Transoral Approach and Extended Modifications for Lesions of the Ventral Foramen Magnum and Craniovertebral Junction

ABSTRACT

Objectives: To describe our method of performing the transoral approach and the extended approaches to the ventral foramen magnum and craniovertebral junction and review the technical aspects and operative nuances. Design: Review. Results: The transoral approach provides direct midline exposure to access extradural disease located at the craniovertebral junction and ventral foramen magnum. The corridor of exposure is generally limited by the extent to which the patient can open his or her mouth. The location of the hard palate relative to the craniovertebral junction limits superior exposure, whereas the mandible and base of the tongue limit the inferior exposure. In most cases, exposure can be obtained from the inferior clivus to the middle to lower C2 vertebral body. Extended transoral approaches can be performed to increase exposure if necessary. These approaches include transmaxillary (Le Fort I maxillotomy), transmaxillary with a midline palatal split (extended “open-door” maxillotomy), transpalatal, and median labiomandibular glossotomy (transmandibular split). Conclusions: The transoral approach effectively provides direct access to extradural midline lesions of the craniovertebral junction. A specialized retractor system can expose the inferior clivus to the C2 body. Extended approaches as described can access lesions that extend beyond these limits.

Craniovertebral junction - foramen magnum - skull base surgery - transoral approach

REFERENCES

• 1 Liu J K, Orlandi R R, Apfelbaum R I, Couldwell W T. Novel closure technique for the endonasal transsphenoidal approach: technical note.  J Neurosurg. 2004;  100 161-164
• 2 Liu J K, Decker D, Schaefer S D et al.. Zones of approach for craniofacial resection: minimizing facial incisions for resection of anterior cranial base and paranasal sinus tumors.  Neurosurgery. 2003;  53 1126-1135 discussion 1135-1137
• 3 Liu J K, Weiss M H, Couldwell W T. Surgical approaches to pituitary tumors.  Neurosurg Clin N Am. 2003;  14 93-107
• 4 Lawton M T, Beals S P, Joganic E F, Han P P, Spetzler R F. The transfacial approaches to midline skull base lesions: a classification scheme.  Oper Tech Neurosurg. 1999;  2 201-217
• 5 Ammirati M, Bernardo A. Analytical evaluation of complex anterior approaches to the cranial base: an anatomic study.  Neurosurgery. 1998;  43 1398-1407 discussion 1407-1408
• 6 Ammirati M, Bernardo A. Management of skull base chordoma.  Crit Rev Neurosurg. 1999;  9 63-69
• 7 Ammirati M, Ma J, Cheatham M L et al.. The mandibular swing-transcervical approach to the skull base: anatomical study. Technical note.  J Neurosurg. 1993;  78 673-681
• 8 James D, Crockard H A. Surgical access to the base of skull and upper cervical spine by extended maxillotomy.  Neurosurgery. 1991;  29 411-416
• 9 Okamura H O, Nishimura-Ogino E, Shinomiya K et al.. New interdisciplinary approach for removing large clivus and upper cervical spine tumors.  ORL J Otorhinolaryngol Relat Spec. 2003;  65 61-65
• 10 Kyoshima K, Matsuo K, Kushima H, Oikawa S, Idomari K, Kobayashi S. Degloving transfacial approach with Le Fort I and nasomaxillary osteotomies: alternative transfacial approach.  Neurosurgery. 2002;  50 813-820 discussion 820-821
• 11 Menezes A H, VanGilder J C. Transoral-transpharyngeal approach to the anterior craniocervical junction: ten-year experience with 72 patients.  J Neurosurg. 1988;  69 895-903
• 12 Alonso W A, Black P, Connor G H, Uematsu S. Transoral transpalatal approach for resection of clival chordoma.  Laryngoscope. 1971;  81 1626-1631
• 13 Crockard H A. The transoral approach to the base of the brain and upper cervical cord.  Ann R Coll Surg Engl. 1985;  67 321-325
• 14 Pásztor E. Transoral approach for epidural craniocervical pathological processes.  Adv Tech Stand Neurosurg. 1985;  12 125-170
• 15 Shaha A R, Johnson R, Miller J, Milhorat T. Transoral-transpharyngeal approach to the upper cervical vertebrae.  Am J Surg. 1993;  166 336-340
• 16 Sandor G K, Charles D A, Lawson V G, Tator C H. Trans oral approach to the nasopharynx and clivus using the Le Fort I osteotomy with midpalatal split.  Int J Oral Maxillofac Surg. 1990;  19 352-355
• 17 Sasaki C T, Lowlicht R A, Astrachan D I et al.. Le Fort I osteotomy approach to the skull base.  Laryngoscope. 1990;  100 1073-1076
• 18 Uttley D, Moore A, Archer D J. Surgical management of midline skull-base tumors: a new approach.  J Neurosurg. 1989;  71 705-710
• 19 Williams W G, Lo L J, Chen Y R. The Le Fort I-palatal split approach for skull base tumors: efficacy, complications, and outcome.  Plast Reconstr Surg. 1998;  102 2310-2319
• 20 Wood G D, Stell P M. Osteotomy at the Le Fort I level: a versatile procedure.  Br J Oral Maxillofac Surg. 1989;  27 33-38
• 21 Arbit E, Patterson Jr R H. Combined transoral and median labiomandibular glossotomy approach to the upper cervical spine.  Neurosurgery. 1981;  8 672-674
• 22 Delgado T E, Garrido E, Harwick R D. Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine.  Neurosurgery. 1981;  8 675-679
• 23 Moore L J, Schwartz H C. Median labiomandibular glossotomy for access to the cervical spine.  J Oral Maxillofac Surg. 1985;  43 909-912
• 24 Nagib M G, Wisiol E S, Simonton S C, Levinson R M. Transoral labiomandibular approach to basiocciput chordomas in childhood.  Childs Nerv Syst. 1990;  6 126-130
• 25 Spiro R H, Gerold F P, Strong E W. Mandibular “swing” approach for oral and oropharyngeal tumors.  Head Neck Surg. 1981;  3 371-378
• 26 Menezes A H, Traynelis V C, Gantz B J. Surgical approaches to the craniovertebral junction.  Clin Neurosurg. 1994;  41 187-203
• 27 Fang H SY, Ong G B. Direct anterior approach to the upper cervical spine.  J Bone Joint Surg Am. 1962;  44 1588-1604
• 28 Snape L. Transmaxillary surgery: new horizons for an old approach.  Ann R Australas Coll Dent Surg. 1991;  11 278-283
• 29 Kassam A, Abla A, Snyderman C, Carrau R, Spiro R. An endoscopic transnasal odontoidectomy to treat cervicomedullary compression with basilar invagination.  Oper Tech Neurosurg. 2005;  8 198-204
• 30 Messina A, Bruno M C, Decq P et al.. Pure endoscopic endonasal odontoidectomy: anatomical study.  Neurosurg Rev. 2007;  30 189-194 , discussion 194
• 31 Wolinsky J P, Sciubba D M, Suk I, Gokaslan Z L. Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach: technical note.  J Neurosurg Spine. 2007;  6 184-191
• 32 Dickman C A, Spetzler R F, Sonntag V KH, Apostolides P J. Transoral approach to the craniovertebral junction. In: Dickman CA, Spetzler RF, Sonntag VKH Surgery of the Craniovertebral Junction. New York; Thieme Medical Publishers 1998: 355-369
• 33 Harkey H L, Crockard H A. Transoral-extended maxillotomy. In: Dickman CA, Spetzler RF, Sonntag VKH Surgery of the Craniovertebral Junction. New York; Thieme Medical Publishers 1998: 371-381
• 34 Dickman C A, Locantro J, Fessler R G. The influence of transoral odontoid resection on stability of the craniovertebral junction.  J Neurosurg. 1992;  77 525-530
• 35 Dickman C A, Crawford N R, Brantley A G, Sonntag V K. Biomechanical effects of transoral odontoidectomy.  Neurosurgery. 1995;  36 1146-1152 discussion 1152-1153
• 36 Le Fort R. Etude experimentale sur les fractures de la machoire superieure.  Rev Chir. 1901;  23 208-227
• 37 Beals S P, Joganic E F. Transfacial approaches to the craniovertebral junction. In: Dickman CA, Spetzler RF, Sonntag VKH Surgery of the Craniovertebral Junction. New York; Thieme Medical Publishers 1998: 395-418
• 38 Trotter W. Operations for malignant diseases of the pharynx.  Br J Surg. 1929;  16 485-495
• 39 Martin H, Tollefsen H R, Gerold F P. Median labiomandibular glossotomy: Trotter's median (anterior) translingual pharyngotomy.  Am J Surg. 1961;  102 753-759
• 40 Alperin K M, Levine H L, Wood B G, Tucker H M. Approach to and reconstruction for lesions of the posterior third of the tongue via midline labiomandibular glossotomy.  Head Neck Surg. 1984;  6 744-750