Editorial: Are there any indications of transoral odontoidectomy today?

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  • Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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The use of transoral odontoidectomy has been reduced significantly following the introduction of techniques such as direct posterior intraoperative reduction, realignment, and fixation.1–7,9,12,13 It may, however, be performed in cases when posterior-only procedures are not useful enough to reduce the spinal compression completely. In cases where C1 is not occipitalized, a C1–C2 screw fixation is usually enough to reduce the atlantoaxial dislocation. Congenital cases where the C1 is fused with the occiput are associated with moderate to severe basilar invagination and atlantoaxial dislocation.

In fact, performing a transoral odontoidectomy may be an elective option, following partial reduction after a posterior procedure. This allows for an easier transoral procedure. In the current scenario, the following may be indications of transoral procedures: 1) An anterior release followed by posterior fixation: Wang et al.15,20 and some others have suggested this procedure. They felt that an anterior release of ligaments would allow a better posterior reduction and realignment. However, in most cases this is not required and a direct reduction and fixation provides excellent alignment. 2) An incomplete or nonreduction following a posterior approach: this is currently the most common indication for a transoral approach. 3) Reduction and fixation from the anterior approach: Some authors have suggested an anterior-only approach to reduce and perform fixation from C1–2 from the anterior route.14

Some important things to consider prior to transoral odontoidectomy include the following: 1) Consider the degree of mouth opening. This should be about three fingers breadth to allow ingress to the surgical approach. 2) Consider examining the oral cavity; exclude any infective conditions and assess oral hygiene prior to surgery. These aspects may be missed when considering surgery.

Neuronavigation has emerged as a useful optimal surgical aid while performing surgery.16–19 This is important especially to delineate the inferior part of the C2 body, as has been shown in this video. The other uses of neuronavigation are to determine the lateral extent. Often, if the surgeon is not experienced, the lateral portion of the base of dens is left behind, and this may cause postoperative compression.

The endoscopic transoral procedure8,10,11,21 is also emerging as a useful alternative to perform an odontoidectomy. The advantage, of course, is that it is minimally invasive and not dependent on the degree of mouth opening.

In summary, the role of transoral odontoidectomy is shrinking fast, but there are still some indications for it, as mentioned.

References

  • 1

    Chandra PS. In reply: different facets in management of congenital atlantoaxial dislocation and basilar invagination. Neurosurgery. 2015;77:E987E988.

    • Search Google Scholar
    • Export Citation
  • 2

    Chandra PS. In reply: distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation. Neurosurgery. 2015;76:E240E242.

    • Search Google Scholar
    • Export Citation
  • 3

    Chandra PS, Goyal N. In reply: the severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indices for the craniovertebral junction. Neurosurgery. 2015;76:E235E239.

    • Search Google Scholar
    • Export Citation
  • 4

    Chandra PS, Goyal N, Chauhan A, The severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indexes for the craniovertebral junction. Neurosurgery. 2014;10(suppl 4):621630.

    • Search Google Scholar
    • Export Citation
  • 5

    Chandra PS, Kumar A, Chauhan A, Distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation: a novel pilot technique. Neurosurgery. 2013;72:10401053.

    • Search Google Scholar
    • Export Citation
  • 6

    Chandra PS, Prabhu M, Goyal N, Distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: prospective study in 79 cases. Neurosurgery. 2015;77:6780.

    • Search Google Scholar
    • Export Citation
  • 7

    Chandra PS, Singh P. In reply: distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: prospective study in 79 cases. Neurosurgery. 2017;80:231235.

    • Search Google Scholar
    • Export Citation
  • 8

    Chibbaro S, Ganau M, Cebula H, The endonasal endoscopic approach to pathologies of the anterior craniocervical junction: analytical review of cases treated at four European neurosurgical centres. Acta Neurochir. 2019(suppl 125):187195.

    • Search Google Scholar
    • Export Citation
  • 9

    Faheem M, Jaiswal M, Ojha BK, Clinico-radiological outcome analysis in craniovertebral junction diseases: an institutional experience of 38 patients in a tertiary care centre. World Neurosurg. 2018;117:e612e630.

    • Search Google Scholar
    • Export Citation
  • 10

    Frempong-Boadu AK, Faunce WA, Fessler RG. Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction. Neurosurgery. 2002;51:S60S66.

    • Search Google Scholar
    • Export Citation
  • 11

    Grose E, Moldovan ID, Kilty S, Clinical outcomes of endoscopic endonasal odontoidectomy: a single-center experience. World Neurosurg. 2020;137:e406e415.

    • Search Google Scholar
    • Export Citation
  • 12

    Joaquim AF, Tedeschi H, Chandra PS. Controversies in the surgical management of congenital craniocervical junction disorders—a critical review. Neurol India. 2018;66:10031015.

    • Search Google Scholar
    • Export Citation
  • 13

    Kumar R, Chandra SP, Sharma BS. Giant intradiploic pseudomeningocele of occipital bone. J Neurosurg Pediatr. 2012;9:8285.

  • 14

    Patkar S. Anterior retropharyngeal cage distraction and fixation for basilar invagination: “the wedge technique”. Neurospine. 2019;16:286292.

    • Search Google Scholar
    • Export Citation
  • 15

    Srivastava SK, Aggarwal RA, Nemade PS, Bhosale SK. Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination. Spine J. 2016;16:19.

    • Search Google Scholar
    • Export Citation
  • 16

    Ternier J, Joshi SM, Thompson DN. Image-guided transoral surgery in childhood. Childs Nerv Syst. 2009;25:563568.

  • 17

    Ugur HC, Kahilogullari G, Attar A, Neuronavigation-assisted transoral-transpharyngeal approach for basilar invagination—two case reports. Neurol Med Chir (Tokyo). 2006;46:306308.

    • Search Google Scholar
    • Export Citation
  • 18

    Veres R, Bago A, Fedorcsak I. Early experiences with image-guided transoral surgery for the pathologies of the upper cervical spine. Spine (Phila Pa 1976). 2001;26:13851388.

    • Search Google Scholar
    • Export Citation
  • 19

    Vougioukas VI, Hubbe U, Schipper J, Spetzger U. Navigated transoral approach to the cranial base and the craniocervical junction: technical note. Neurosurgery. 2003;52:247251.

    • Search Google Scholar
    • Export Citation
  • 20

    Wang Q, Mao K, Wang C, Mei W. Transoral atlantoaxial release and posterior reduction by occipitocervical plate fixation for the treatment of basilar invagination with irreducible atlantoaxial dislocation. J Neurol Surg A Cent Eur Neurosurg. 2017;78:313320.

    • Search Google Scholar
    • Export Citation
  • 21

    Wolinsky JP, Sciubba DM, Suk I, Gokaslan ZL. Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note. J Neurosurg Spine. 2007;6:184191

    • Search Google Scholar
    • Export Citation

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Contributor Notes

Correspondence P. Sarat Chandra, All India Institute of Medical Sciences (AIIMS), New Delhi, India. saratpchandra3@gmail.com.

ACCOMPANYING ARTICLE DOI: 10.3171/2020.4.FocusVid.20158.

INCLUDE WHEN CITING DOI: 10.3171/2020.4.FocusVid.20332.

Disclosures The authors report no conflict of interest.

  • 1

    Chandra PS. In reply: different facets in management of congenital atlantoaxial dislocation and basilar invagination. Neurosurgery. 2015;77:E987E988.

    • Search Google Scholar
    • Export Citation
  • 2

    Chandra PS. In reply: distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation. Neurosurgery. 2015;76:E240E242.

    • Search Google Scholar
    • Export Citation
  • 3

    Chandra PS, Goyal N. In reply: the severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indices for the craniovertebral junction. Neurosurgery. 2015;76:E235E239.

    • Search Google Scholar
    • Export Citation
  • 4

    Chandra PS, Goyal N, Chauhan A, The severity of basilar invagination and atlantoaxial dislocation correlates with sagittal joint inclination, coronal joint inclination, and craniocervical tilt: a description of new indexes for the craniovertebral junction. Neurosurgery. 2014;10(suppl 4):621630.

    • Search Google Scholar
    • Export Citation
  • 5

    Chandra PS, Kumar A, Chauhan A, Distraction, compression, and extension reduction of basilar invagination and atlantoaxial dislocation: a novel pilot technique. Neurosurgery. 2013;72:10401053.

    • Search Google Scholar
    • Export Citation
  • 6

    Chandra PS, Prabhu M, Goyal N, Distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: prospective study in 79 cases. Neurosurgery. 2015;77:6780.

    • Search Google Scholar
    • Export Citation
  • 7

    Chandra PS, Singh P. In reply: distraction, compression, extension, and reduction combined with joint remodeling and extra-articular distraction: description of 2 new modifications for its application in basilar invagination and atlantoaxial dislocation: prospective study in 79 cases. Neurosurgery. 2017;80:231235.

    • Search Google Scholar
    • Export Citation
  • 8

    Chibbaro S, Ganau M, Cebula H, The endonasal endoscopic approach to pathologies of the anterior craniocervical junction: analytical review of cases treated at four European neurosurgical centres. Acta Neurochir. 2019(suppl 125):187195.

    • Search Google Scholar
    • Export Citation
  • 9

    Faheem M, Jaiswal M, Ojha BK, Clinico-radiological outcome analysis in craniovertebral junction diseases: an institutional experience of 38 patients in a tertiary care centre. World Neurosurg. 2018;117:e612e630.

    • Search Google Scholar
    • Export Citation
  • 10

    Frempong-Boadu AK, Faunce WA, Fessler RG. Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction. Neurosurgery. 2002;51:S60S66.

    • Search Google Scholar
    • Export Citation
  • 11

    Grose E, Moldovan ID, Kilty S, Clinical outcomes of endoscopic endonasal odontoidectomy: a single-center experience. World Neurosurg. 2020;137:e406e415.

    • Search Google Scholar
    • Export Citation
  • 12

    Joaquim AF, Tedeschi H, Chandra PS. Controversies in the surgical management of congenital craniocervical junction disorders—a critical review. Neurol India. 2018;66:10031015.

    • Search Google Scholar
    • Export Citation
  • 13

    Kumar R, Chandra SP, Sharma BS. Giant intradiploic pseudomeningocele of occipital bone. J Neurosurg Pediatr. 2012;9:8285.

  • 14

    Patkar S. Anterior retropharyngeal cage distraction and fixation for basilar invagination: “the wedge technique”. Neurospine. 2019;16:286292.

    • Search Google Scholar
    • Export Citation
  • 15

    Srivastava SK, Aggarwal RA, Nemade PS, Bhosale SK. Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination. Spine J. 2016;16:19.

    • Search Google Scholar
    • Export Citation
  • 16

    Ternier J, Joshi SM, Thompson DN. Image-guided transoral surgery in childhood. Childs Nerv Syst. 2009;25:563568.

  • 17

    Ugur HC, Kahilogullari G, Attar A, Neuronavigation-assisted transoral-transpharyngeal approach for basilar invagination—two case reports. Neurol Med Chir (Tokyo). 2006;46:306308.

    • Search Google Scholar
    • Export Citation
  • 18

    Veres R, Bago A, Fedorcsak I. Early experiences with image-guided transoral surgery for the pathologies of the upper cervical spine. Spine (Phila Pa 1976). 2001;26:13851388.

    • Search Google Scholar
    • Export Citation
  • 19

    Vougioukas VI, Hubbe U, Schipper J, Spetzger U. Navigated transoral approach to the cranial base and the craniocervical junction: technical note. Neurosurgery. 2003;52:247251.

    • Search Google Scholar
    • Export Citation
  • 20

    Wang Q, Mao K, Wang C, Mei W. Transoral atlantoaxial release and posterior reduction by occipitocervical plate fixation for the treatment of basilar invagination with irreducible atlantoaxial dislocation. J Neurol Surg A Cent Eur Neurosurg. 2017;78:313320.

    • Search Google Scholar
    • Export Citation
  • 21

    Wolinsky JP, Sciubba DM, Suk I, Gokaslan ZL. Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note. J Neurosurg Spine. 2007;6:184191

    • Search Google Scholar
    • Export Citation

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