OUTCOME OF TRANSORAL SURGERY

Abstract

Orthopaedic pathology at the craniocervical junction (CCJ) is uncommon. This is a retrospective analysis of 37 patients who underwent transoral surgery. The indications were fixed rotatory subluxation in 12 patients, myelopathy following nonunion of the dens in 15, tuberculous abscesses in seven, congenital anomalies in two and chordoma in one. There were 29 males and the mean age was 24 years (3 to 57). Neurological deficit was present in 19 patients. Other symptoms included hoarseness, difficulty swallowing, neck pain and limitation of movement. All patients had a CT scan, MR angiography, MRI and dental consultation to exclude oral sepsis. After the transoral release, 29 patients underwent atlanto-axial fusion and two occipito-axial fusion. Following nasal intubation the skull was immobilised in tongs with 2-kg traction. A Jacques catheter was used to retract the uvula. The CCJ was located with an image intensifier and the posterior pharyngeal wall was infiltrated with 5 cc of local anaesthetic and Por-8. The atlanto-axial joints (AAJ) were released and in children with fixed rotatory subluxation the atlantodentate interval was cleared of fibrous tissue. The 15 patients with non-union of the dens underwent anterior release of the AAJs and the fracture site. The seven patients with abscesses had incision and drainage. Two patients with basilar invagination required excision of the dens. The chordoma was partially excised. One patient required a partial excision of the dens to reduce a posterior dislocation of the AAJ. A patient with chronic atlanto-axial subluxation owing to a type-I fracture required a partial excision of the superior part of atlas. Two patients with CSF leaks were treated successfully. There were cases of sepsis. Two patients developed occipital pressure sores. One patient died 5 days after surgery because of pulmonary embolus.

The transoral approach is safe and effective in treating pathology at the CCJ.