarcoma of the second cervical vertebra

STUDY DESIGN

A case of primary osteogenic sarcoma at the second cervical vertebra is reported.

OBJECTIVES

To document an osteogenic sarcoma of the second cervical vertebra and its treatment, and to review the literature.

SUMMARY OF BACKGROUND DATA

Primary osteosarcoma of the cervical spine is encountered infrequently, and its location in the upper cervical spine is extremely rare. Two cases of osteosarcoma in the second cervical vertebra have been reported previously in the literature.

METHODS

A 15-year-old boy with a mass lesion in the axis was treated surgically by anterior transoral resection, fusion, and reconstruction of the defect with a Harms cage. The resection was completed by posterior excision of the remaining vertebral elements, and by occipitocervical instrumentation and fusion between the occiput and the fourth cervical vertebra. The therapy was completed by adjuvant chemotherapy and radiotherapy.

RESULTS

At this writing, 40 months after the initial diagnosis, the patient was in a good state of health with his underlying disease.

CONCLUSIONS

The axis is a very rare location for the occurrence of primary osteosarcoma. Osteosarcoma may histologically mimic chondroblastoma. The axis can be surgically exposed, resected, and instrumented transorally. The stabilization must be augmented by posterior occipitocervical fusion.

Inflammatory disorders of the cervical spine

The most common inflammatory disorders affecting the cervical spine include adult and juvenile rheumatoid arthritis, ankylosing spondylitis, Reiter's syndrome, and psoriatic arthritis. These disorders are characterized by typical deformities and instabilities of the cervical spine that result from the destruction caused by synovitis in bony and ligamentous structures in the neck. The treatment of these inflammatory lesions differs from the treatment of similar lesions found in the posttraumatic or degenerative spine. This article attempts to outline the epidemiology, clinical manifestations, and natural history of these conditions. Various radiographic parameters for evaluating disease progression have been used over the years, and their usefulness is reviewed in the context of recent studies better defining the radiographic natural history of these lesions. An algorithm for the use of the various imaging methods including magnetic resonance scanning is provided, and recent progress in delineating the proper timing of surgical intervention and the predictors of neurologic recovery is presented. The current surgical procedures available to treat these conditions are discussed with emphasis on distinguishing those cases in which stabilization alone is required from those in which a decompression procedure is also necessary.

The superiorly based pharyngeal flap: a modification of the transoral approach to the upper cervical spine

The transoral approach has become a well established method of gaining access to the upper cervical spine. The use of a superiorly based pharyngeal flap rather than the more usual midline longitudinal incision is decribed. This flap improves exposure of the operative field which simplifies the subsequent neurosurgical procedure.