Transoral approach to extradural non-neoplastic lesions of the craniovertebral junction

Abstract

Background: The transoral approach allows for an unobstructed anterior view of the craniovertebral junction from the lower clivus to C1 and C2. It can be applied to a heterogeneous spectrum of pathological lesions involving this area including craniovertebral junction malformations, atlanto-axial synovial cysts, pseudoarthrosis following odontoid fractures, selected cases of retro-odontoid pannus, and vertical translocation in rheumatoid patients.

Methods: Microsurgical strategy is dictated by the nature and site of the target lesion. Atlas preservation during transoral approach (atlas-sparing technique) minimizes postoperative instability and is suitable for the majority of extradural non-neoplastic lesions of the craniovertebral junction. The transoral trans-atlas approach allows for a wider exposure of the anterior craniovertebral junction, but at the price of a higher incidence of postoperative instability; it is usually required in patients with severe basilar invagination or irreducible vertical translocation in rheumatoid arthritis.

Conclusions: The transoral corridor is an effective route to approach a variety of anterior extradural lesions of the craniovertebral junction. Tailoring the approach to each specific lesion provides the needed exposure whilst limiting postoperative instability.