Transoral Versus Transnasal Approach for Craniovertebral Junction Pathologies: Never Say Never

Objective

For many years, the microsurgical transoral approach (TOA) has been accepted as the “gold standard” for the surgical treatment of a variety of congenital, developmental, and acquired pathologies affecting the craniovertebral junction. In the present study, we try to investigate both experimental and clinical fronts of such a challenging surgery, starting from the updated literature experience. TOA is actually presented as an “old-fashioned” surgical technique dealing with possible bacterial contamination, the need of postoperative nose gastric tube feeding for a week, the possible nasopharyngeal incompetence, and the postoperative tongue swelling. Otherwise, the endoscopic endonasal approach (EEA) appears strongly supported by the modern literature as the true “minimally invasive” procedure.

Methods

Our clinical experience deals with 23 anterior procedures in paediatric and adult patients (17 TOA and 6 EEA). We further report on our experimental cadaver laboratory study of 12 subjects.

Results

All the patients of TOA group but one were discharged after posterior procedures within two weeks and improved or remained unchanged after surgery and during the follow-up. No mayor complications occurred in TOA group. In EEA group two patients died for cerebrospinal fluid infection, for disease progression and for heart attack.

Conclusion

Our and other available data suggest that no clear superiority of EEA over endoscopic TOA can be assessed so far; on the other hand, EEA can produce complications similar to TOA in craniovertebral junction surgery.

Introduction

For many years, the microsurgical transoral approach (TOA) has been accepted as the “gold standard” for the surgical treatment of a variety of congenital, developmental, and acquired pathologies affecting the craniovertebral junction (CVJ). This surgery, although burdened by possible bacterial contamination, the need of postoperative nose gastric tube feeding for a week, the possible nasopharyngeal incompetence, and the postoperative tongue swelling, was strongly supported by the clinical introduction by Kassam et al.¹ regarding the endoscopic endonasal approach (EEA).¹ The EEA appeared potentially promising in overcoming previous technical challenges and surgical complications, progressively gaining favor over TOA; however, the exact role of this approach in the treatment of CVJ pathology is yet to be defined. In 2009, the de Almeida et al.² introduced the nasopalatine line (NPL), connecting the most inferior point on the nasal bone and the most posterior point on the hard palate toward the inferior aspect of the body of C2, as a reliable predictor of the maximal extent of inferior dissection. Odontoid surgery can be performed reliably according to the preoperative radiologic study of the possible anatomic limitations of the endonasal approach. Moreover, a novel “surgical” nasoaxial Line (NAxL) was conceived to be obtained preoperatively and radiologically to overcome the imprecision of the NPL.3, 4 Otherwise, no conceptually analogue radiologic line has been introduced as a reliable predictor of the maximal superior extension of the transoral approach.

We report on our experimental and surgical experience with TOA and EEA for different CVJ pathologies, and we discuss the pertinent literature critically assessing the feasibility, advantages, and limitations of this approach. Although the available reports are limited, most of which are single cases or case series including relatively small number of patients, we try to demonstrate that TOA still deserves a high consideration and that, in some cases, it can be considered superior to EEA.