Professional Documents
Culture Documents
Modified from Operative Techniques in Neurosurgery, 1:58 – 62, Apostolides, Vishteh, and Sonntag,
“Technique of transoral odontoidectomy,” copyright 1998, with permission from Elsevier.
7.1
Terminology
The transoral approach to the craniovertebral junction
is an excellent surgical technique for treating ventral
midline extradural compressive pathology. The target
region is reached by an approach crossing the oral cavi-
ty through the open mouth (“transoral”).
7.2
Surgical Principle
The transoral operation provides direct midline access
to the ventral craniovertebral junction to facilitate de-
compression of the lower brain stem and upper cervical
spinal cord. The surgical exposure typically extends
from the inferior third of the clivus to the top of the C3
vertebra (Fig. 7.1) and is limited primarily by the pa-
tient’s ability to open his or her mouth. The standard located within or ventral to the lesion. The transoral
transoral exposure can be extended superiorly with a approach is usually inappropriate for intradural pa-
transpalatal or transmaxillary approach [3 – 5, 16 – 23], thology because of the significant risks of CSF leakage
or inferiorly with a mandibulotomy and median glos- and meningitis associated with the frequent inability to
sotomy (Fig. 7.1a, b) [3, 8, 14, 16 – 20]. achieve a watertight dural closure [7, 10 – 12, 21].
7.3 7.7
History Patient’s Informed Consent
The approach was described first by Kanavel in 1917 Informed consent of the patients should include explana-
[15]. Since then and especially since the application of tions of the potential complications such as lesions to the
the surgical microscope, the approach has been de- tongue, postoperative hematoma, irritation, and sensory
scribed by many authors mainly for the extirpation and deficits in the oral cavity. It should also include the risk of
treatment of extradural lesions [3, 7, 8, 11, 13, 18, 22]. disturbed senses of taste and smell or swallowing due to
postoperative swelling of the intraoral structures. The
risk of postoperative infection and the necessity for anti-
7.4 biotic medication should be emphasized.
Advantages
This approach is the direct and unobstructed way to the 7.8
anterior part of the craniocervical junction. The anteri- Surgical Technique
or bony structures (inferior third of the clivus, anterior
7.8.1
arch of C1, and anterior part of C2 and C3) can be ex-
Preoperative Preparation
posed by dissection of the posterior wall of the phar-
ynx. The apex of the odontoid process as well as the an- All transoral surgeries are performed under general
terior part of the foramen magnum can be exposed af- anesthesia administered via a fiber-optically placed
ter resection of the anterior arch of C1. orotracheal tube that can be retracted from the surgical
field to provide optimal exposure of the posterior oro-
pharynx. Routine tracheostomy is rarely necessary un-
7.5 less severe preoperative bulbar or respiratory distur-
Disadvantages bances are present [1, 2, 9, 13, 23]. All patients receive
routine perioperative antibiotics (cefuroxime, 1.5 g).
The approach is limited by the surgical corridor pro- Unlike some authors, [6, 18, 23] we do not obtain rou-
vided through the open mouth. There is a considerable tine preoperative nasal and oropharyngeal cultures un-
risk of severe complications such as infection with or less an active infection is suspected based on the pa-
without involvement of the meninges, disturbances of tient’s history or clinical examination.
wound healing, cerebrospinal fluid (CSF) leakage as Continuous intraoperative somatosensory evoked-
well as complications arising from trauma to the uvula potential monitoring and brain stem auditory evoked-
and soft palate. In patients with rheumatoid arthritis potential monitoring are used to assess the physiologic
involving the mandibular joints, the approach is occa- status of the spinal cord and brain stem during the pro-
sionally limited by the inability to open the mouth suf- cedure.
ficiently (> 2.5 cm).
7.8.2
Positioning
7.6
Indications and Contraindications The patient’s head is secured with a Mayfield clamp and
the patient is placed in the supine position. The head is
The primary indication for a transoral procedure is an placed in a neutral position and the neck is slightly ex-
irreducible midline extradural lesion that compresses tended.
the cervicomedullary junction. A transoral procedure
occasionally may be required to obtain a tissue diagno-
7.8.3
sis or to debride an infection.
Surgical Steps
Transoral surgery is contraindicated if the patient
has an active nasopharyngeal infection or reducible A low-profile self-retaining transoral retractor system
ventral lesion, or if the vertebral or basilar arteries are (Spetzler-Sonntag, Aesculap, San Francisco, CA) is
7 Technique of Transoral Odontoidectomy 37
b c
a b
Fig. 7.4. Transoral odontoidectomy. a A vertical midline incision is made in the median raphé of the posterior oropharynx to ex-
pose the anterior arch of C1 and the body of C2. b The inferior portion of the anterior C1 arch is resected to expose the base of
the odontoid process.
7 Technique of Transoral Odontoidectomy 39
tenuate the tissue layers and weaken the incision line. A CSF leakage represents a significant risk to the pa-
nasogastric feeding tube is inserted while directly visu- tient and should be addressed promptly. Appropriate
alizing the oropharyngeal incision to avoid inadvertent treatment includes dural patching, meticulous pharyn-
malpositioning of the tube. geal wound closure, and placement of a lumbar drain. If
a CSF leak stops with lumbar drainage but recurs after
the drain has been closed or discontinued, the patient
7.9 requires a lumboperitoneal shunt. If CSF leakage per-
Postoperative Care sists despite lumboperitoneal drainage, reoperation
and dural patching are required. Postoperative menin-
Moderate tongue and pharyngeal swelling can be ex- gitis should raise the suspicion of a CSF leak. Proper
pected for the first 24 – 72 hours after surgery. The en- treatment includes intravenous antibiotics and place-
dotracheal tube should be maintained until the swell- ment of a lumbar drain.
ing subsides because premature extubation can lead to Neurological deterioration after transoral surgery is
respiratory distress, respiratory arrest, and death. In rare. Patients with new neurological deficits should be
our experience, topical steroids provide little if any evaluated for loss of spinal alignment, persistent cervi-
benefit in minimizing soft tissue swelling and therefore comedullary compression, epidural hematoma, epidu-
are not used routinely. ral abscess, meningitis, or vertebrobasilar occlusion.
Enteral nutrition via the indwelling feeding tube is
started on postoperative day 1 and continued 3 – 5 days.
The patient’s diet is slowly advanced from liquids to soft 7.11
regular foods and then to regular foods usually within Conclusions
14 days. If the feeding tube is inadvertently removed
before oral feedings have been started, appropriate par- The transoral approach is an effective surgical method
enteral nutrition should be provided. Replacing the for the direct decompression of irreducible ventral
feeding tube risks penetration of the healing mucosal midline extradural compressive pathology of the cranio-
incision and inadvertent malpositioning of the tube. vertebral junction. Specialized low-profile retractor
Postoperative spinal instability should be expected systems, the surgical microscope, contemporary mi-
after transoral odontoidectomy. Patients should there- crosurgical dissection and dural closure techniques,
fore remain in an external orthosis until spinal stability and meticulous postoperative radiographic assessment
can be restored. Although some authors advocate im- of spinal stability minimize perioperative complica-
mediate posterior fixation of the spine after transoral tions and facilitate good long-term outcomes.
decompression, we prefer to wait several days to reduce
the risk of infection in the posterior cervical wound.
References
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7.10 nique of transoral odontoidectomy. Operative Techniques
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