Surgical approaches: postoperative care and complications “transoral–transpalatopharyngeal approach to the craniocervical junction”

The ventral approach to the craniocervical border has been described for decompression of irreducible extradural pathology. The procedures utilized encompass the transoropharyngeal and median mandibulotomy with glossotomy and the transpalatal procedures. This study was aimed to review the utility of the transoral–transpalatopharyngeal approach.

Seven hundred thirty-three patients underwent transpalatopharyngeal approach for decompression of the brain stem and cervicomedullary junction. Of these, 280 were children below the age of 16 years. The main indication was irreducible ventral pathology compressing the brain stem and cervicomedullary junction. Two hundred two children had irreducible basilar invagination, 28 had proatlas segmentation abnormalities, os odontoideum with a dystopic os odontoideum in 30, and spinal tumors in seven (chordoma, fibrous dysplasia, osteoblastoma). Seven patients with Down’s syndrome and irreducible bony compression of the ventral cervicomedullary junction were seen. There were six other miscellaneous diagnoses. All children required craniocervical stabilization which was carried out under the same anesthetic as the transoral procedure.

The procedure entailed fiber-optic intubation. The patient was placed in cervical traction prior to the anterior procedure. The soft palate was split only in individuals with a short clivus with a high riding clivus-odontoid articulation. Craniocervical stabilization was performed in the prone position under the same anesthetic.

There was one retropharyngeal infection postoperatively. No cesium fluoride leaks were encountered. Velopalatine incompetence was seen in five children who already had preoperative brain stem dysfunction. Neurological recovery was the rule. Patients who had preoperative syringohydromyelia had resolution of the syrinx on postoperative magnetic resonance imaging.

The author’s technique is described. Since 1977, the procedure has been performed in 732 patients (280 children) and has evolved into a safe and direct approach to the ventral cervicomedullary junction with minimal morbidity and mortality.