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Chapter 7

Technique of Transoral Odontoidectomy 7
P.J. Apostolides, A.G. Vishteh, R.M. Galler, V.K.H. Sonntag

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-

a

Fig. 7.1. a Routine transoral
exposure. This exposure may
be increased superiorly with
a transpalatal extension or
inferiorly with a transman-
dibular extension. b Sagittal
view showing routine trans-
oral exposure with normal
and pathological anatomy
(inset). With permission from
Barrow Neurological Insti-
tute b

and meningitis associated with the frequent inability to sotomy (Fig.3 7. All transoral surgeries are performed under general terior part of the foramen magnum can be exposed af. Aesculap. or if the vertebral or basilar arteries are (Spetzler-Sonntag. 16 – 20]. 11. the approach is occa. 23] we do not obtain rou- vided through the open mouth. postoperative hematoma. 1. The risk of postoperative infection and the necessity for anti- 7. and sensory scribed by many authors mainly for the extirpation and deficits in the oral cavity. the approach has been de. 7.8.8. 8. 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. 22]. San Francisco. Surgical Technique or bony structures (inferior third of the clivus. Since then and especially since the application of tions of the potential complications such as lesions to the the surgical microscope. 7. 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. The transoral transoral exposure can be extended superiorly with a approach is usually inappropriate for intradural pa- transpalatal or transmaxillary approach [3 – 5. disturbed senses of taste and smell or swallowing due to postoperative swelling of the intraoral structures. the cervicomedullary junction. 9. 21]. Advantages This approach is the direct and unobstructed way to the 7.4 biotic medication should be emphasized. 23]. wound healing. 2.3 sis or to debride an infection.2 Positioning 7. 10 – 12. 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. 7.1 arch of C1. 14. The approach is limited by the surgical corridor pro. The standard located within or ventral to the lesion.5 less severe preoperative bulbar or respiratory distur- Disadvantages bances are present [1. 8.8. tongue. ficiently (> 2. Unlike some authors.1a.5 cm). irritation.6 Indications and Contraindications The patient’s head is secured with a Mayfield clamp and the patient is placed in the supine position. [6. The anteri. anterior 7. achieve a watertight dural closure [7. 13. 7. 16 – 23].7 History Patient’s Informed Consent The approach was described first by Kanavel in 1917 Informed consent of the patients should include explana- [15]. 18. b) [3. anesthesia administered via a fiber-optically placed ter resection of the anterior 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. CA) is . status of the spinal cord and brain stem during the pro- sionally limited by the inability to open the mouth suf. Routine tracheostomy is rarely necessary un- 7. disturbances of tient’s history or clinical examination.8 anterior part of the craniocervical junction. 13. 18. cedure. All patients receive routine perioperative antibiotics (cefuroxime. The apex of the odontoid process as well as the an. 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. thology because of the significant risks of CSF leakage or inferiorly with a mandibulotomy and median glos. A transoral procedure occasionally may be required to obtain a tissue diagno- 7. It should also include the risk of treatment of extradural lesions [3.36 Cervical Spine – Odontoid tient’s ability to open his or her mouth. orotracheal tube that can be retracted from the surgical field to provide optimal exposure of the posterior oro- pharynx. In patients with rheumatoid arthritis potential monitoring are used to assess the physiologic involving the mandibular joints.5 g).

7.000 epinephrine. A vertical midline . telescoping tooth-bladed retractors are attached to the retractor frame and inserted into the oropharynx to retract the pharyngeal flaps laterally to widen the exposure. The patient’s head is secured with a Mayfield clamp. Adjustable. the tongue should be inspected carefully to ensure that it is not pinched between the retractor blade and the patient’s teeth.3a). An intraoperative radiograph often is obtained to judge spinal alignment after posi- tioning and to confirm the extent of the rostral and cau- dal exposure provided by the retractor system. and to allow the co-surgeon to observe and assist dur- ing the procedure. The surgical microscope is used immediately to improve lighting.5 % or 1 % lido- caine with 1/200.3b). To avoid severe swelling or necrosis. b ). The ta- ble is often placed in the Trendelenburg position to provide the best perspective of the craniovertebral junction. The rectangular retractor frame is placed over the patient’s mouth and attached to the operating room table via crossbars to stabilize the instrumenta- tion and to allow the table to be rotated during the pro- cedure (Fig. The midline posterior oropha- ryngeal mucosa is infiltrated with 0.2a. The patient is placed in the supine position with the head in the neutral posi- tion and the neck slightly extend- ed.2. Superior (a) and lateral (b) views of patient positioning and the retractor system used in the transoral approach. The rectangular retractor frame is placed over the patient’s mouth and attached to the oper- ating room table via crossbars. The soft palate and uvula are retracted superiorly with a malleable-blade retractor. The tongue and endotracheal tube are retracted caudally with a rigid wide-blade retractor. b The C1 tubercle is palpated to verify the position of the midline (Fig. 7. With permission from Barrow Neurological Institute a used to achieve wide exposure of the posterior oro- pharynx. 7. The surgeon sits above the patient’s head and has a direct view of the patient’s mouth and oropharynx (Fig. The oropharynx and the retractors are sterilized with Betadine solution. 7 Technique of Transoral Odontoidectomy 37 Fig. 7. to provide variable magnification.

Transoral odontoidectomy. c Anatomical relation- ships of the alar and apical ligaments fixating the dens to a the occiput.38 Cervical Spine – Odontoid Fig. a Surgeon’s view of patient’s mouth and orophar- ynx after placement of the low-profile. 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. 7. With permission from Barrow Neurological Institute b c a b Fig. 7. . C1-C2. b Anatomical relationships of the anterior aspects of the clivus.4. and the adjacent vascular structures underlying the posterior oropharynx mucosa and muscles. b The inferior portion of the anterior C1 arch is resected to expose the base of the odontoid process. The C1 tubercle is a key landmark that veri- fies the position of the mid- line.3. self-retaining re- tractor system.

If an intraoperative CSF leak occurs. e The incision is tic navigation. the base of the odontoid process. and the C2 vertebral body. The dens is grasped with a toothed odontoid rongeur and removed en bloc (Fig. and ligaments (Fig. and antibiotic coverage and the lumbar drain are maintained for at least 5 – 7 days. 7. pharyngeal muscles. Multi- palatal incision is avoided because it can cause nasal re. the anterior arch of C1. If possible. the lateral margins of the odontoid are defined. dysphagia. cauterization or a Shaw scalpel (Fig. The layers of the posterior oropharynx are maintained as a single thick layer to facilitate a strong tissue closure. Adequate decompression is confirmed closed in a single layer with a running 2 – 0 vicryl suture. However. However. With permission from Barrow Neurological Institute when the dura bows into the wound and assumes its usual anatomic contour. 7. a pharyngeal muscles. enough bone must be removed to ex- pose the dens adequately.4e). The trans- verse ligament and tectorial membrane also may need to be removed to adequately visualize the dura and nor- mal pulsation of the thecal sac. and a nasal tone of voice. 7 Technique of Transoral Odontoidectomy 39 gurgitation. Curettes and periosteal elevators are used to define the boundaries of the clivus. the anterior C1 arch should be resected completely. Once the brain stem and spinal cord have been decompressed. and the inferior clivus. The dens can be removed in a piece- meal fashion.) c The dens is transected at its base. The inferior one-third to two-thirds of the anteri- or C1 arch is resected to expose the base of the odontoid process using a high-speed air drill and Kerrison ron- geurs (Fig. We try to limit the resection of the an- c terior C1 arch to preserve the structural integrity of the C1 ring. which is associated with a high risk of postop- erative morbidity and mortality. 7. 7. a fascial patch is placed directly over the dura and secured with fibrin glue.4c). Meticulous microsurgical techniques are necessary to avoid a CSF leak from inadvertent du- ral entry. but it is often more difficult to access its apex. After the base of the dens has been exposed satisfac- torily. The base of the dens is partially tran- sected with a cutting burr (Fig. the osteotomy is completed by removing the posterior cortex with a small Kerrison rongeur or diamond burr. layer closures are more difficult to perform and can at- . The alar and apical ligaments are detached sharply with curved curettes. If necessary. 7. (cont.4. the C2 vertebral body. The boundaries of the decompression can be as- sessed intraoperatively by placing iodinated contrast e material into the decompression site and obtaining a Fig. A lumbar drain is inserted postoperatively. the surgeon must beware of attenuated dura and ligaments that ad- here to the dura. d Soft tissue pathology often must be resected to de- compress the neural elements adequately. pharyngeal wall mucosa.4a).4b). d The dens is lateral cervical radiograph or by employing stereotac- removed to complete the decompression. and the The wound is closed with interrupted or running 2 – 0 anterior longitudinal ligament using either monopolar vicryl suture in a single layer that includes the mucosa. Periosteal elevators are used to dissect the anterior lon- gitudinal ligament subperiosteally and to separate the tissue flap from the anterior surfaces of the C1 arch. 7. the wound is irrigated incision is made in the median raphé of the posterior with antibiotic solution and hemostasis is achieved.4d).

Weiss MH. Patients with new neurological deficits should be our experience. Crockard HA. 9. Enteral nutrition via the indwelling feeding tube is started on postoperative day 1 and continued 3 – 5 days. posterior fusion for rheumatoid atlanto-axial subluxation. or cranial fossa and clival tumors. Specialized low-profile retractor Postoperative spinal instability should be expected systems. Crockard HA (1993) Transoral approach to intra/extradu- and after surgery. Raven. Hamilton MG. epidural hematoma. are common after per cervical spine. Postoperative menin- Moderate tongue and pharyngeal swelling can be ex.11 regular foods and then to regular foods usually within Conclusions 14 days. contemporary mi- after transoral odontoidectomy. the management of intradural lesions at the cranioverte- bral junction: review of 7 cases. Essigman WK (1986) Transoral decompression and of these potential complications. If the feeding tube is inadvertently removed before oral feedings have been started. 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. Joganic EF (1992) Transfacial exposure of anteri- preoperative neurological deficits or debilitating medi. meticulous pharyn- malpositioning of the tube. treatment includes intravenous antibiotics and place- dotracheal tube should be maintained until the swell. Appropriate alizing the oropharyngeal incision to avoid inadvertent treatment includes dural patching. Clin Plast Surg 22: patient’s general medical condition before surgery and 491 – 511 to use prophylaxis for deep venous thrombosis during 6. epidu- are not used routinely. cal techniques for upper cervical spine decompression and ble underlying retropharyngeal infection or abscess. Crockard HA. and myocardial infarctions. Although some authors advocate im. pulmonary medial labiomandibular glossotomy approach to the up- emboli. tient and should be addressed promptly. pp 225 – 234 7. In: Sekhar LN. including pneumonia. the surgical microscope. Therefore. Karahalios DG (1997) Surgi- ter the first week should raise the suspicion of a possi. In rare. respiratory arrest. ing subsides because premature extubation can lead to Neurological deterioration after transoral surgery is respiratory distress. Dickman CA. Vishteh AG. nial base tumors. Sen CN (1991) The transoral approach for available. Kendall lized early after stabilization to limit the development BE. urinary sure of the atlantoaxial region. or vertebrobasilar occlusion. Clin Neurosurg 44:137 – 160 . deep venous thrombosis. Beals SP. of spinal stability minimize perioperative complica- mediate posterior fixation of the spine after transoral tions and facilitate good long-term outcomes. ment of a lumbar drain. BNI Quarterly 8:2 – 18 cal illnesses. appropriate par. Apostolides PJ. vertebral junction. fore remain in an external orthosis until spinal stability and meticulous postoperative radiographic assessment can be restored. Spetzler RF (1995) Pos- terior skull base transfacial approaches. Apuzzo ML. particularly in patients with severe 4. stabilization. ral abscess. A CSF leakage represents a significant risk to the pa- nasogastric feeding tube is inserted while directly visu. gitis should raise the suspicion of a CSF leak. Neurosurgery 28:88 – 98 eration and reclosure.40 Cervical Spine – Odontoid tenuate the tissue layers and weaken the incision line. If CSF leakage per- Postoperative Care sists despite lumboperitoneal drainage. and death. and placement of a lumbar drain. References 1. Wound infections should be treated with broad. pulmonary toilet ral tumors. meningitis. The en. Heiden JS (1978) Transoral expo- Medical complications. Arbit E. topical steroids provide little if any evaluated for loss of spinal alignment. Janecka IP (eds) Surgery of cra- should be aggressive. Wound dehiscence occurring af. J Bone Joint Surg Br 68:350 – 356 spectrum antibiotics until culture sensitivities are 8. Neurosurgery 3:201 – 207 3. Ransford AO. persistent cervi- benefit in minimizing soft tissue swelling and therefore comedullary compression. it is important to optimize the 5. The transoral approach is an effective surgical method enteral nutrition should be provided. the patient 7. Stevens JM.10 nique of transoral odontoidectomy. Joganic EF. If a CSF leak stops with lumbar drainage but recurs after the drain has been closed or discontinued. Apostolides PJ. geal wound closure. Patterson RH Jr (1981) Combined transoral and tract infections. Sonntag VKH (1998) Tech- 7. Neurosurgery 8:672 – 674 transoral surgery. reoperation and dural patching are required. New York. Proper pected for the first 24 – 72 hours after surgery. and the patient should be mobi. The patient’s diet is slowly advanced from liquids to soft 7. Pozo JL.9 requires a lumboperitoneal shunt. Wound dehiscence at any time requires reop. we prefer to wait several days to reduce the risk of infection in the posterior cervical wound. crosurgical dissection and dural closure techniques. Beals SP. Patients should there. decompression. Operative Techniques Hazards and Complications in Neurosurgery 1:58 – 62 2. Postoperatively.

Int J Oral 15. lar aneurysms. Sonntag VKH (1991) The trans- Surg Clin Chir 1:361 – 366 oral approach to the anterior cervical spine. McGraw-Hill. Beals SP. Lawson VG. In: Menezes AH. Hadley MN. Sonntag VKH (eds) . Principles of spinal surgery. New York. pp 1335 – 1353 12. 19. posterior circulation. In: Youmans JR (ed) Neurological rosurg 71:16 – 23 surgery. J Neu. Kanavel A (1917) Bullet located between the atlas and the Maxillofac Surg 19:352 – 355 base of the skull: technique of removal through the mouth. Murota K. 23. Shiba R. Spetzler RF. Spallone A (1980) Benign extramedullary tu. Saunders. Lawton MT. Contemp 16. Menezes AH (1996) Tumors of the craniocervical junction. Spetzler RF. Drake CG (1982) Management of aneurysms of cases of extradural cervicomedullary compression. Clin Neurosurg 16:114 – 169 pp 1241 – 1251 11. McGraw-Hill. Surg Neurol 13:9 – 17 glossotomy for access to the cervical spine. pp 1742 14. Sonntag VKH (eds) Principles of spinal 29:155 – 156 surgery. Honma G. Uttley D. Joganic EF. Sonntag VKH (1989) The trans. 22. J Neurosurg 17. Dickman CA. J Oral Maxillo- 13. Moore LJ. ral lesions at the craniocervical junction. 7 Technique of Transoral Odontoidectomy 41 10. New York. Goel A (1991) Transoral approach for removal of intradu. Drake CG (1969) The surgical treatment of vertebral-basi. Moore A. Tator CH (1990) and tongue-splitting approach for giant cell tumor of axis. Hamilton MG. Menezes AH (1996) Transoral approaches to the clivus and 71:705 – 710 upper cervical spine. Transoral approach to the nasopharynx and clivus using Spine 14:1204 – 1210 the Le Fort 1 osteotomy with midpalatal split. Kondo H (1989) Mandible 21. 18. Guidetti B. Schwartz HC (1985) Median labiomandibular mors of the foramen magnum. Charles DA. A review of 53 20. Philadelphia. Peerless SJ. Archer DJ (1989) Surgical management Clin Neurosurg 42:43 – 70 of midline skull-base tumors: a new approach. fac Surg 43:909 – 912 oral approach to the superior cervical spine. Neurosurgery In: Menezes AH. Spetzler Neurosurg 13:1 – 6 RF (1995) Radical resection of anterior skull base tumors. Sandor GK.