Decompression and Fusion

Michael F. O’Brien

Goals of Surgical Treatment

Figure 1–1
Cranial cervical junction algorithm.

Posterior Approaches: Disadvantages

1. CCJ pathology usually has significant anterior component.

2. Neuroaxial decompression in fixed kyphosis must be performed anteriorly.

3. CCJ deformity, typically kyphosis, may be difficult to treat via a posterior only approach.

4. Lack of anterior column support may contribute to failure of posterior instrumentation.

Procedure

Transoral Approach

The transoral approach is the preferred method to directly access the anterior craniocervical junction. Access can be gained from the inferior third of the clivus to the superior aspect of C3. Proximal extension can be achieved by splitting the soft palate in the midline with retraction of the uvula superiorly. Additional superior extension can be achieved by osteotomy of the hard palate. Caudal extension can be achieved by splitting the tongue either in the midline without mandibular osteotomy or in the midline with osteotomy of the mandible, and caudal retraction of the tongue. In this way, surgical exposure can be achieved from the mid-clivus to C3.

Figure 1–2
(A–G) Illustrative case. (See text for complete discussion.)

Figure 1–3
Transoral retractor positioning (anterior). 1, Armored nasotracheal tube; 2, soft palate retractors; 3, perioral ring; 4, tongue retractor. (See Color Plate 1–3.)

Figure 1–4
Transoral retractor positioning (lateral). 1, Red rubber catheter; 2, armored nasotracheal tube; 3, soft palate retractor; 4, tongue retractor. (See Color Plate 1–4.)

Figure 1–5
Retropharyngeal anatomy and retractor. 1, anterior atlanto-occipital membrane; 2, armored nasotracheal tube; 3, longus colli muscle; 4, anterior longitudinal ligament; 5, clivus; 6, longus capitis muscle; 7, rectus capitis anterior muscle; 8, anterior tubercle of C1; 9, lateral atlantoaxial joint capsule; 10, retropharyngeal soft tissue retractor. (See Color Plate 1–5.)

Figure 1–6
Open-door maxillotomy (lateral). 1, Maxillotomy retractor; 2, armored nasotracheal tube; 3, tongue retractor. (See Color Plate 1–6.)

Figure 1–7
Posterior dissection. 1, Intracranial vertebral artery; 2, extracranial vertebral artery. (See Color Plate 1–7.)

Figure 1–8
Posterior instrumentation. 1, Drill; 2, screw tap; 3, screw driver. (See Color Plate 1–8.)

Careful preoperative evaluation of the oral cavity is mandatory to identify sepsis. If necessary, cultures and sensitivities may be performed. The condition of the teeth must be evaluated. In those patients with significant dental problems or in the edentulous patients, special protective dental guards may be necessary. Soft dental molds may be useful to protect the teeth and gums from the rostral and caudal retractors. If the interdental distance is less than 25 mm with the patient’s mouth maximally opened, it is unlikely that a conventional transoral procedure will be possible. Patients with large, thick tongues (Down syndrome) may also present a challenge to retractor positioning.

Anesthesia

For most transoral procedures, tracheostomy is not necessary. Either an oral endotracheal or an armored nasal tracheal tube may be used. The armored nasal tracheal tube is preferred. It enters nasally, out of the operative field, and is easily retracted laterally intraorally by the transoral retractor system CODMAN. Patients remain intubated for several days postsurgery to allow retropharyngeal swelling to subside. Nasotracheal tubes are more comfortable during this period than oral tracheal tube. Awake intubation may be necessary for those patients with an unstable CCJ or tenuous neurologic function.