To compare transoral and endoscopic transnasal anterior release without odontoidectomy and posterior reduction and fixation to treat irreducible atlantoaxial dislocation (IAAD).
From June 2006 to January 2017, 35 consecutive patients with IAAD underwent transoral (Tr-Oral group) or endoscopic transnasal (Tr-Nasal group) release and posterior fixation and fusion in our department. Clinical neurological recovery (Japanese Orthopedic Association (JOA) score) and radiological reduction parameters including atlantodontoid interval (ADI), space available for the cord (SAC) and cervicomedullary angle (CMA) were analyzed and compared. The operation duration, blood loss, length of intensive care unit (ICU)/hospital stay and complications were recorded.
All 35 patients (18 and 17 patients in the Tr-Oral and Tr-Nasal groups, respectively) were followed up for a mean of 36.4 months (range, 21–60 months). All patients achieved excellent anatomical reduction and clinical neurological recovery, with no significant differences between the two groups. The JOA score, ADI, SAC and CMA were not significantly different between the two groups at various postoperative points. Although the Tr-Oral group had shorter operation time and less blood loss than the Tr-Nasal group, the Tr-Nasal group tended to have a significantly shorter hospital/ICU stay, earlier extubation and earlier oral intake than the Tr-Oral group.
The transoral and endoscopic transnasal approaches can achieve equivalent release and reduction effects when treating IAAD. Compared to the transoral approach, the endoscopic transnasal route is less invasive with earlier extubation and oral intake, shorter hospital/ICU stays and lower medical costs, which is conducive to enhanced recovery after surgery.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
Xu JJ, Yin QS, Xia H et al (2013) New clinical classification system for atlantoaxial dislocation. Orthop 36:95–100. https://doi.org/10.3928/01477447-20121217-25
Xu ZW, Liu TJ, He BR et al (2015) Transoral anterior release, odontoid partial resection, and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoid fracture malunion. Eur Spine J 24:694–701. https://doi.org/10.1007/s00586-014-3747-3
Wang C, Yan M, Zhou HT et al (2006) Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine (Phila Pa 1976) 31:E306–E313. https://doi.org/10.1097/01.brs.0000217686.80327.e4
Mouchaty H, Perrini P, Conti R, Di Lorenzo N (2009) Craniovertebral junction lesions: Our experience with the transoral surgical approach. Eur Spine J 18:13–19. https://doi.org/10.1007/s00586-009-0988-7
Landeiro JA, Boechat S, Christoph DDH et al (2007) Transoral approach to the craniovertebral junction. Arq Neuropsiquiatr 65:1166–1171. https://doi.org/10.1590/S0004-282X2007000700014
DeMonte F, Diaz E, Callender D, Suk I (2001) Transmandibular, circumglossal, retropharyngeal approach for chordomas of the clivus and upper cervical spine. Tech Note Neurosurg Focus 10:1–5. https://doi.org/10.3171/foc.2001.10.3.11
Balasingam V, Anderson GJ, Gross ND et al (2006) Anatomical analysis of transoral surgical approaches to the clivus. J Neurosurg 105:301–308. https://doi.org/10.3171/jns.2006.105.2.301
Dasenbrock HH, Clarke MJ, Bydon A et al (2012) Endoscopic image-guided transcervical odontoidectomy. Neurosurgery 70:351–360. https://doi.org/10.1227/neu.0b013e318230e59a
Shriver MF, Kshettry VR, Sindwani R et al (2016) Transoral and transnasal odontoidectomy complications : a systematic review and meta-analysis. Clin Neurol Neurosurg 148:121–129. https://doi.org/10.1016/j.clineuro.2016.07.019
Kassam AB, Snyderman C, Gardner P et al (2005) The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 57:E213. https://doi.org/10.1227/01.NEU.0000163687.64774.E4
Gempt J, Lehmberg J, Grams AE et al (2011) Endoscopic transnasal resection of the odontoid: case series and clinical course. Eur Spine J 20:661–666. https://doi.org/10.1007/s00586-010-1629-x
Tang X, Wu X, Tan M et al (2019) Endoscopic transnasal anterior release and posterior reduction without odontoidectomy for irreducible atlantoaxial dislocation. J Orthop Surg Res 14:119. https://doi.org/10.1186/s13018-019-1167-0
Chibbaro S, Cebula H, Aldea S et al (2017) Endonasal endoscopic odontoidectomy in ventral diseases of the craniocervical junction: results of a multicenter experience. World Neurosurg 106:382–393. https://doi.org/10.1016/j.wneu.2017.06.148
Ma H, Dong L, Liu C et al (2016) Modified technique of transoral release in one-stage anterior release and posterior reduction for irreducible atlantoaxial dislocation. J Orthop Sci 21:7–12. https://doi.org/10.1016/j.jos.2015.10.012
Yen Y-S, Chang P-Y, Huang W-C et al (2014) Endoscopic transnasal odontoidectomy without resection of nasal turbinates: clinical outcomes of 13 patients. J Neurosurg Spine 21:929–937. https://doi.org/10.3171/2014.8.SPINE13504
Yu Y, Wang X, Zhang X et al (2013) Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations. Eur Spine J 22:1127–1136. https://doi.org/10.1007/s00586-012-2605-4
Tan M, Wang H, Wang Y et al (2003) Morphometric evaluation of screw fixation in atlas via posterior arch and lateral mass. Spine (Phila Pa 1976) 28:888–895. https://doi.org/10.1097/00007632-200305010-00010
Yin M, Wang H, Ma J et al (2019) Radiological characteristics and surgical outcome of patients with long ossification of the posterior longitudinal ligament resulting in ossified lesions in the upper cervical spine. World Neurosurg 127:e299–e310. https://doi.org/10.1016/j.wneu.2019.03.112
Shao J, Gao Y, Gao K, Yu Z (2019) Comparison of imaging parameters pre- and post- reductive procedure for atlantoaxial dislocation via posterior fixation using pedicle screw and rod: a cross-sectional study. BMC Musculoskelet Disord 20:451. https://doi.org/10.1186/s12891-019-2842-3
Buchowski JM, Liu G, Bunmaprasert T et al (2008) Anterior cervical fusion assessment: surgical exploration versus radiographic evaluation. Spine (Phila Pa 1976) 33:1185–1191. https://doi.org/10.1097/BRS.0b013e318171927c
Tubbs RS, Demerdash A, Rizk E et al (2016) Complications of transoral and transnasal odontoidectomy: a comprehensive review. Child’s Nerv Syst 32:55–59. https://doi.org/10.1007/s00381-015-2864-6
El-Sayed IH, Wu JC, Ames CP et al (2010) Combined transnasal and transoral endoscopic approaches to the craniovertebral junction. J Craniovertebr Junction Spine 1:44–48. https://doi.org/10.4103/0974-8237.65481
Sexton MA, Abcejo AS, Pasternak JJ (2017) Comparison of anesthetic management and outcomes in patients having either transnasal or transoral endoscopic odontoid process surgery. J Neurosurg Anesthesiol 00:1. https://doi.org/10.1097/ANA.0000000000000420
Goel A, Kulkarni AG, Sharma P (2005) Reduction of fixed atlantoaxial dislocation in 24 cases: technical note. J Neurosurg Spine 2:505–509. https://doi.org/10.3171/spi.2005.2.4.0505
Salunke P, Sahoo SK, Deepak AN et al (2015) Comprehensive drilling of the C1–2 facets to achieve direct posterior reduction in irreducible atlantoaxial dislocation. J Neurosurg Spine 23:294–302. https://doi.org/10.3171/2014.12.SPINE14310
Salunke P, Sahoo SK, Savardekar A et al (2015) Factors influencing feasibility of direct posterior reduction in irreducible traumatic atlantoaxial dislocation secondary to isolated odontoid fracture. Br J Neurosurg 29:513–519. https://doi.org/10.3109/02688697.2015.1019421
Hao D, He B, Zheng Y, Zhang Z (2016) Single-stage anterior release and sequential posterior fusion for irreducible atlantoaxial dislocation. Clin Spine Surg 29:E240–E245. https://doi.org/10.1097/BSD.0b013e31826be885
Srivastava SK, Aggarwal RA, Nemade PS, Bhosale SK (2016) Single-stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination. Spine J 16:1–9. https://doi.org/10.1016/j.spinee.2015.09.037
Seker A, Inoue K, Osawa S et al (2010) Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction. World Neurosurg 74:583–602. https://doi.org/10.1016/j.wneu.2010.06.033
Van Abel KM, Mallory GW, Kasperbauer JL et al (2014) Transnasal odontoid resection: is there an anatomic explanation for differing swallowing outcomes? Neurosurg Focus 37:E16. https://doi.org/10.3171/2014.7.FOCUS14338
Marda M, Pandia MP, Rath GP et al (2016) A comparative study of early and late extubation following transoral odontoidectomy and posterior fixation. J Anaesthesiol Clin Pharmacol 32:33–37. https://doi.org/10.4103/0970-9185.173344
Komotar RJ, Starke RM, Raper DMS et al (2012) Endoscopic endonasal versus open transcranial resection of anterior midline skull base meningiomas. World Neurosurg 77:713–724. https://doi.org/10.1016/j.wneu.2011.08.025
Goldschlager T, Härtl R, Greenfield JP et al (2015) The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding. J Neurosurg 122:511–518. https://doi.org/10.3171/2014.9.JNS14733
Yin Q, Xia H, Wu Z et al (2016) Surgical site infections following the transoral approach. Clin Spine Surg 29:E502–E508. https://doi.org/10.1097/BSD.0b013e3182aa68fc
This study was funded by Capital Characteristic Clinical project of Beijing Municipal Science & Technology Commission (http: //www. bjkw.gov.cn/n8785584/index.html) (Grant No. Z161100000516009).
Conflict of interest
The authors declare that they have no conflict of interest.
Our retrospective study was approved by the institutional ethics committee of the China-Japan Friendship Hospital.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
About this article
Cite this article
Dong, C., Yang, F., Wei, H. et al. Anterior release without odontoidectomy for irreducible atlantoaxial dislocation: transoral or endoscopic transnasal?. Eur Spine J 30, 507–516 (2021). https://doi.org/10.1007/s00586-020-06527-z
- Atlantoaxial dislocation
- Anterior release
- Endoscopic transnasal