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

Abstract

<jats:p>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.</jats:p> <jats:p>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.</jats:p>

Combined preoperative traction with instrumented posterior occipitocervical fusion for severe ventral brainstem compression secondary to displaced os odontoideum: technical report of 2 cases

“…3,15 As outlined in an excellent review on the evolution of transoral and transnasal approaches to the craniovertebral junction, Dlouhy et al suggested the use of acute cervical traction and the addition of intraoperative neuromuscular blockade and, if the pathology is still irreducible, a transnasal or transoral approach depending on if the pathology is above or below the hard palate. 4 There is some evidence that, compared with transoral routes, transnasal approaches may have fewer complication risks, including decreased risks of infection, and could permit early extubation and early feeding. 9,14,18 Our Case 1 suggests that a combined approach works better than a single approach, as a posterior decompression, fixation, and stabilization procedure had previously failed.…”

The rise and fall of the craniocervical junction relative to the hard palate: a lifetime story

“…Recently, Dlouhy et al have further modified their algorithm originally proposed at University of Iowa for addressing craniovertebral junction pathology and now include the position of the nasopharynx and oropharynx relative to the hard palate as a discriminator of the surgical approach (endonasal, transoral, or transcervical) chosen in cases with irreducible pathology. 9 In contrast to studies that evaluate surgical corridors in cadavers and mostly small adult cohorts, we indirectly assessed the impact of age on these corridors. Although the present study is an anatomical study based on advanced imaging, the variance with age and sex does suggest that the extent of the endoscopic corridors will also likely vary with these variables.…”

Comparison of hinged and contoured rods for occipitocervical arthrodesis in adults: A clinical study

“…[316] Fixation across the CVJ is occasionally necessary in the face of CVJ instability that may result from trauma, syndromic anomalies, osteoarthritis, rheumatoid arthritis, Down's syndrome, neoplasm, and many other conditions. [2356171819202122]…”

“…[123456789] Rigid constructs have been shown in biomechanical studies to provide superior fixation to semi-rigid constructs. [479101112131415] Rods are contoured to connect an occipital plate and upper cervical spine screws,[479] inviting biomechanical fatigue failure of the rod.…”