Robotic-Assisted Tubular Transoral Parapharyngeal Approach to the Ventral Craniovertebral Junction

Abstract

BACKGROUND Transoral robotic surgery (TORS) has become a routine technique for treating benign and malignant lesions of the oropharynx with the advantage of reducing morbidity compared to open surgical techniques. However, TORS has not been used routinely for accessing lesions of the spine. OBJECTIVE To describe how TORS can be used to access spinal lesions. METHODS We describe our technique of accessing the parapharyngeal space using the robotic technique, and then dissecting the prevertebral muscles to expose the ventral craniovertebral junction. Tubular retraction with endoscopic visualization is then employed for surgical resection. We then report a case of a 14-yr-old competitive athlete who presented with an osseous lesion of C1, which underwent resection using this novel TORS approach. RESULTS Our patient underwent successful resection of a lateral C1 osteoid osteoma utilizing a combined TORS/endoscopic approach. She tolerated soft diet immediately and was discharged on postoperative day 2. Postoperative imaging revealed complete resection of the lesion, and she returned to competitive athletics within 6 wk. CONCLUSION Utilizing this novel, robotic-assisted approach can definitively treat osseous cervical spine lesions while reducing morbidity, allowing for early return to normal diet and minimizing overall length of hospital stay.

Commentary: Endoscopic Endonasal Versus Transoral Odontoidectomy for Non-Neoplastic Craniovertebral Junction Disease: A Case Series

“…Typical accessible boundaries for an endoscopic endonasal approach are thought to be midline and above the nasopalatine line, requiring a transoral approach or a combined approach if inaccessible by these general parameters. 6 The authors bring out an excellent point that, in their experience, the accessible boundaries set by radiographical parameters can often be expanded with utilization of a 30-degree endoscope, 1 which is a point corroborated by others in the literature. 7,8 The endoscopic endonasal approach to pathology of the craniocervical junction is a comparatively newer approach than the transoral approach, and it indeed has a steep learning curve.…”

“…We recently published on this approach for craniocervical pathology, combining endoscopy and the transoral approach, which is performed with otolaryngologists using transoral robotic tubular retraction with endoscopic visualization. 6 Despite the learning curve and the necessary coordination of multidisciplinary surgical teams for an endoscopic approach, the improved postoperative recovery makes this a useful tool for approach to pathology in this region that is worth the learned versatility as a skull base surgeon.…”

Novelties for increased safety in cranio-vertebral surgery: a review

“…Robotized navigation systems represent the new generation of computer-assisted systems with the aim of further enhancing surgical precision, which is of particular significance in the tight bony anatomy of the cervical spine. Recently, use of robotic systems has been expanded to CVJ surgery, both for the posterior [ 1 , 16 , 67 ] and anterior approaches [ 3 , 48 ]. In their review, Lebl et al describe the various applications of robot-assisted surgery in the cervical spine and, in particular, at the CVJ, C1 lateral mass instrumentation, C2 odontoid fracture fixation, C2 pedicle screw placement, and C2 translaminar screw fixation [ 43 ].…”