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Borba, Luis A. B. et al.: 2021 Microsurgical and Endoscopic Approaches to the Skull Base DOI: 10.1055/b-0041-182728
Section II Anterior Approaches Transnasal and Transoral

7 The Microsurgical Transoral Approach

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Editors: Borba, Luis A. B.; de Oliveira, Jean G.

Authors: Ahmed, A. Karim; Almeida, Joao Paulo; Alzhrani, Gmaan A.; Aragón-Arreola, Jorge F.; Barbero, Juan Manuel Revuelta; Berumen, Enrique Lopez; Borghei-Ravazi, Hamid; Braga, Fernando Menezes; Burhan, Hira; Cabral, Gustavo Augusto Porto Sereno; Caffaratti, Guido; Campero, Alvaro; Cândido, Duarte N. C.; Carrau, Ricardo L.; Cassidy, Matthew; Castellanos, Alberto Manuel Ángeles; Catapano, Joshua S.; Ceccato, Guilherme Henrique Weiler; Centeno, Tomás Ries; Cerezo, Eugenio; Chakravarthi, Srikant; Chaudhary, Pramod; Cherian, Iype; Cohen, Alan R.; Colli, Benedicto Oscar; Couldwell, William T.; Dodson, Vincent; Eguiluz-Meléndez, Aldo G.; Elizalde, Ramiro López; Eloy, Jean Anderson; Felicio, Thiago Albonette; Felix, Vinod; Ferrarez, Carlos Eduardo Prata Fernandes; Ferreira, Mauro A. Tostes; Fernandez-Miranda, Juan C.; Filho, Miguel Giudicissi; Froelich, Sébastien; García, Martín Granados; Gardner, Paul A.; Gentili, Fred; Giacomelli, Richard; Goel, Atul; Gómez-Amador, Juan Luis; Gozal, Yair M.; Gondim, Guilherme Gozzoli Podolsky; Gusmão, Sebastião Nataniel Silva; Hanakita, Shunya; Hardesty, D. A.; Herrera, Daniel Londoño; Hsueh, Wayne D.; Joshi, Krishna C.; Jradi, Ahmed Al; Kadri, Paulo A. S.; Kafle, Prakash; Kalb, Samuel; Kalkmann, Gabriela F.; Kanaan, Imad N.; Karekezi, Claire; Kassam, Amin; Kovalev, Aleksandr Yurievich; Kshettry, Varun R.; Labidi, Moujahed; Landeiro, José Alberto; Lang, Michael J.; Lawton, Michael T.; Lem-Carrillo, Mónica; Liu, James K.; Longo-Calderón, Gabriel Mauricio; Lopez, Juan; Lovato, Renan M.; Majmundar, Neil; Marian-Magaña, Ricardo; Maluf, Felipe Bicalho; Martínez-Manrique, José de Jesús; Martins, Carolina; Martins, Warley; Markin, Egor S.; Méndez, Humberto Reyna; Monroy-Sosa, Alejandro; Mora, José Alfredo Espinosa; Mukherjee, Debraj; Munakomi, Sunil; Mura, Jorge; Nakaji, Peter; Narendrakumar, Veerasigamani; Nathal, Edgar; Nunes, Cristian Ferrareze; Oliveira, Marcelo Magaldi; Ortega-Porcayo, Luis Alberto; Otto, Bradley A.; Park, HunHo; Peres, Gabriel H.; Porras, Jose Luis; Prevedello, Daniel M.; Rassi, Marcio S.; Rassi-Neto, Aziz; Recinos, Pablo F.; Rehder, Roberta; Reis, Cassius Vinicius Correa dos; Reyes, Laura Matilde Ubaldo; Rhoton, Albert; Ribas, Eduardo Carvalhal; Ríos-Zermeño, Jorge; Rocha, Eder da Silva; Romano-Feinholz, Samuel; Ronconi, Daniel; Rosito, Diego Méndez; S., Vignesh; Sáenz, Amparo; Safarov, Aidar Kh.; Sagar, Soumya; Sanchez, Miguel M.; Shrestha, Sudeep; Silva, Izabel Eugênia Costa e; da Silveira, Roberto Leal; Snyderman, Carl H.; Socolovsky, Mariano; Spetzler, Robert F.; Sufianov, Rinat A.; Sufianov, Albert A.; Thingujam, Jagadish; Todeschini, Alexandre B.; Valença, Marcelo; Valencia-Ramos, Cristopher G.; Veiga, José Carlos Esteves; Vescan, Allan; Villalonga, Juan F.; Volovetz, Josephine; Wang, Eric W.; Watanabe, Kentaro; Wicks, Robert T.; Witterick, Ian; Yasuda, Alexandre; Zadeh, Gelareh; Zagzoog, Nirmeen; Zahrani, Abdulrahman Al; Zhao, Xiaochun; Zoli, M.

Title: Microsurgical and Endoscopic Approaches to the Skull Base

Subtitle: Anatomy, Tactics, and Techniques

Print ISBN: 9781626239661; Online ISBN: 9781684203772; Book DOI: 10.1055/b000000340

1. Edition © 2021. Thieme. All rights reserved.
Thieme Medical Publishers, Inc., New York

Subjects: Neurosurgery;Otorhinolaryngology, Phoniatrics, Audiology

Thieme Clinical Collections (English Language)



 
José Alberto Landeiro and Gustavo Augusto Porto Sereno Cabral

Abstract

The transoral approach is a safe and effective surgical procedure for pathologies of the craniovertebral junction (CVJ). It provides direct access from the inferior third of the clivus to the C3 body and allows excellent decompression of the ventral brainstem and upper cervical spinal cord. Understanding the complex anatomy and biomechanics of this region is critical for surgical planning. The choice for this approach depends on patient and pathology details, as with all surgical techniques. The main indications are irreducible ventral compression, with the most common being basilar invagination. There are several peculiarities in the preoperative evaluation, like assessment of oral and dental hygiene, and nutritional. Postoperative care requires evaluation of instability of the CVJ. In recent years, endoscopic endonasal approach has emerged as a valuable option for pathologies of the CVJ.

Key words

craniovertebral junction - transoral approach - microsurgery - atlantoaxial instability - skull base
 
  • 1 Menezes AH, Traynelis VC. Anatomy and biomechanics of normal craniovertebral junction (a) and biomechanics of stabilization (b).. Childs Nerv Syst 2008; 24 (10) 1091-1100 PubMed (PMID: 18389261)
    PubMedGoogle Scholar
  • 3 Southwick WO, Robinson RA. Surgical approaches to the vertebral bodies in the cervical and lumbar regions.. J Bone Joint Surg Am 1957; 39-A (3) 631-644 PubMed (PMID: 13428808)
    PubMedGoogle Scholar
  • 4 Fang HS, Ong GB. Direct anterior approach to the upper cervical spine.. J Bone Joint Surg Am 1962; 44: 1588-1604 (PMID: NOT_FOUND)
    Google Scholar
  • 6 Greenberg AD, Scoville WB, Davey LM. Transoral decompression of atlanto-axial dislocation due to odontoid hypoplasia. Report of two cases.. J Neurosurg 1968; 28 (3) 266-269 PubMed (PMID: 5643918)
    PubMedGoogle Scholar
  • 9 Menezes AH, Graf CJ, Hibri N. Abnormalities of the cranio-vertebral junction with cervico-medullary compression: a rational approach to surgical treatment in children.. Childs Brain 1980; 7 (1) 15-30 PubMed (PMID: 7428493)
    PubMedGoogle Scholar
  • 10 Menezes AH, VanGilder JC, Graf CJ, McDonnell DE. Craniocervical abnormalities: a comprehensive surgical approach.. J Neurosurg 1980; 53 (4) 444-455 PubMed (PMID: 7420164)
    PubMedGoogle Scholar
  • 11 Menezes AH, VanGilder JC. Transoral-transpharyngeal approach to the anterior craniocervical junction: ten-year experience with 72 patients.. J Neurosurg 1988; 69 (6) 895-903 PubMed (PMID: 3193195)
    PubMedGoogle Scholar
  • 12 Crockard HA. The transoral approach to the base of the brain and upper cervical cord.. Ann R Coll Surg Engl 1985; 67 (5) 321-325 PubMed (PMID: 3901865)
    PubMedGoogle Scholar
  • 13 Crockard HA, Essigman WK, Stevens JM, Pozo JL, Ransford AO, Kendall BE. Surgical treatment of cervical cord compression in rheumatoid arthritis.. Ann Rheum Dis 1985; 44 (12) 809-816 PubMed (PMID: 4083936)
    PubMedGoogle Scholar
  • 14 Hadley MN, Spetzler RF, Sonntag VKH. The transoral approach to the superior cervical spine: a review of 53 cases of extradural cervicomedullary compression.. J Neurosurg 1989; 71 (1) 16-23 PubMed (PMID: 2738638)
    PubMedGoogle Scholar
  • 17 Wolfla CE. Anatomical, biomechanical, and practical considerations in posterior occipitocervical instrumentation.. Spine J 2006; 6 (6) (Suppl. Suppl) 225S-232S PubMed (PMID: 17097542)
    PubMedGoogle Scholar
  • 19 Chethan P, Prakash KG, Murlimanju BV et al. Morphological analysis and morphometry of the foramen magnum: an anatomical investigation.. Turk Neurosurg 2012; 22 (4) 416-419 PubMed (PMID: 22843456)
    PubMedGoogle Scholar
  • 20 Govsa F, Ozer MA, Celik S, Ozmutaf NM. Three-dimensional anatomic landmarks of the foramen magnum for the craniovertebral junction.. J Craniofac Surg 2011; 22 (3) 1073-1076 PubMed (PMID: 21586947)
    PubMedGoogle Scholar
  • 21 Muthukumar N, Swaminathan R, Venkatesh G, Bhanumathy SP. A morphometric analysis of the foramen magnum region as it relates to the transcondylar approach.. Acta Neurochir (Wien) 2005; 147 (8) 889-895 PubMed (PMID: 15924208)
    PubMedGoogle Scholar
  • 22 Steinmetz MP, Mroz TE, Benzel EC. Craniovertebral junction: biomechanical considerations.. Neurosurgery 2010; 66 (3) (Suppl. Suppl) 7-12 PubMed (PMID: 20173531)
    PubMedGoogle Scholar
  • 23 Tubbs RS, Kelly DR, Humphrey ER et al. The tectorial membrane: anatomical, biomechanical, and histological analysis.. Clin Anat 2007; 20 (4) 382-386 PubMed (PMID: 16617439)
    PubMedGoogle Scholar
  • 25 White III AA, Panjabi MM. The clinical biomechanics of the occipitoatlantoaxial complex.. Orthop Clin North Am 1978; 9 (4) 867-878 PubMed (PMID: 740380)
    PubMedGoogle Scholar
  • 27 Crockard HA, Bradford R. Transoral transclival removal of a schwannoma anterior to the craniocervical junction. Case report.. J Neurosurg 1985; 62 (2) 293-295 PubMed (PMID: 3968569)
    PubMedGoogle Scholar
  • 28 Bonkowski JA, Gibson RD, Snape L. Foramen magnum meningioma: transoral resection with a bone baffle to prevent CSF leakage. Case report.. J Neurosurg 1990; 72 (3) 493-496 PubMed (PMID: 2303883)
    PubMedGoogle Scholar
  • 29 Crockard HA, Sen CN. The transoral approach for the management of intradural lesions at the craniovertebral junction: review of 7 cases.. Neurosurgery 1991; 28 (1) 88-97, discussion 97–98 PubMed (PMID: 1994287)
    PubMedGoogle Scholar
  • 30 Crockard HA, Johnston F. Development of transoral approaches to lesions of the skull base and craniovertebral junction.. Neurosurg Q 1993; 3: 61-82 (PMID: NOT_FOUND)
    Google Scholar
  • 31 Landeiro JA, Boechat S, Christoph DdeH et al. Transoral approach to the craniovertebral junction.. Arq Neuropsiquiatr 2007; 65 (Suppl. 4B) 1166-1171 PubMed (PMID: 18345423)
    Google Scholar
  • 32 Menezes AH. Developmental and acquired abnormalities of the craniovertebral junction. In: Van Gilder JC, Menezes AH, Dolan KD, eds. The Craniovertebral Junction and Its Abnormalities. New York: Futura Publishing; 1987:109–158
  • 33 Sawin PD, Menezes AH. Basilar invagination in osteogenesis imperfecta and related osteochondrodysplasias: medical and surgical management.. J Neurosurg 1997; 86 (6) 950-960 PubMed (PMID: 9171173)
    PubMedGoogle Scholar
  • 35 Kanamori Y, Miyamoto K, Hosoe H, Fujitsuka H, Tatematsu N, Shimizu K. Transoral approach using the mandibular osteotomy for atlantoaxial vertical subluxation in juvenile rheumatoid arthritis associated with mandibular micrognathia.. J Spinal Disord Tech 2003; 16 (2) 221-224 PubMed (PMID: 12679681)
    PubMedGoogle Scholar
  • 36 Vishteh AG, Beals SP, Joganic EF et al. Bilateral sagittal split mandibular osteotomies as an adjunct to the transoral approach to the anterior craniovertebral junction. Technical note.. J Neurosurg 1999; 90 (2) (Suppl. Suppl) 267-270 PubMed (PMID: 10199263)
    Google Scholar
  • 37 Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report.. Neurosurgery 2005; 57 (1) (Suppl. Suppl) E213-, discussion E213 PubMed (PMID: 15987596)
    PubMedGoogle Scholar
  • 38 Beech TJ, McDermott AL, Kay AD, Ahmed SK. Endoscopic endonasal resection of the odontoid peg—case report and literature review.. Childs Nerv Syst 2012; 28 (10) 1795-1799 PubMed (PMID: 22585452)
    PubMedGoogle Scholar
  • 39 Duntze J, Eap C, Kleiber JC et al. Advantages and limitations of endoscopic endonasal odontoidectomy: a series of nine cases.. Orthop Traumatol Surg Res 2014; 100 (7) 775-778 PubMed (PMID: 25281548)
    PubMedGoogle Scholar
  • 40 Gempt J, Lehmberg J, Grams AE, Berends L, Meyer B, Stoffel M. Endoscopic transnasal resection of the odontoid: case series and clinical course.. Eur Spine J 2011; 20 (4) 661-666 PubMed (PMID: 21125300)
    PubMedGoogle Scholar
  • 41 Goldschlager T, Härtl R, Greenfield JP, Anand VK, Schwartz TH. The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding.. J Neurosurg 2015; 122 (3) 511-518 PubMed (PMID: 25361480)
    Google Scholar
  • 42 Hankinson TC, Grunstein E, Gardner P, Spinks TJ, Anderson RC. Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation type I and ventral brainstem compression.. J Neurosurg Pediatr 2010; 5 (6) 549-553 PubMed (PMID: 20515325)
    PubMedGoogle Scholar
  • 43 Hansen MA, da Cruz MJ, Owler BK. Endoscopic transnasal decompression for management of basilar invagination in osteogenesis imperfecta.. J Neurosurg Spine 2008; 9 (4) 354-357 PubMed (PMID: 18939921)
    PubMedGoogle Scholar
  • 44 Hickman ZL, McDowell MM, Barton SM, Sussman ES, Grunstein E, Anderson RC. Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review.. Neurosurg Focus 2013; 35 (2) E14 PubMed (PMID: 23905952)
    PubMedGoogle Scholar
  • 45 Iacoangeli M, Gladi M, Alvaro L, Di Rienzo A, Specchia N, Scerrati M. Endoscopic endonasal odontoidectomy with anterior C1 arch preservation in elderly patients affected by rheumatoid arthritis.. Spine J 2013; 13 (5) 542-548 PubMed (PMID: 23453575)
    PubMedGoogle Scholar
  • 46 Laufer I, Greenfield JP, Anand VK, Härtl R, Schwartz TH. Endonasal endoscopic resection of the odontoid process in a nonachondroplastic dwarf with juvenile rheumatoid arthritis: feasibility of the approach and utility of the intraoperative Iso-C three-dimensional navigation. Case report.. J Neurosurg Spine 2008; 8 (4) 376-380 PubMed (PMID: 18377323)
    PubMedGoogle Scholar
  • 47 Leng LZ, Anand VK, Hartl R, Schwartz TH. Endonasal endoscopic resection of an os odontoideum to decompress the cervicomedullary junction: a minimal access surgical technique.. Spine 2009; 34 (4) E139-E143 PubMed (PMID: 19214083)
    PubMedGoogle Scholar
  • 48 Nayak JV, Gardner PA, Vescan AD, Carrau RL, Kassam AB, Snyderman CH. Experience with the expanded endonasal approach for resection of the odontoid process in rheumatoid disease.. Am J Rhinol 2007; 21 (5) 601-606 PubMed (PMID: 17999797)
    PubMedGoogle Scholar
  • 49 Patel AJ, Boatey J, Muns J et al. Endoscopic endonasal odontoidectomy in a child with chronic type 3 atlantoaxial rotatory fixation: case report and literature review.. Childs Nerv Syst 2012; 28 (11) 1971-1975 PubMed (PMID: 22763656)
    PubMedGoogle Scholar
  • 50 Ponce-Gómez JA, Ortega-Porcayo LA, Soriano-Barón HE et al. Evolution from microscopic transoral to endoscopic endonasal odontoidectomy.. Neurosurg Focus 2014; 37 (4) E15 PubMed (PMID: 25270134)
    PubMedGoogle Scholar
  • 51 Rawal RB, Shah RN, Zanation AM. Endonasal odontoidectomy for basilar impression and brainstem compression due to radiation fibrosis.. Laryngoscope 2013; 123 (3) 584-587 PubMed (PMID: 23070878)
    PubMedGoogle Scholar
  • 52 Sinha S, Mirza S, Bishop N, Zaki H, McMullan J. Endoscopic endonasal resection of the odontoid peg for paediatric basilar invagination.. Br J Neurosurg 2012; 26 (4) 487-489 PubMed (PMID: 22348299)
    PubMedGoogle Scholar
  • 53 Tomazic PV, Stammberger H, Mokry M, Gerstenberger C, Habermann W. Endoscopic resection of odontoid process in Arnold Chiari malformation type II.. B-ENT 2011; 7 (3) 209-213 PubMed (PMID: 22026144)
    PubMedGoogle Scholar
  • 54 Wu JC, Huang WC, Cheng H et al. Endoscopic transnasal transclival odontoidectomy: a new approach to decompression: technical case report.. Neurosurgery 2008; 63 (1) (Suppl. Suppl 1) ONSE92-94, discussion ONSE94 PubMed (PMID: 18728615)
    PubMedGoogle Scholar
  • 55 Yen YS, Chang PY, Huang WC et al. Endoscopic transnasal odontoidectomy without resection of nasal turbinates: clinical outcomes of 13 patients.. J Neurosurg Spine 2014; 21 (6) 929-937 PubMed (PMID: 25279654)
    PubMedGoogle Scholar
  • 56 de Almeida JR, Zanation AM, Snyderman CH et al. Defining the nasopalatine line: the limit for endonasal surgery of the spine.. Laryngoscope 2009; 119 (2) 239-244 PubMed (PMID: 19172603)
    PubMedGoogle Scholar
  • 57 El-Sayed IH, Wu JC, Dhillon N, Ames CP, Mummaneni P. The importance of platybasia and the palatine line in patient selection for endonasal surgery of the craniocervical junction: a radiographic study of 12 patients.. World Neurosurg 2011; 76 (1–2) 183-188, discussion 74–78 PubMed (PMID: 21839972)
    PubMedGoogle Scholar
  • 58 Lindley T, Greenlee JD, Teo C. Minimally invasive surgery (endonasal) for anterior fossa and sellar tumors.. Neurosurg Clin N Am 2010; 21 (4) 607-620, v PubMed (PMID: 20947030)
    PubMedGoogle Scholar
  • 59 Di Lorenzo N. Craniocervical junction malformation treated by transoral approach: a survey of 25 cases with emphasis on postoperative instability and outcome.. Acta Neurochir (Wien) 1992; 118 (3–4) 112-116 PubMed (PMID: 1456094)
    PubMedGoogle Scholar
  • 60 Dickman CA, Crawford NR, Brantley AGU, Sonntag VKH. Biomechanical effects of transoral odontoidectomy.. Neurosurgery 1995; 36 (6) 1146-1152, discussion 1152–1153 PubMed (PMID: 7643995)
    PubMedGoogle Scholar
  • 61 Dickman CA, Locantro J, Fessler RG. The influence of transoral odontoid resection on stability of the craniovertebral junction.. J Neurosurg 1992; 77 (4) 525-530 PubMed (PMID: 1527609)
    PubMedGoogle Scholar
  • 62 Dlouhy BJ, Dahdaleh NS, Menezes AH. Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update.. Neurosurg Focus 2015; 38 (4) E8 PubMed (PMID: 25828502)
    PubMedGoogle Scholar