1. Endoscopic trans-oral management of fixed Atlanto-Axial dislocation
Y R Yadav, Vijay Parihar, Shailendra Ratre, Yatin Kher
Department of Neurosurgery
NSCB (Government) Medical College Jabalpur MP India
Recipient of Charak award (IMA MP state 2011)
Chairman fellowship program of one week brain and spine endoscopic training
Executive member of Neurological surgeons society of India
E mail
Web site
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2. Introduction:
Although most of the CVJ anomaly can be managed by posterior approach and a number of other surgical procedures.
Transoral-transpharyngeal approach is the direct surgical approach in selected patients.

3. The options available for treatment of Irreducible Atlanto-axial Dislocation (IAAD) with or without basilar invagination are:
Posterior only: Facet joint distraction, reduction and fusion
Anterior only: Release, reduction and fusion, decompression and fusion.
Anterior and posterior:
Anterior release and posterior fusion
Anterior decompression and posterior fusion

4. Flexion, extension X-rays
Facet joint anatomy
Reduction under GA
Irreducible AAD
Oblique C1-C2 joint
Tissue in between C1 arch and odontoid,
Contracted tissue anterior to C1 and C2,
Mal-union with fibrosis or callous
Injury to facet precludes facet manipulation.
No movement or less than 50% reduction at C1-C2.
Severe anterior posterior or cranial dislocation
Surgeon not expert for complicated posterior release and fusion.

5. Normal joints

6. Prof Jain et al

7. Abnormal vertically aligned joints

8. Pre Op Images

9. Irreducible AAD needs to be re-evaluated as the anomaly that looks ‘fixed’ or ‘irreducible’ on dynamic images can be surgically reduced in majority of cases (Atul Goel. Expert’s comment concerning Grand Rounds case entitled ‘‘Treatment strategies for severe C1C2 luxation due to congenital os odontoideum causing tetraplegia’’ (by C. M. Bach, D. Arbab and M. Thaler, doi: /s )
Using anterior or posterior release and reduction technique certain percentage does not reduce satisfactorily. (Srivastava SK, Aggarwal RA, Nemade PS, Bhosale SK. Single stage anterior release and posterior instrumented fusion for irreducible atlantoaxial dislocation with basilar invagination. Spine J Sep 24. pii: S (15) doi: /j.spinee [Epub ahead of print],
Less than 50% reduction (constitute 8%) required trans oral surgery in a large study. (Yin YH, Tong HY, Qiao GY, Yu XG. Posterior Reduction of Fixed Atlantoaxial Dislocation and Basilar Invagination by Atlantoaxial Facet Joint Release and Fixation: A Modified Technique With 174 Cases. Neurosurgery Sep 24. [Epub ahead of print]
About 30% out of total 904 patients required anterior approach (anterior release / excision and then posterior fusion. Wang S, Wang C, Yan M, Zhou H, Dang G. Novel surgical classification and treatment strategy for atlantoaxial dislocations. Spine (Phila Pa 1976) Oct 1;38(21):E doi: /BRS.0b013e3182a1e5e4.

10. Indication:
Irreducible AAD (Flexion, extension, abnormal vertical joint, severe dislocation and not reducing in GA).
Infection
Healed Trauma
Extradural tumor lying anterior.

11. Introduction:
Recently endoscopic (endonasal and trans oral) approaches to the craniovertebral junction are proposed.
Endoscopic trans oral excision of odontoid has been found to be most direct, effective and safe .

12. Endoscopic management of fixed Atlanto-Axial dislocation
Each approach has its own advantages and disadvantages.
Surgeons should be familiar with the various midline anterior approaches and their modifications to select the most appropriate approach for the given patient.

13. Endoscopic management of fixed Atlanto-Axial dislocation
Transoral approach is best suited for strictly midline extradural lesions that located from the inferior part of clivus to the C2 vertebral body.
Limitations:
Intra dural lesions
Lateral extension

14. Extent of exposure Inferior extent
Open mouth CT Scanogram or MR
The superior extent of the exposure:
Imaginary line joining lower teeth, hard palate toward CVJ.
Inferior extent
Imaginary line joining upper teeth, retracted tongue towards vertebrae.

15. Comparison of extend of exposure in trans oral and trans nasal odontoid excision

16. Operative technique: Supine position
Slight neck extension or neutral position
Cervical traction
Endotracheal tube is placed in left side corner.
Operative techniques are same as used in micro surgery.

17. Showing neck extension using sandbag under the shoulder and head ring.

18. 30-cm long, zero degree endoscope is placed in the center of mouth.
30 cm long scope is better than the 18-cm endoscope as the camera and light source cable are kept away from operative field.

19. Infant feeding tube B A
Infant feeding tube (arrow down) being used to retract uvula. (B) Uvula after the retraction.

20. Infiltration of posterior pharyngeal wall with lidocaine and adrenaline

21. Oro-pharynx packing to prevent aspiration Midline incision in posterior pharyngeal wall

22. Exposure after removal of soft tissue:
Anterior surfaces of the clivus ?
C1 anterior arch,
Odontoid and the body of C2
Laterally up to the C1-2 facet joints on either side

23. Decompression by excising the part of C2 above the Wackenheim's clival canal line (not only odontoid but body of C2)
Should not be any kinking of cord
Lateral decompression just beyond the lateral dural margins on either side.

26. Advantages of endoscopic trans oral excision:
Most direct, effective and safe.
Palatal spiting or prolonged retraction can be avoided.
Can be done when oral opening is as small as 1.0 cm as compared to at least 2.5 to 3 cms opening needed for microscopic excision.
Surgery can be done in any neck position (flexion or extension).
It gives good exposure from lower clivus to C2-3 disc space.

27. Endoscopic trans oral excision:
Limitations:
The risk of contamination by bacterial flora
Difficulties in closing duramater
Difficulty in early oral feeding.

28. Pillai et al compared the surgical working area in endoscopic and microscopic approach in cadaveric specimens:
Exposure over the posterior pharyngeal wall
Clivus exposure

29. Pillai et al examined 4 cadaveric specimens to compare the surgical working area and surgical freedom associated with an endoscopic and a microscopic approach
/ mm3
(P < 0.05)
/ mm3

30. Better clivus exposure
(9.5 +/- 0.7 mm)
(P < 0.05)
(2.0 +/- 0.4 mm)

31. Endoscopic trans oral excision:
Yadav et al, Mazhar Husain et al, Frempong-Boadu AK et al, and Lee et al found, trans oral endoscopic approach very effective and safe

32. Microscopic trans oral
Serial no
Endoscopic trans oral
Endoscopic endonasal
Microscopic trans oral
Advan-tage
Most direct minimally invasive technique
Effective and safe.
Palatal spiting or prolonged retraction can be avoided.
Can be done when oral opening is as small as 1.0 cm
Surgery can be done in any neck position (flexion or extension).
Good exposure from lower clivus to C2-3 disc space.
Minimally invasive technique.
Early Feeding
Palatal splitting not required
No tongue edema.
Can be done in any mouth opening
Can be done in the head immobilized or in a halo jacket.
Can be done in any neck position (flexion or extension).
Reduce infection risk
Most neurosur-geons are familiar to this procedure.

33. L I M T A O N s Serial no Endoscopic trans oral Endoscopic endonasal
Microscopic trans oral L I M T A O N s
Water tight dural closure is difficult.
There is a risk of infection as the operation is done through a contaminated route
There is narrow exposure .
Caudal exposure is limited by the nasal bones anteriorly and the hard palate posteriorly (nasopalatine line).
It is very difficult to assess structure inferior to this line .
Water tight closure is difficult.
Odontoid exposure is limited by the extent to mouth opening.
Superior exposure is limited by the location of the hard palate,
Mandible and base of the tongue limit the inferior exposure.
Palate need to be split specially in basilar invasion resulting in velopharyngeal insufficiency, palatal dehiscence,
Upper airway obstruction, ischemic necrosis of the tongue, swallowing difficulties, and meningitis could be other complications.
At least 2.5 to 3 cms opening is needed.

34. Practical tips: Remain in midline.
Procedure is indicated mainly for midline extradural pathology
Posterior fixation should be done after careful turning of the patient on traction.
Care should be taken during anesthetic intubation and extubation to avoid trauma to the atlantoaxial joint and cord
Extubation after proper assessment of airway.

35. Endoscopic management of fixed Atlanto-Axial dislocation
Conclusion:
Endoscopic Trans oral odontoidectomy is a direct minimally invasive technique which is safe and effective and is indicated in selected patients.
Improved exposure from clivus to C2 body.
Palatal splitting is not required even in basilar invasion.
Mouth opening of as small as 1.0 cm is enough.

36. Yadav YR; Shenoy R; Mukerji G; Sherekar S; Parihar V
Yadav YR; Shenoy R; Mukerji G; Sherekar S; Parihar V. Endoscopic transoral excision of odontoid process in irreducible atlanto-axial dislocation. In Progress in Clinical Neurosciences. 24. Banerji APD (ed). Byword Books Private Limited (1 Jan 2010). ISBN  X, ISBN13:
Yadav YR, Madhariya SN, Parihar VS, et al. 
Endoscopic Transoral Excision of Odontoid Process in Irreducible Atlantoaxial Dislocation: Our Experience of 34 Patients. [JOURNAL ARTICLE] J Neurol Surg A Cent Eur Neurosurg 2012 Oct 8.
Yadav YR, Parihar V, Ratre S. Endoscopic transoral Odontoidectomy. Video Atlas of Spine, Surgical Techniques. Publications Bentham eBooks
Yadav YR, Parihar V, Kher Y. Complication  avoidance and its management in endoscopic neurosurgery. Neurol India 2013;61:
Yadav YR, Parihar V, Ratre S, Iqbal M. Microneurosurgical skills training. J Neurol Surg A Cent Eur Neurosurg 2015 Apr 27. [Epub ahead of print] DOI: /s

38. Thankful to my teachers

39. Thankful to my colleagues