Submandibular approach for single-stage craniovertebral junction ventral decompression and stabilization: a preliminary cadaveric study of technical feasibility.

BACKGROUND: The craniovertebral junction (CVJ) may be affected by several diseases. It is an anatomically complex region, involving osteo-ligamentous, vascular and nervous structures, which makes surgeries challenging. In case of ventral compression an anterior approach is preferable, although a posterior fixation is often required. Anterior trans-mucosal approaches are associated with high rates of complications. However, decompression and fixation using retropharyngeal (RF) extra-mucosal approaches may result challenging.

OBJECTIVE: To investigate the feasibility of a single stage, anterior extra-mucosal submandibular (SM) approach modification to the CVJ for simultaneous decompression and stabilization.

MATERIALS AND METHODS: This is a preliminary cadaveric feasibility study on 2 injected specimens. Submandibular approach variation with a short "boomerang" incision, microsurgical decompression of the ventral CVJ and a new hybrid construct for an anterior atlanto-axial stabilization were investigated. The surgical approach, the decompression and the instrumentation technique have been described. In addition, intra-procedural images and x-rays, and post-procedural CT scan images were collected. Furthermore, surgical exposure, working corridors and angles, and decompression grade were measured.

RESULTS: SM approach provides a wide exposure of ventral CVJ, and the possibility for instrumentation and decompression by removing the anterior arch of c1 and the odontoid process.

CONCLUSION: A single stage anterior extra-mucosal SM approach for decompression and stabilization of CVJ is feasible and could result in shorter surgical duration avoiding both trans-mucosal and prone position related complications, although specific related risks exist. Mechanical investigations of this hybrid system and in-vivo studies are needed to confirm our results.