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

Liu et al present a “Transoral Approach and Extended Modifications for Lesions of the Ventral Foramen Magnum and Craniovertebral Junction.” Pathology at the ventral craniovertebral junction remains a technical challenge to remedy. The authors present a well-written review of the transoral approach and its extensions to access lesions from the inferior clivus to the C2. The article is easy to read and the illustrations enable a visual understanding of the local anatomy; these attributes make this an excellent educational reference for neurosurgical residents and skull base neophytes.

Endoscopic endonasal techniques to expose this area have also been described as an alternative to the often morbid transoral, transfacial, and transmandibular approaches. Accessing the area and resecting the pathology appear quite feasible via the less invasive endoscopic approach. There are some technical tips that may assist in this approach. We prefer using a small pediatric feeding tube, and then using a 2-0 silk tie to attach the uvula to the pediatric feeding tube. This helps get the uvula out of the way and increases the level of exposure. We prefer to use the Codman Crockard Retractor (Randolph, MA), which has worked very well for our approaches. The major complications that we have encountered in our series of transoral approaches have involved rheumatoid arthritis patients, who were immunosuppressed and for whom healing is not optimal. We had one cerebrospinal fluid leak that resolved with lumbar drainage.

In conclusion, this is an excellent review article, with concise yet complete techniques and illustrations. The article will serve as an excellent reference for those who perform surgery in this area.