Transoral Transpharyngeal approach to Craniovertebral Junction: Indications, Management and outcomes in a Survey of 7 Cases

Abstract

Introduction: The transoral-transpharyngeal surgical

approach is a direct operative approach for pathology

ventral to the craniovertebral junction and upper spinal

cord. In selected patients, this approach is effective in the

treatment of extradural compressive lesions

from the cervico-medullary junction to the C3 vertebra. We

present 7 patients who underwent transoral

transpharyngeal surgeries by a single surgeon (BVJ) for

ventral CVJ compression due to different pathologies.

Material and Methods: Retrospective data analysis of

7 patients who underwent transoral transpharyngeal

surgeries for various pathologies affecting the

craniovertebral junction was performed from January 2015

to January 2017. The hospital records, outpatient

physician records, and radiographic studies of all

7 patients were reviewed. Results: The mean age of the

study group was 36 (range 10-64) years. There were

4 (57.1%) males and 3 (42.9%) females. 6 (85.7%) out of

seven patients presented with features of cervical cord

compression. In one patient (14.3%) only neck pain with

restriction of neck movement was present. Of the

7 patients, 3 (42.8%) had irreducible atlantoaxial

dislocation with basilar invagination, 2 (28.6%) had

irreducible atlantoaxial dislocation and 2 (28.6%) had CVJ

tuberculosis. The most common presenting symptom of

the group was spastic quadriparesis and paresthesias

involving all four limbs. The mean preoperative Nurick

grade was 1.9 and the mean imJOA score was 13.5/19 for

the group. All patients were operated through

transoral-transpharyngeal approach and all of them

underwent occipito-cervical fusion subsequently. 5 (71.4%)

out of 7 patients had symptomatic improvement

postoperatively. One patient (14.3%) required

tracheostomy postoperatively for prolonged ventilation and

he was discharged on BIPAP.

However he expired after three months of surgery due

ventilator associated pneumonia. One patient (14.3%) had

transient hoarseness of voice and difficulty in swallowing

postoperatively for which improved over next two weeks. The

mean follow-up of our series (n=5) was 18.4 months. One

patient was lost to follow-up. The mean Nurick grade

improved to 0 and mean imJOA improved to 19/19 at

follow-up. All patients were symptom-free at follow-up and

there was radiological reduction with bony fusion in all of

them. Conclusion: Transoral odontoidectomy is a safe and

efficacious approach for the treatment of selected patients

with compressive pathology of the ventral brain stem and

upper cervical cord. Patients must be selected judiciously and

a detailed radiological examination is advised to define the

extent of compression, reducibility, and instability present in

an individual patient.