Surgery for Craniovertebral Junction Pathologies: Minimally Invasive Anterior Submandibular Retropharyngeal Key-Hole Approach

Abstract BackgroundOur objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches.MethodsDuring the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1-C2 fusion according to Harms. C1-C2 decompressive laminectomy was performed in all four cases. Ventral C1-C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR similarly to the traditional anterior retropharyngeal surgery – preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor.ResultsThe MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2 / 6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.ConclusionBased on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risks of complications.

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Surgery for craniovertebral junction pathologies: minimally invasive anterior submandibular retropharyngeal key-hole approach

BMC Surgery ◽

10.1186/s12893-021-01198-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Árpád Viola ◽

István Kozma ◽

Dávid Süvegh

Keyword(s):

Minimally Invasive ◽

Wound Dehiscence ◽

Craniovertebral Junction ◽

Transoral Approach ◽

Velopharyngeal Insufficiency ◽

Safe Alternative ◽

Decompressive Laminectomy ◽

Neurological Improvement ◽

Second Stage ◽

Minimally Invasive Surgical

Abstract Background Our objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches. Methods During the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1–C2 fusion according to Harms. C1–C2 decompressive laminectomy was performed in all four cases. Ventral C1–C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR—similarly to the traditional anterior retropharyngeal surgery—preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor. Results The MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2/6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement. Conclusion Based on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications.

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Endoscopic Transnasal Odontoidectomy With Anterior C1 Arch Preservation and Anterior Vertebral Column Reconstruction in Patients With Irreducible Bulbomedullary Compression by Complex Craniovertebral Junction Abnormalities: Operative Nuance

Operative Neurosurgery ◽

10.1227/neu.0000000000001330 ◽

2016 ◽

Vol 12 (3) ◽

pp. 222-230 ◽

Cited By ~ 5

Author(s):

Maurizio Iacoangeli ◽

Alessandro Di Rienzo ◽

Roberto Colasanti ◽

Massimo Re ◽

Davide Nasi ◽

...

Keyword(s):

Minimally Invasive ◽

Tube Feeding ◽

Odontoid Process ◽

Craniovertebral Junction ◽

Craniocervical Junction ◽

Safe Alternative ◽

Transnasal Approach ◽

Oral Flora ◽

Neurological Improvement ◽

Surgical Corridor

Abstract BACKGROUND During the past decades, the transoral transpharyngeal approach has been advocated as the standard route for the removal of odontoid causing an irreducible symptomatic neural compression. However, it may be potentially associated with a significant built-in morbidity because of the splitting of the soft palate for an adequate working angle, tracheostomy, and incision of the oral mucosa, causing exposure to a higher risk of infection by oral flora. OBJECTIVE To describe our experience with the minimally invasive pure endoscopic transnasal odontoidectomy in patients with bulbomedullary compression affected by complex anterior craniovertebral junction abnormalities. METHODS Five patients underwent a pure endoscopic neuronavigation-assisted transnasal odontoidectomy with anterior C1 arch preservation. Moreover, the anterior cervical spine column was reconstructed by filling the gap between the C1 arch and the residual C2 body with autologous/artificial bone. Neither tracheostomy nor enteral tube feeding were needed in any case. RESULTS A postoperative neurological improvement was observed in all patients. Postoperative imaging confirmed a satisfactory spinal cord decompression with cervical anterior column arthrodesis, and without evidence of instability at follow-up, so far. CONCLUSION The endoscopic transnasal approach seems to represent an efficient and safe alternative to the transoral route for the resection of odontoid process causing irreducible bulbomedullary compression. It provides a straightforward and minimally invasive natural surgical corridor to the anterior craniocervical junction, allowing a better working angle with preservation of spine biomechanics, while minimizing potential comorbidities.

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The endoscopic transoral approach to the craniovertebral junction: an anatomical study with a clinical example

Neurosurgical FOCUS ◽

10.3171/2015.11.focus15498 ◽

2016 ◽

Vol 40 (2) ◽

pp. E11 ◽

Cited By ~ 7

Author(s):

Andrew K. Chan ◽

Arnau Benet ◽

Junichi Ohya ◽

Xin Zhang ◽

Todd D. Vogel ◽

...

Keyword(s):

Anatomical Study ◽

Linear Measurement ◽

Craniovertebral Junction ◽

Transoral Approach ◽

Velopharyngeal Insufficiency ◽

Measurement Tool ◽

Splitting Technique ◽

Soft Tissue Dissection ◽

Expanded Endonasal Approach ◽

The Right

OBJECTIVE The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption. METHODS A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video. RESULTS The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1–27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6–23.7 mm) and 16.70 mm on the left side (range 8.1–26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2–41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range −4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range −1.5 to 7.3 mm); and palatal line relative to the C-1 arch, −2.75 mm (range −5.8 to 0 mm). CONCLUSIONS The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.

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Minimally invasive approach for small ventrally located intradural lesions of the craniovertebral junction

Neurosurgical FOCUS ◽

10.3171/2015.2.focus14799 ◽

2015 ◽

Vol 38 (4) ◽

pp. E10 ◽

Cited By ~ 8

Author(s):

Sven O. Eicker ◽

Klaus Christian Mende ◽

Lasse Dührsen ◽

Nils Ole Schmidt

Keyword(s):

Minimally Invasive ◽

Medical Center ◽

Craniovertebral Junction ◽

Upper Cervical Spine ◽

Small Lesion ◽

Neutral Position ◽

Dorsal Approach ◽

Who Grade ◽

Invasive Approach ◽

Minimally Invasive Surgical

OBJECT The surgical management of lesions ventral to the neuraxis at the level of the craniovertebral junction (CVJ) and upper cervical spine is challenging. Here, the authors describe a minimally invasive dorsal approach for small ventrally located intradural lesions at the CVJ as an alternative for the more extensive classic transoral approach or variants of suboccipital approaches. METHODS Between 2012 and 2014, 6 symptomatic patients with a small lesion of the ventral aspect at the CVJ level were treated using a minimally invasive dorsal approach at the University Medical Center in Hamburg-Eppendorf, Germany. The anatomical distance between the posterior atlantooccipital membrane and the posterior atlantoaxial ligament, as determined by CT images, was assessed in the treated patients and in 100 untreated persons. RESULTS The authors treated 6 patients (mean age 54.7 years) who had a clinical presentation of mild neurological symptoms that disappeared after resection. Minimally invasive surgical dorsal access was achieved by using tubular systems and using the natural space between the occiput (C-0) and C-1, and in 1 case between C-1 and C-2, without having to remove bony structures. The postoperative course in each of the 6 patients was uneventful. The neuropatho-logical findings confirmed a meningotheliomatous meningioma (WHO Grade I) in 5 cases and an extramedullary cavernous hemangioma in 1 case. MRI confirmed complete resection of all the lesions. The atlantooccipital distances ranged from 3 to 17 mm (mean 8.98 mm) in the supine neutral position, and the atlantoaxial distances ranged from 5 to 17 mm (mean 10.56 mm). There were no significant differences between women and men (atlantooccipital p = 0.14; atlantoaxial p = 0.72). CONCLUSIONS The results of this study demonstrate that the minimally invasive dorsal approach using the space between C-0 and C-1 or C-1 and C-2 provides direct and sufficient exposure for the safe surgical resection of small ventrally located intradural lesions at the CVJ level while reducing the necessity for musculoskeletal preparation to a minimum.

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Endoscopic endonasal transclival transodontoid approach for ventral decompression of the craniovertebral junction: operative technique and nuances

Neurosurgical FOCUS ◽

10.3171/2015.1.focus14813 ◽

2015 ◽

Vol 38 (4) ◽

pp. E17 ◽

Cited By ~ 30

Author(s):

James K. Liu ◽

Jimmy Patel ◽

Ira M. Goldstein ◽

Jean Anderson Eloy

Keyword(s):

Craniovertebral Junction ◽

Basilar Invagination ◽

Postoperative Recovery ◽

Velopharyngeal Insufficiency ◽

Endoscopic Endonasal ◽

Prolonged Intubation ◽

Minimally Invasive Surgical ◽

Pathological Conditions ◽

Tongue Swelling ◽

Hospital Stays

The transoral approach is considered the gold-standard surgical route for performing anterior odontoidectomy and ventral decompression of the craniovertebral junction for pathological conditions that result in symptomatic cervicomedullary compression, including basilar invagination, rheumatoid pannus, platybasia with retroflexed odontoid processes, and neoplasms. Extended modifications to increase the operative corridor and exposure include the transmaxillary, extended “open-door” maxillotomy, transpalatal, and transmandibular approaches. With the advent of extended endoscopic endonasal skull base techniques, there has been increased interest in the last decade in the endoscopic endonasal transclival transodontoid approach to the craniovertebral junction. The endonasal route represents an attractive minimally invasive surgical alternative, especially in cases of irreducible basilar invagination in which the pathology is situated well above the palatine line. Angled endoscopes and instrumentation can also be used for lower-lying pathology. By avoiding the oral cavity and subsequently using a transoral retractor, the endonasal route has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia. Postoperative recovery is quicker, and hospital stays are shorter. In this report, the authors describe and illustrate their method of purely endoscopic endonasal transclival odonotoidectomy for anterior decompression of the craniovertebral junction and describe various operative pearls and nuances of the technique for avoiding complications.

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Extended Transoral Approaches

Neurosurgery ◽

10.1227/01.neu.0000366117.04095.ec ◽

2010 ◽

Vol 66 (suppl_3) ◽

pp. A126-A134 ◽

Cited By ~ 23

Author(s):

A. Samy Youssef ◽

Andrew E. Sloan

Keyword(s):

Preoperative Evaluation ◽

Significant Risk ◽

Craniovertebral Junction ◽

Transoral Approach ◽

Velopharyngeal Insufficiency ◽

Direct Exposure ◽

Extended Approach ◽

Surgical Complexity ◽

Upper Third ◽

Selection Of

Abstract 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.

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Considerations in Dysphagia Management Following Esophagectomy

Perspectives of the ASHA Special Interest Groups ◽

10.1044/persp1.sig13.169 ◽

2016 ◽

Vol 1 (13) ◽

pp. 169-176

Author(s):

Lisa M. Evangelista ◽

James L. Coyle

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Minimally Invasive Surgical Procedures ◽

Esophageal Resection ◽

Minimally Invasive Surgical ◽

Operative Complications ◽

Swallowing Difficulties ◽

Epidemiological Impact ◽

Invasive Techniques ◽

Management Of Dysphagia

Esophageal cancer is the sixth leading cause of death from cancer worldwide. Esophageal resection is the mainstay treatment for cancers of the esophagus. While curative, surgical resection may result in swallowing difficulties that require intervention from speech-language pathologists (SLPs). Minimally invasive surgical procedures for esophageal resection have aimed to reduce morbidity and mortality associated with more invasive techniques. Both intra-operative and post-operative complications, regardless of the surgical approach, can result in dysphagia. This article will review the epidemiological impact of esophageal cancers, operative complications resulting in dysphagia, and clinical assessment and management of dysphagia pertinent to esophageal resection.

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