Abstract
Introduction
The ventral approach to the craniocervical border has been described for decompression of irreducible extradural pathology. The procedures utilized encompass the transoropharyngeal and median mandibulotomy with glossotomy and the transpalatal procedures. This study was aimed to review the utility of the transoral–transpalatopharyngeal approach.
Clinical materials and methods
Seven hundred thirty-three patients underwent transpalatopharyngeal approach for decompression of the brain stem and cervicomedullary junction. Of these, 280 were children below the age of 16 years. The main indication was irreducible ventral pathology compressing the brain stem and cervicomedullary junction. Two hundred two children had irreducible basilar invagination, 28 had proatlas segmentation abnormalities, os odontoideum with a dystopic os odontoideum in 30, and spinal tumors in seven (chordoma, fibrous dysplasia, osteoblastoma). Seven patients with Down’s syndrome and irreducible bony compression of the ventral cervicomedullary junction were seen. There were six other miscellaneous diagnoses. All children required craniocervical stabilization which was carried out under the same anesthetic as the transoral procedure.
Operative procedure
The procedure entailed fiber-optic intubation. The patient was placed in cervical traction prior to the anterior procedure. The soft palate was split only in individuals with a short clivus with a high riding clivus-odontoid articulation. Craniocervical stabilization was performed in the prone position under the same anesthetic.
Results
There was one retropharyngeal infection postoperatively. No cesium fluoride leaks were encountered. Velopalatine incompetence was seen in five children who already had preoperative brain stem dysfunction. Neurological recovery was the rule. Patients who had preoperative syringohydromyelia had resolution of the syrinx on postoperative magnetic resonance imaging.
Discussion
The author’s technique is described. Since 1977, the procedure has been performed in 732 patients (280 children) and has evolved into a safe and direct approach to the ventral cervicomedullary junction with minimal morbidity and mortality.
Similar content being viewed by others
References
Crockard HA, Pozo JL, Ransford AO, Stevens JM, Kendall BE, Essigman WK (1986) Transoral decompression and posterior fusion for rheumatoid atlantoaxial subluxation. J Bone Joint Surg 68B:350–356
Di Lorenzo N, Fortuna A, Guidetti B (1982) Craniovertebral junction malformations. Clinicoradiological findings, long-term results and surgical indications in 63 cases. J Neurosurg 57(5):603–608
Gehweiler JA Jr, Daffner RH, Roberts LJ Jr (1983) Malformations of the atlas vertebra simulating the Jefferson fracture. Am J Roentgenol 140:1083–1086
Goel A, Sharma P (2005) Craniovertebral junction realignment for the treatment of basilar invagination with syringomyelia: preliminary report of 12 cases. Neurol Med Chir (Tokyo) 45(10):512–517
Hadley MN, Spetzler RF, Sonntag VK (1989) The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression. J Neurosurg 71:16–23
Hall JE, Denis F, Murray J (1977) Exposure of the upper cervical spine for spinal decompression by a mandible and tongue-splitting approach. J Bone Joint Surg 59A:121–123
Hayakawa T, Kamakawa K, Ohnishi T, Yoshimine T (1981) Prevention of postoperative complications after a transoral transclival approach to basilar aneurysms. J Neurosurg 54:699–703
Honma G, Murota K, Shiba R, Kondo H (1989) Mandible and tongue-splitting approach for giant cell tumor of axis. Spine 14(11):1204–1210
Jain VK, Behari S, Banerji D, Bhargava V, Chhabra DK (1999) Transoral decompression for craniovertebral osseous anomalies: perioperative management dilemmas. Neurol India 47(3):188–195
Kotil K, Kalayci M, Bilge T (2007) Management of cervicomedullary compression in patients with congenital and acquired osseous-ligamentous pathologies. J Clin Neurosci 14(6):540–549
Menezes AH (1991) Anterior approaches to the craniocervical junction. Clin Neurosurg 37:756–769
Menezes AH (1991-1992) Complications of surgery at the craniovertebral junction–avoidance and management. Pediatr Neurosurg 17(5):254–266
Menezes AH (1992) The anterior midline approach to the craniocervical region in children. Pediatr Neurosurg 18:272–281
Menezes AH, VanGilder JC, Graf CJ, McDonnell DE (1980) Craniocervical abnormalities: a comprehensive surgical approach. J Neurosurg 53:444–455
Menezes AH (2003) Developmental abnormalities of the craniovertebral junction. In: Winn HR (ed) Youman’s Neurological Surgery. Saunders, Philadelphia, pp 3331–3345
Menezes AH (2004) Evaluation and treatment of congenital and developmental anomalies of the cervical spine. J Neurosurg (Spine 1) 2:188–197
Menezes AH, Foltz GD (2005) Transoral approach to the ventral craniocervical border. Oper Tech Neurosurg 8:150–157
Menezes AH, Traynelis VC, Gantz BJ (1994) Surgical approaches to the craniovertebral junction. Clin Neurosurg 41:187–203
Menezes AH, VanGilder JC (1988) Transoral transpharyngeal approach to the anterior craniocervical junction. 10-year experience with 72 patients. J Neurosurg 69:895–903
Niskikawa M, Ohata K, Baba M, Terakawa Y, Hara M (2004) Chiari I malformation associated with ventral compression and instability: one-stage posterior decompression and fusion with a new instrumentation technique. Neurosurgery 54(6):1430–1434
Pollack IF, Welch W, Jacobs GB, Janecka IP (1995) Frameless stereotactic guidance. An intraoperative adjunct in the transoral approach for ventral cervicomedullary junction decompression. Spine 20(2):216–220
Taggard DA, Menezes AH, Ryken TC (1999) Instability of the craniovertebral junction and treatment outcomes in patients with Down’s syndrome. Neurosurg Focus 6(6):Article 3
Tuite GF, Veres R, Crockard HA, Sell D (1996) Pediatric transoral surgery: indications, complications and long-term outcome. J Neurosurg 84(4):573–583
Ulmer JL, Elster AD, Ginsberg LE, Williams DW 3rd (1993) Klippel-Feil syndrome: CT and MR of acquired and congenital abnormalities of cervical spine and cord. J Comput Assist Tomogr 17:215–224
Vishteh AG, Beals SP, Joganic EF, Reiff JL, Dickman CA, Sonntag VK, Spetzler RF (1999) Bilateral sagittal split mandibular osteotomies as an adjunct to the transoral approach to the anterior craniovertebral junction. Technical note. J Neurosurg 90:267–270
Welch WC, Kassam A (2003) Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction. Neurosurgery 52(6):1511–1512
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Menezes, A.H. Surgical approaches: postoperative care and complications “transoral–transpalatopharyngeal approach to the craniocervical junction”. Childs Nerv Syst 24, 1187–1193 (2008). https://doi.org/10.1007/s00381-008-0599-3
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00381-008-0599-3