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transoral_transpharyngeal_approach

Transoral transpharyngeal approach

The transoral transpharyngeal approach is the standard approach for transoral odontoidectomy and decompress the cervicomedullary spinal cord.

In the early 1990s, transoral surgical procedures were commonplace in neurosurgery, used for lesions extending from the sella turcica, clivus to the top of the fifth cervical vertebrae 1).

Although the standard technique of transoral surgery is conceptually simple, anatomic relationships are not so readily appreciated.

Today, its popularity has waned somewhat, mainly stemming from the many potential difficulties and complications it poses 2).

Other ventral approaches, such as transmandibular and circumglossal, endoscopic transcervical, and endoscopic transnasal approach, 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 3).

Indications

Transoral surgery in the field of spine surgery has been used mostly for atlantoaxial lesions such as rheumatoid arthritis, spinal tumors and other inflammatory or infectious abnormalities. Severe cord compression due to the pannus in patients with rheumatoid arthritis sometimes demands direct decompression of the pannus and odontoidectomy rather than posterior decompression and fixation 4) 5).

Type I Basilar invagination: Basilar invagination without Chiari malformation. Tip of odontoid tends to be above Chamberlain’s line, McRae's line, and Wackenheims line

Brainstem compression is due to odontoid process invagination. 85% can be reduced with traction.

Treatment: transoral surgery is recommended, usually accompanied by posterior fusion.

In cases with Chiari malformation ventral brain-stem compression, some authors advocate performing a transoral clivus-odontoid resection as they feel these patients may potentially deteriorate with posterior fossa decompression alone 6).


Atlantoaxial rotatory subluxation: For irreducible fixation, a staged procedure can be done with anterior transoral release of the atlantoaxial complex (the exposure is taken laterally to expose the atlantoaxial joints which must be done carefully to avoid injury to the VAs, soft tissue is carefully removed from the joints and the atlantodental interval, no attempt at reduction was made at the time of this 1st stage) followed by gradual skull traction and then a second stage posterior C1–2 fusion 7).

Isolated atlas fractures: Surgical options that do not involve arthrodesis include: posterior C1 screw placement, anterior transoral screw/plate placement.


Atlantoaxial subluxation (AAS) in Rheumatoid Arthritis: Posterior fusion alone does not provide adequate relief if the subluxation is irreducible, or if pannus causes significant compression (however, there may be some reduction of pannus after fusion). In these cases, transoral odontoidectomy may be indicated. Performing the posterior stabilization and decompression first allows some patients to avoid a second operation, and permits the remainder to undergo the anterior approach without becoming destabilized. Still, some surgeons do the odontoidectomy first 8) (requires the patient to remain in traction until the fusion). Reminder: the patient must be able to open the mouth greater than ≈ 25 mm in order to perform transoral odontoidectomy without splitting the mandible.


Basilar impression in rheumatoid arthritis: Irreducible cases: requires transoral resection of odontoid. May perform before posterior fusion (but then must be kept in traction while waiting for posterior fusion).


Transoral biopsy of C2 (axis) vertebral body lesions 9).


see Transoral approach of anteriorly placed meningioma.

Complications

Case reports

References

1)
Crockard HA. Transoral surgery : some lessons learned. Br J Neurosurg. 1995;9:283–294
2)
Crockard HA. The transoral approach to the base of the brain and upper cervical cord. Ann R Coll Surg Engl. 1985;67:321–325
3)
Archer J, Thatikunta M, Jea A. Posterior transdural approach for odontoidectomy in a child: case report. J Neurosurg Pediatr. 2019 Oct 11:1-5. doi: 10.3171/2019.7.PEDS19337. [Epub ahead of print] PubMed PMID: 31604321.
4)
Kerschbaumer F, Kandziora F, Klein C, Mittlmeier T, Starker M. Transoral decompression, anterior plate fixation, and posterior wire fusion for irreducible atlantoaxial kyphosis in rheumatoid arthritis. Spine (Phila Pa 1976) 2000;25:2708–2715.
5)
Mummaneni PV, Haid RW. Transoral odontoidectomy. Neurosurgery. 2005;56:1045–1050. discussion 1045-1050.
6)
Dyste GN, Menezes AH, VanGilder JC. Symptomatic Chiari Malformations: An Analysis of Presentation, Management, and Long-Term Outcome. J Neurosurg. 1989; 71:159–168
7)
Govender S, Kumar KP. Staged reduction and stabilisation in chronic atlantoaxial rotatory fixation. J Bone Joint Surg Br. 2002; 84:727–731
8)
Papadopoulos SM, Dickman CA, Sonntag VKH. Atlantoaxial Stabilization in Rheumatoid Arthritis. J Neurosurg. 1991; 74:1–7
9)
Patil AA. Transoral Stereotactic Biopsy of the Second Cervical Vertebral Body: Case Report with Technical Note. Neurosurgery. 1989; 25:999–1002
transoral_transpharyngeal_approach.txt · Last modified: 2019/10/12 20:28 by administrador