Skip to main content

Advertisement

SpringerLink
Log in

Clival screw and plate fixation by the transoral approach for the craniovertebral junction: a CT-based feasibility study

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

A clivus screw and plate was invented and proved to strengthen the stability of the craniovertebral junction (CVJ). However, it is unclear whether the clivus screw and plate could be placed onto the CVJ by transoral approach. Therefore, the present study aims to evaluate the feasibility of clivus screw and plate placement by transoral approach and investigate its relative anatomic parameters.

Methods

A total of 80 normal adults (40 males/40 females) with an average age of 60.4 ± 11.6 years old were enrolled in this study. All parameters were measured in a supposed maximums mouth-opening status on computed tomography images, where the vertex of lower incisor was defined as Point A. The vertical intersection from Point A to extracranial clivus was defined as Point B, and its distance to the bottom of clivus was measured as B length. Point B was considered as ideal screw entry point. All the cases were divided into three types based on the location of Point B: above the top portion (Type 1), between the top and bottom portion (Type 2), and below the bottom portion (Type 3) of extracranial clivus. The B Length was defined as a minus value if the case belonged to Type 3. The anterior skull base angle, the angles between tangent of extracranial clivus and the lines from Point A to different parts of clivus, and distances between Point A and clivus and C1-3 vertebra were also measured.

Results

One in eighty cases (1.2%) belonged to Type 1 with a B Length of 32.12 mm. Most cases (61.3%) were Type 2 with a B Length of 8.7 mm, while Type 3’s was − 9.7 mm occupying for 37.5%. Significant statistic differences were found in anterior skull base angle between these three types (128.9°, 122.7° and 118.5° for Type 1, 2 and 3, respectively). The distances from Point A to the top and bottom portion of the clivus and the pharyngeal tubercle were 97.5, 96.0 and 96.8 mm, respectively. The angles between the tangent of the clivus and the lines from Point A to the above three structures were 75.7°, 92.3° and 84.0°, respectively. The distances from Point A to the middle point of anterior margin of C1 anterior tubercle, C2 vertebra and C3 vertebra were 79.1, 73.4 and 61.5 mm, respectively.

Conclusion

The clivus screw and plate placement could be accomplished with optimal screw angle by transoral approach in most of patients. Mandibular splitting would be needed in patients with greater anterior skull angle.

Graphic abstract

These slides can be retrieved under Electronic Supplementary Material.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Lee SC, Chen JF, Lee ST (2004) Complications of fixation to the occiput-anatomical and design implications. Br J Neurosurg 18:590–597

    Article  CAS  Google Scholar 

  2. Garrido BJ, Sasso RC (2012) Occipitocervical fusion. Orthop Clin North Am 43:1–9. https://doi.org/10.1016/j.ocl.2011.08.009

    Article  PubMed  Google Scholar 

  3. Menezes AH (2012) Craniocervical fusions in children. J Neurosurg Pediatr 9:573–585. https://doi.org/10.3171/2012.2.PEDS11371

    Article  PubMed  Google Scholar 

  4. Fard SA, Patel AS, Avila MJ, Sattarov KV, Walter CM, Skoch J, Baaj AA (2015) Anatomic considerations of the anterior upper cervical spine during decompression and instrumentation: a cadaveric based study. J Clin Neurosci 22:1810–1815. https://doi.org/10.1016/j.jocn.2015.05.012

    Article  PubMed  Google Scholar 

  5. Suchomel P, Buchvald P, Barsa P, Froehlich R, Choutka O, Krejzar Z, Sourkova P, Endrych L, Dzan L (2007) Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note. J Neurosurg Spine 6:611–618. https://doi.org/10.3171/spi.2007.6.6.17

    Article  PubMed  Google Scholar 

  6. Guppy KH, Chakrabarti I, Isaacs RS, Jun JH (2013) En bloc resection of a multilevel high-cervical chordoma involving C-2: new operative modalities: technical note. J Neurosurg Spine 19:232–242. https://doi.org/10.3171/2013.5.SPINE121039

    Article  PubMed  Google Scholar 

  7. Ji W, Wang XY, Xu HZ, Yang XD, Chi YL, Yang JS, Yan SF, Zheng JW, Chen ZX (2012) The anatomic study of clival screw fixation for the craniovertebral region. Eur Spine J 21:1483–1491. https://doi.org/10.1007/s00586-012-2151-0

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ji W, Kong GG, Zheng MH, Wang XY, Chen JT, Zhu QA (2015) Computed tomographic morphometric analysis of pediatric clival screw placement at the craniovertebral junction. Spine (Phila Pa 1976) 40:E259–E265. https://doi.org/10.1097/brs.0000000000000749

    Article  Google Scholar 

  9. Ji W, Tong J, Huang Z, Zheng M, Wu X, Chen J, Zhu Q (2015) A clivus plate fixation for reconstruction of ventral defect of the craniovertebral junction: a novel fixation device for craniovertebral instability. Eur Spine J 24:1658–1665. https://doi.org/10.1007/s00586-015-4025-8

    Article  PubMed  Google Scholar 

  10. Ji W, Tong J, Huang Z, Zheng M, Wu X, Chen J, Zhu Q (2016) Stabilization of the craniovertebral junction with clivus plate constructs: biomechanical comparison with conventional technique. World Neurosurg 94:42–49. https://doi.org/10.1016/j.wneu.2016.06.104

    Article  PubMed  Google Scholar 

  11. Dlouhy BJ, Dahdaleh NS, Menezes AH (2015) Evolution of transoral approaches, endoscopic endonasal approaches, and reduction strategies for treatment of craniovertebral junction pathology: a treatment algorithm update. Neurosurg Focus 38:E8. https://doi.org/10.3171/2015.1.FOCUS14837

    Article  PubMed  Google Scholar 

  12. Perrini P, Benedetto N, Di Lorenzo N (2014) Transoral approach to extradural non-neoplastic lesions of the craniovertebral junction. Acta Neurochir (Wien) 156:1231–1236. https://doi.org/10.1007/s00701-014-2057-1

    Article  Google Scholar 

  13. Li X, Jia C, Zhang Z (2017) The normal range of maximum mouth opening and its correlation with height or weight in the young adult Chinese population. J Dent Sci 12:56–59. https://doi.org/10.1016/j.jds.2016.09.002

    Article  PubMed  Google Scholar 

  14. Burke K, Benet A, Aghi MK, El-Sayed I (2014) Impact of platybasia and anatomic variance on surgical approaches to the craniovertebral junction. Laryngoscope 124:1760–1766. https://doi.org/10.1002/lary.24639

    Article  PubMed  Google Scholar 

  15. Wang Z, Xia H, Wu Z, Ai F, Xu J, Yin Q (2014) Detailed anatomy for the transoral approach to the craniovertebral junction: an exposure and safety study. J Neurol Surg B Skull Base 75:133–139. https://doi.org/10.1055/s-0033-1363170

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Drommer RB (1986) The history of the “Le Fort I osteotomy”. J Maxillofac Surg 14:119–122

    Article  CAS  Google Scholar 

  17. Martin H, Tollefsen HR, Gerold FP (1961) Median labiomandibular glossotomy. Trotter’s median (anterior) translingual pharyngotomy. Am J Surg 102:753–759

    Article  CAS  Google Scholar 

  18. Morales-Valero SF, Serchi E, Zoli M, Mazzatenta D, Van Gompel JJ (2015) Endoscopic endonasal approach for craniovertebral junction pathology: a review of the literature. Neurosurg Focus 38:E15. https://doi.org/10.3171/2015.1.FOCUS14831

    Article  PubMed  Google Scholar 

  19. Visocchi M, Iacopino DG, Signorelli F, Olivi A, Maugeri R (2018) Walk the line. The surgical highways to the craniovertebral junction in endoscopic approaches: a historical perspective. World Neurosurg 110:544–557. https://doi.org/10.1016/j.wneu.2017.06.125

    Article  PubMed  Google Scholar 

  20. Karam YR, Menezes AH, Traynelis VC (2010) Posterolateral approaches to the craniovertebral junction. Neurosurgery 66:135–140. https://doi.org/10.1227/01.NEU.0000365828.03949.D0

    Article  PubMed  Google Scholar 

  21. Singh H, Harrop J, Schiffmacher P, Rosen M, Evans J (2010) Ventral surgical approaches to craniovertebral junction chordomas. Neurosurgery 66:96–103. https://doi.org/10.1227/01.NEU.0000365855.12257.D1

    Article  PubMed  Google Scholar 

  22. Ji W, Liu X, Huang W, Huang Z, Chen J, Zhu Q, Wu Z (2016) Clival screw placement in patient with atlas assimilation: a CT-based feasibility study. Sci Rep 6:31648. https://doi.org/10.1038/srep31648

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Smoker WR (1994) Craniovertebral junction: normal anatomy, craniometry, and congenital anomalies. Radiographics 14:255–277. https://doi.org/10.1148/radiographics.14.2.8190952

    Article  CAS  PubMed  Google Scholar 

  24. Zawawi KH, Al-Badawi EA, Lobo SL, Melis M, Mehta NR (2003) An index for the measurement of normal maximum mouth opening. J Can Dent Assoc 69:737–741

    PubMed  Google Scholar 

  25. Yao K, Lin C, Hung C (2009) Maximum mouth opening of ethnic Chinese in Taiwan. J Dent Sci 4:40–44. https://doi.org/10.1016/S1991-7902(09)60007-6

    Article  Google Scholar 

  26. Ying QV, Bacic J, Abramowicz S, Sonis A (2013) Cross sectional: normal maximal incisal opening and associations with physical variables in children. Pediatr Dent 35:61–66

    PubMed  Google Scholar 

Download references

Acknowledgements

This study was sponsored by the National Natural Science Foundation of China (No. 81702192), the Outstanding Youths Development Scheme of Nanfang Hospital, Southern Medical University, China (No. 2017J008) and the President Foundation of Nanfang Hospital, Southern Medical University, China (No. 2016C021).

Author information

Authors and Affiliations

  1. Department of Spinal Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou, China

    Junyu Lin, Ganggang Kong, Xiaolin Xu, Qi Liu, Zucheng Huang, Qingan Zhu & Wei Ji

  2. Department of Orthopaedic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China

    Ganggang Kong

Authors
  1. Junyu Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ganggang Kong
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xiaolin Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Qi Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zucheng Huang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Qingan Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Wei Ji
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Qingan Zhu or Wei Ji.

Ethics declarations

Conflict of interest

The authors have no personal, financial, or institutional interest and ethical/legal conflicts involved in this article. The Manuscript submitted does not contain information about medical device(s)/drug(s).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 133 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lin, J., Kong, G., Xu, X. et al. Clival screw and plate fixation by the transoral approach for the craniovertebral junction: a CT-based feasibility study. Eur Spine J 28, 2342–2351 (2019). https://doi.org/10.1007/s00586-019-06039-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-019-06039-5

Keywords

Search

Navigation