Transoral-transpharyngeal approach to the upper cervical vertebrae.

The classical operative approaches to the cervical spine include the posterior one and the anterior exposure along the sternomastoid muscle. However, neither of these are helpful in exposing the upper cervical vertebrae, especially the odontoid process, atlas, and axis. We have used the transoral-transpharyngeal exposure for lesions of the odontoid process and upper (first to third) cervical vertebrae in six patients. The pathologic processes included rheumatoid disease and fracture of the cervical vertebrae, suspected tumor with compression of the spinal cord, basilar invagination, and compression of the medulla. In all six patients, the exposure was excellent, and postoperative morbidity was minimal. Tracheostomy was performed routinely in all these patients. In five patients, vertebral stabilization was performed as a secondary procedure a few days after the initial anterior decompressive surgery. The transoral-transpharyngeal approach appears to be relatively easy. It is associated with minimal complications and provides excellent exposure of the odontoid and upper cervical vertebrae for a microneurosurgical approach. Modifications of this approach include incision of the soft palate, excision of a portion of the hard palate, and, occasionally, transmandibular median labio-mandibulo-glossotomy (Trotter's) approach. Although the technique was described initially approximately 35 years ago, this neglected anatomic approach will facilitate cooperative efforts between head and neck surgeons and neurosurgeons.