Extended transoral approaches: Surgical technique and analysis

Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
Neurosurgery (Impact Factor: 3.62). 03/2010; 66(3 Suppl):126-34. DOI: 10.1227/01.NEU.0000366117.04095.EC
Source: PubMed


The transoral approach provides the most direct exposure to extradural lesions of the ventral craniovertebral junction. Lesions that extend beyond the exposure provided by the standard transoral approach require an extended transoral modification. The exposure can be expanded in the sagittal and axial planes by adding mandibulotomy, mandibuloglossotomy, palatotomy, and transmaxillary approaches to the standard transoral approach. Extended transoral approaches increase the surgical complexity and the risk of cosmetic and functional complications. Until recently, selection of an extended approach has been arbitrary and dependent on the surgeon's familiarity with the surgical approach.
We review the literature of extended transoral approaches and analyze the different modifications in terms of the technical aspects, added exposure, and complications.
Classic approaches and recently published morphometric studies that objectively document the gain in exposure provided by several modifications were analyzed and tabulated to outline the limits of exposure and risk of complications associated with the various modifications.
Transmaxillary approaches expand the exposure to include the sphenoid sinus and upper lateral clivus. To expand the exposure more inferiorly to C4-C5, mandibulotomy or mandibuloglossotomy can be applied. Mandibuloglossotomy increases the rostral exposure as well to the upper third of the clivus. Palatotomy increases rostral exposure without requiring a facial incision or perioperative tracheostomy, but is associated with a significant risk of velopharyngeal insufficiency.
Surgical decisions can be based on comprehensive preoperative evaluation of anatomy, pathology, and radiographic studies to maximize exposure while minimizing complications.

3 Reads

  • Journal of Neurosurgery 04/1968; 28(3):266-9. DOI:10.3171/jns.1968.28.3.0266 · 3.74 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: An optimal power and bandwidth allocation problem is considered for multi-rate frequency-division multiplexing (FDM) and frequency-division multiple-access (FDMA) over overloaded channels. We have derived the optimum frequency-division system that minimizes the total transmitted power subject to the QoS of users defined in terms of the transmission rates and the SINR requirements. The necessary and sufficient condition is found for the admissibility of the users, and the optimum power, bandwidth, transmit waveform, and receive waveform are found for each user. It is shown that the optimum frequency-division system performs exactly the same as the optimum CDMA system when all the users have the same transmission rate and channel gain. It is also shown that the optimum frequency-division system always outperforms the ETSC-minimizing code-division system when all the overloading users have the same transmission rate.
    Global Telecommunications Conference, 2004. GLOBECOM '04. IEEE; 01/2004
  • [Show abstract] [Hide abstract]
    ABSTRACT: Surgical exposure of lesions located along the ventral foramen magnum (FM) and clivus poses a unique set of challenges to neurosurgeons. Several approaches have been developed to access these regions with varying degrees of exposure and approach-related morbidity. To describe the microsurgical anatomy of the high anterior cervical approach to the clivus and foramen magnum, and describe novel skull base extensions of the approach. Eight adult cadaveric specimens were included in this study. The high anterior cervical approach includes a minimal anterior clivectomy and its lateral skull base extensions: the extended anterior far-lateral clivectomy and the inferior petrosectomy. The microsurgical anatomy and exposure of the various extensions of the approach were analyzed. In addition, the capability of complementary endoscopy was evaluated. With proper positioning, the minimal anterior clivectomy exposed the vertebrobasilar junction, proximal basilar artery, anteroinferior cerebellar arteries, and 6th cranial nerve. The lateral skull base extensions provided access to the anterior FM, mid-lower clivus, and petroclival region, up to the Meckel cave, contralateral to the side of the surgical approach. The high anterior cervical approach with skull base extensions is an alternative to the classic approaches to the ventral FM and mid-lower clivus. A minimal anterior clivectomy provides access to the midline mid-lower clivus. The addition of an extended anterior far-lateral clivectomy and an inferior petrosectomy extends the exposure to the anterior FM and cerebellopontine angle lying anterior to the cranial nerves. The approach is also ideally suited for endoscopic-assisted techniques.
    Neurosurgery 03/2011; 69(1 Suppl Operative):ons103-14; discussion ons115-6. DOI:10.1227/NEU.0b013e31821664a6 · 3.62 Impact Factor
Show more