Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update.

The craniovertebral junction (CVJ), or the craniocervical junction (CCJ) as it is otherwise known, houses the crossroads of the CNS and is composed of the occipital bone that surrounds the foramen magnum, the atlas vertebrae, the axis vertebrae, and their associated ligaments and musculature. The musculoskeletal organization of the CVJ is unique and complex, resulting in a wide range of congenital, developmental, and acquired pathology. The refinements of the transoral approach to the CVJ by the senior author (A.H.M.) in the late 1970s revolutionized the treatment of CVJ pathology. At the same time, a physiological approach to CVJ management was adopted at the University of Iowa Hospitals and Clinics in 1977 based on the stability and motion dynamics of the CVJ and the site of encroachment, incorporating the transoral approach for irreducible ventral CVJ pathology. Since then, approaches and techniques to treat ventral CVJ lesions have evolved. In the last 40 years at University of Iowa Hospitals and Clinics, multiple approaches to the CVJ have evolved and a better understanding of CVJ pathology has been established. In addition, new reduction strategies that have diminished the need to perform ventral decompressive approaches have been developed and implemented. In this era of surgical subspecialization, to properly treat complex CVJ pathology, the CVJ specialist must be trained in skull base transoral and endoscopic endonasal approaches, pediatric and adult CVJ spine surgery, and must understand and be able to treat the complex CSF dynamics present in CVJ pathology to provide the appropriate, optimal, and tailored treatment strategy for each individual patient, both child and adult. This is a comprehensive review of the history and evolution of the transoral approaches, extended transoral approaches, endoscopie assisted transoral approaches, endoscopie endonasal approaches, and CVJ reduction strategies. Incorporating these advancements, the authors update the initial algorithm for the treatment of CVJ abnormalities first published in 1980 by the senior author.

Anterior Spinal Reconstruction to the Clivus Using an Expandable Cage After C2 Chordoma Resection Via a Labiomandibular Glossotomy Approach: A Technical Report.

INTRODUCTION: En bloc resection of high-cervical chordomas is a technically challenging procedure associated with significant morbidity. Two key components of this procedure include the approach and the method of spinal reconstruction. A limited number of reported cases of en bloc resection of high-cervical chordomas have been reported in the literature. CASE PRESENTATION: We report a novel case using an expandable cage to reconstruct the anterior spinal column above C2 with fixation to the clivus. We also report a novel anterior approach to the high-cervical spine via a midline labiomandibular glossotomy. We detail the management of complications related to 2 instances of wound dehiscence and hardware exposure requiring two additional operations. The final surgical procedure involved explantation of the anterior cervical plate and use of a vascularized radial graft to close the posterior pharyngeal defect and protect the hardware. At 26-month follow-up, the patient remained disease free without any neurologic deficit. DISCUSSION: We report the novel use of the midline labiomandibular glossotomy for surgical approach and reconstruction of the anterior column to the clivus with an expandable cage. The unique features of this operative strategy allowed the surgical team to tailor the construct intraoperatively, resulting in solid arthrodesis without significant neurologic sequelae. CONCLUSIONS: Labiomandibular glossotomy for approach to high anterior cervical chordomas followed by craniospinal reconstruction to the clivus with an expandable cage represents a novel technique for managing high cervical chordomas.

A Case of Curretage and Anterior Fusion of Cervical Tuberculous Spondylitis Via Trotter Approach

A ase of 47 years old female with cervical tuberculous spondylits involving C2,3 and C4 is reported. The lesion was treated surgically by curretage and anterior fusion with iliac bone autograft via median labiomandibular glossotomy.

High Cervical Chordoma Removed via Median Labiomandibular Glossotomy Approach

The authors report two cases of high cervical spinal chordomas that were removed via the median labiomandibular glossotomy(MLG) approach. One patient was a 62-year-old female in whom an extradural chordoma was found at the level of C3 vertebra with huge prevertebral extension, and causing dyspnea and dysphagia; the other was a 47-year-old female, found to be suffering from a chordoma of C2 vertebral body, which was found incidentally. After removal of the tumors, ventral instrumented fusions were performed in both patients, who showed good recoveries with only minor complications. The MLG approach is radical, and rarely performed by neurosurgeons, but for treatment of an expanded high cervical lesion that needs ventral surgery and seems to be inaccessible via the conventional transoropharyngeal or anterolateral retropharyngeal route, it should be considered. The authors discuss the clinicopathological characteristics of spinal chordomas and general considerations of the MLG approach to high cervical lesions, and briefly describe the surgical techniques involved in this approach.