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Transoral removal of a fractured odontoid process
C L IN IC A L
REPO RTS
Transoral removal of a fractured odontoid process E ric P au l S h ab er, DDS R ic h a rd K. G ongloff, DMD B ruce A. Everett, MD S am J. P o idm ore, DDS
The transoral approach to the upper cervical spine was used with the cooperation of several specialists in a multidisciplinary effort to solve a complex problem.
patient sustained a cervical sprain and was wearing a cervical collar. The his tory also show ed excessive use of alcohol and an allergy to penicillin. The patient smoked m ore than two packages of cigarettes and drank more than a quart of gin daily.
c
P h ysica l exam in ation
pecialization w ithin the health professions has provided higher quality m edical and dental care. Specialization has also em phasized the advantage of a m ultidisciplinary approach w hen more complex m ed ical and surgical problem s are en countered. A ppropriate consultation is the problem -solving tool available to the specialist w hen such a prob lem arises. This report describes an instance w hen the oral and m axillo facial surgeon and the neurosurgeon com bined energies to solve a com plex problem efficaciously.
Report of case A 50-year-old w hite woman had a history of excessive use of alcohol and frequent traum atic episodes. On May 12,1975, the patient came to the emergency room of the Long Beach Veterans A dm inistration H ospital w ith severe pain in the left hip and inability to walk, as she had fallen approxim ately five hours earlier. The m edical history disclosed a cerebrovascular accident on the right side w ith residual left paresis and m ulti ple fractures of the long bones. Two m onths before the current adm ission, the
Physical exam ination disclosed a poorly developed, m alnourished patient who appeared m uch older than 50 years. Her blood pressure was 160/80 mm Hg; pulse, 80/min; and respirations, 20/min. There were m ultiple spider nevi and loss of skin turgor over the upper part of the thorax. No jaundice or other lesions were noticed. Exam ination of the head, eyes, ears, nose, and throat was noncontributory. The cervical collar was removed from the neck w hich was supple, nontender, and had a norm al range of motion. Results of exam ination of the heart and lungs were w ithin norm al limits; the abdom en was soft and nontender, w ith active bowel sounds. The liver was palpated as a firm, nodular, nontender mass approxim ately 5 cm below the right costal margin. Neurologic exam ination disclosed that th e cranial nerves II to XII were grossly intact, and deep tendon reflexes were functioning norm ally. The low er part of the left leg was 2 cm shorter than the right w ith internal rotation. Paresthesia was noticed over the left ulnar nerve. Results of laboratory tests show ed SMA-12 w ithin norm al limits. The SMA-6 disclosed sodium , 133 mEq/ liter; chloride, 79 mEq/liter; and blood urea nitrogen, 5 mg%. Carbon dioxide
and potassium were w ithin norm al lim its. The com plete blood cell and differen tial counts show ed red blood cells de creased to 3.55 m illion w ith hemoglobin, 12 gm/100 ml, and hem atocrit, 35%. Red blood ccll indexes were w ithin norm al limits, except for an elevation of the mean corpuscular volum e to 104 cu /x. The w hite blood cell and differential counts w ere w ithin norm al limits. Urinalysis show ed a specific gravity of 1.015, pH of 5.0, and a m icroscopic ex am ination show ed negative results for cells and casts. A radiograph of the chest disclosed no active disease; the electrocardiogram show ed sinus rhythm w ith occasional prem ature ventricular contractions. Radiographic exam ination of the left hip disclosed a com m inuted subtrochanteric-intratrochanteric frac ture (Boyd’s type III).
T rea tm en t Treatm ent consisted of rehydration dur ing the first 24 hours. On May 13, the pa tient was taken to the operating room w here an open reduction of the fracture of the left hip w ith internal fixation was performed. The postoperative course was uncom plicated, and the patient was ready for transfer to the departm ent of rehabilitation m edicine on the seventh postoperative day. Before the patient was transferred, radiographs of the left hip and cervical spine were obtained. The reduction of the fracture was adequate; however, films of the cervical spine show ed a fracture dislocation of C -l and C-2 and posterior displacem ent of the odontoid process against the spinal cord. On May 22, the patient was transferred JADA, V ol. 98, February 1979 ■ 229
C L IN IC A L
REPORTS
to the neurosurgery service w here cervi cal traction was placed w ith GardnerWells tongs and 5 lb of traction. During the next six weeks, traction was in creased to 10 lb w ith no im provem ent of the fracture dislocation show n on the radiographs. Therefore, on July 2, a pos terior bony fusion of C-l, C-2, and C-3 w as accom plished w ith a graft from the iliac crest. Traction was m aintained w ith Crutchfield tongs and 7V2 lb of pressure. T he postoperative course was uncom pli cated. Unfortunately, however, the odon toid process rem ained persistently u n stable. It w as believed that, because of the p atient’s history, removal of the dens was indicated to allay the risk of com pression of the cord. The transoral route was chosen for its direct access.1 At that tim e, consultation w ith th e oral and maxillofacial surgery departm ent was obtained.
Preoperative culture and sensitivity tests were obtained on the nasal, oral, and pharyngeal secretions to facilitate appropriate antibiotic coverage. Normal flora that were sensitive to erythromycin were found. On Aug 6, erythrom ycin (500 mg, every six hours) w as given; the next day, the patient w as taken to the operating room. A tracheostom y was performed. Access to the pharyngeal cavity w as ob tained w ith a M clvor m outh gag. V isual ization of the posterior pharyngeal wall, however, was obstructed by the soft pa late. A transpalatal suture placed through a 2-cm section of a no. 10 Red Robinson catheter w as used to reflect the soft palate superiorly into the naso pharynx, thereby gaining adequate visualization of the superior pharyngeal region (C-l through C-2 level). The su ture was secured around the columella. W ith use of a Zeiss microscope, an inci sion in th e m idline of the posterior pharyngeal wall was m ade, and th e an terior arch of the atlas and the body of the axis were exposed. A portion of th e an terior arch w as rem oved w ith a Hall drill to allow exposure of the displaced odon toid process. W ith Cloward bone
230 ■ JADA, V ol. 98, February 1979
punches, a Hall drill, and sharp curettes, the mobile segment of the dens was freed from the fibrous dural covering of the cord. The wound was irrigated with an tibiotic irrigant (bacitracin, neomycin sulfate, and polymixin-B sulfate) and was closed with interrupted no. 3-0 polyglycolic acid sutures. The mucosa was closed with a no. 3-0 polyglycolic acid continuous horizontal mattress su tures. The patient received nothing by mouth for the first five postoperative days dur ing which time fluids were administered intravenously, and the wound received constant oral antibiotic lavage. Edema was minimal. On the tenth postoperative day, the tracheostomy tube was removed, and the antibiotics were discontinued. The patient continued to improve and in the third postoperative week was trans ferred to a nursing care facility.
Discussion The transoral approach to the upper cervical spine is not a new proce d u re .2 Since the early days of m edicine before the era of antibiotic therapy, posterior or retropharyn geal abscesses have been success fully drained w ithout secondary in fection or sinus formation. Scoville and Sherm an 3 reported its use for the removal of the odontoid process in basilar im pression; Southwick and Robinson 4 and Mosberg and Lippm an 5 described the transoral treatm ent of lesions of the second cervical vertebra; Fang and O ng 2 re ported six cases of transoral reduc tion and fusion of atlantoaxial dislo cation.
Summary The indications for an anterior ap proach are lesions located predom i nantly in the body of the vertebra or
intervertebral disks. Among these are spondylolisthesis, tuberculosis of the spine, prolapsed interver tebral disks, neoplasms, spinal biop sies, correction of fixed spinal curves, fractures, and fracture dislo cations of the spine. Despite m any indications, this approach is rarely used, prim arily because of unfam iliarity w ith the surgical field, instrum entation, and oral microbiota. Use of appropriate disciplines and consultations en abled this patient to receive com prehensive treatm ent from a com m unity of health care specialists.
Dr. S h ab er is chief, d iv isio n o f o ra l an d m axillofacial su rg e ry service, a n d d ire c to r, m ax illo facial p a in u n it, V eterans A d m in is tra tio n M ed ic a l C enter, 4150 C lem en t S t, San F ran cisco , 94121. Dr. G ongloff is c h ie f, oral a n d m ax illo fa c ia l su rg e ry service, V eterans A d m in is tra tio n M edical C enter, Lom a L inda, C alif. Dr. E verett is in th e p riv a te p ra c tic e of n e u ro s u rg e ry in W h ittier, Calif. Dr. P o id m o re is chief, oral a n d m ax illo facial su rg e ry service, V eterans A d m in is tra tio n M edical C en ter, Long B each, C alif. A d d re ss re q u e sts fo r re p rin ts to Dr. Shaber. 1. A le x an d e r, E., Jr., a n d others. D islo ca tio n of th e a tla s o n th e axis. T h e v a lu e of e arly fu sio n of C -l, C-2, a n d C-3. J N eu ro su rg 15(4):353-371, 1958. 2. Fang, H .S. a n d O ng, G.B. D irect a n te rio r a p p ro a c h to th e u p p e r cervical sp in e. J B one Joint S u rg 44A :1588-1604, 1962. 3. Scoville, W.B., a n d S h e rm a n , I.J. P latybasia: re p o rt o f te n cases w ith c o m m e n ts o n fam ilial te n d e n cy , s p ec ia l d ia g n o stic sign, a n d e n d re s u lts of operatio n . A n n Surg 133:496-502, 1951. 4. S o uthw ick, W .O., a n d R ob in so n , R.A. S u rg ic a l a p p ro a c h e s to th e ve rte b ra l b o d ie s in th e cervical an d lu m b a r reg io n s. J B o n e Joint S u rg 39A (3):631-644, 1957. 5. M osberg, W .H., Jr., a n d L ip p m an , E.M. A n te rio r a p p ro a c h to th e cervical v erteb ral bo d ies. B ull Sch M ed U n iv M d 4 5 :1 0 -17,1960.
REPO RTS
Transoral removal of a fractured odontoid process E ric P au l S h ab er, DDS R ic h a rd K. G ongloff, DMD B ruce A. Everett, MD S am J. P o idm ore, DDS
The transoral approach to the upper cervical spine was used with the cooperation of several specialists in a multidisciplinary effort to solve a complex problem.
patient sustained a cervical sprain and was wearing a cervical collar. The his tory also show ed excessive use of alcohol and an allergy to penicillin. The patient smoked m ore than two packages of cigarettes and drank more than a quart of gin daily.
c
P h ysica l exam in ation
pecialization w ithin the health professions has provided higher quality m edical and dental care. Specialization has also em phasized the advantage of a m ultidisciplinary approach w hen more complex m ed ical and surgical problem s are en countered. A ppropriate consultation is the problem -solving tool available to the specialist w hen such a prob lem arises. This report describes an instance w hen the oral and m axillo facial surgeon and the neurosurgeon com bined energies to solve a com plex problem efficaciously.
Report of case A 50-year-old w hite woman had a history of excessive use of alcohol and frequent traum atic episodes. On May 12,1975, the patient came to the emergency room of the Long Beach Veterans A dm inistration H ospital w ith severe pain in the left hip and inability to walk, as she had fallen approxim ately five hours earlier. The m edical history disclosed a cerebrovascular accident on the right side w ith residual left paresis and m ulti ple fractures of the long bones. Two m onths before the current adm ission, the
Physical exam ination disclosed a poorly developed, m alnourished patient who appeared m uch older than 50 years. Her blood pressure was 160/80 mm Hg; pulse, 80/min; and respirations, 20/min. There were m ultiple spider nevi and loss of skin turgor over the upper part of the thorax. No jaundice or other lesions were noticed. Exam ination of the head, eyes, ears, nose, and throat was noncontributory. The cervical collar was removed from the neck w hich was supple, nontender, and had a norm al range of motion. Results of exam ination of the heart and lungs were w ithin norm al limits; the abdom en was soft and nontender, w ith active bowel sounds. The liver was palpated as a firm, nodular, nontender mass approxim ately 5 cm below the right costal margin. Neurologic exam ination disclosed that th e cranial nerves II to XII were grossly intact, and deep tendon reflexes were functioning norm ally. The low er part of the left leg was 2 cm shorter than the right w ith internal rotation. Paresthesia was noticed over the left ulnar nerve. Results of laboratory tests show ed SMA-12 w ithin norm al limits. The SMA-6 disclosed sodium , 133 mEq/ liter; chloride, 79 mEq/liter; and blood urea nitrogen, 5 mg%. Carbon dioxide
and potassium were w ithin norm al lim its. The com plete blood cell and differen tial counts show ed red blood cells de creased to 3.55 m illion w ith hemoglobin, 12 gm/100 ml, and hem atocrit, 35%. Red blood ccll indexes were w ithin norm al limits, except for an elevation of the mean corpuscular volum e to 104 cu /x. The w hite blood cell and differential counts w ere w ithin norm al limits. Urinalysis show ed a specific gravity of 1.015, pH of 5.0, and a m icroscopic ex am ination show ed negative results for cells and casts. A radiograph of the chest disclosed no active disease; the electrocardiogram show ed sinus rhythm w ith occasional prem ature ventricular contractions. Radiographic exam ination of the left hip disclosed a com m inuted subtrochanteric-intratrochanteric frac ture (Boyd’s type III).
T rea tm en t Treatm ent consisted of rehydration dur ing the first 24 hours. On May 13, the pa tient was taken to the operating room w here an open reduction of the fracture of the left hip w ith internal fixation was performed. The postoperative course was uncom plicated, and the patient was ready for transfer to the departm ent of rehabilitation m edicine on the seventh postoperative day. Before the patient was transferred, radiographs of the left hip and cervical spine were obtained. The reduction of the fracture was adequate; however, films of the cervical spine show ed a fracture dislocation of C -l and C-2 and posterior displacem ent of the odontoid process against the spinal cord. On May 22, the patient was transferred JADA, V ol. 98, February 1979 ■ 229
C L IN IC A L
REPORTS
to the neurosurgery service w here cervi cal traction was placed w ith GardnerWells tongs and 5 lb of traction. During the next six weeks, traction was in creased to 10 lb w ith no im provem ent of the fracture dislocation show n on the radiographs. Therefore, on July 2, a pos terior bony fusion of C-l, C-2, and C-3 w as accom plished w ith a graft from the iliac crest. Traction was m aintained w ith Crutchfield tongs and 7V2 lb of pressure. T he postoperative course was uncom pli cated. Unfortunately, however, the odon toid process rem ained persistently u n stable. It w as believed that, because of the p atient’s history, removal of the dens was indicated to allay the risk of com pression of the cord. The transoral route was chosen for its direct access.1 At that tim e, consultation w ith th e oral and maxillofacial surgery departm ent was obtained.
Preoperative culture and sensitivity tests were obtained on the nasal, oral, and pharyngeal secretions to facilitate appropriate antibiotic coverage. Normal flora that were sensitive to erythromycin were found. On Aug 6, erythrom ycin (500 mg, every six hours) w as given; the next day, the patient w as taken to the operating room. A tracheostom y was performed. Access to the pharyngeal cavity w as ob tained w ith a M clvor m outh gag. V isual ization of the posterior pharyngeal wall, however, was obstructed by the soft pa late. A transpalatal suture placed through a 2-cm section of a no. 10 Red Robinson catheter w as used to reflect the soft palate superiorly into the naso pharynx, thereby gaining adequate visualization of the superior pharyngeal region (C-l through C-2 level). The su ture was secured around the columella. W ith use of a Zeiss microscope, an inci sion in th e m idline of the posterior pharyngeal wall was m ade, and th e an terior arch of the atlas and the body of the axis were exposed. A portion of th e an terior arch w as rem oved w ith a Hall drill to allow exposure of the displaced odon toid process. W ith Cloward bone
230 ■ JADA, V ol. 98, February 1979
punches, a Hall drill, and sharp curettes, the mobile segment of the dens was freed from the fibrous dural covering of the cord. The wound was irrigated with an tibiotic irrigant (bacitracin, neomycin sulfate, and polymixin-B sulfate) and was closed with interrupted no. 3-0 polyglycolic acid sutures. The mucosa was closed with a no. 3-0 polyglycolic acid continuous horizontal mattress su tures. The patient received nothing by mouth for the first five postoperative days dur ing which time fluids were administered intravenously, and the wound received constant oral antibiotic lavage. Edema was minimal. On the tenth postoperative day, the tracheostomy tube was removed, and the antibiotics were discontinued. The patient continued to improve and in the third postoperative week was trans ferred to a nursing care facility.
Discussion The transoral approach to the upper cervical spine is not a new proce d u re .2 Since the early days of m edicine before the era of antibiotic therapy, posterior or retropharyn geal abscesses have been success fully drained w ithout secondary in fection or sinus formation. Scoville and Sherm an 3 reported its use for the removal of the odontoid process in basilar im pression; Southwick and Robinson 4 and Mosberg and Lippm an 5 described the transoral treatm ent of lesions of the second cervical vertebra; Fang and O ng 2 re ported six cases of transoral reduc tion and fusion of atlantoaxial dislo cation.
Summary The indications for an anterior ap proach are lesions located predom i nantly in the body of the vertebra or
intervertebral disks. Among these are spondylolisthesis, tuberculosis of the spine, prolapsed interver tebral disks, neoplasms, spinal biop sies, correction of fixed spinal curves, fractures, and fracture dislo cations of the spine. Despite m any indications, this approach is rarely used, prim arily because of unfam iliarity w ith the surgical field, instrum entation, and oral microbiota. Use of appropriate disciplines and consultations en abled this patient to receive com prehensive treatm ent from a com m unity of health care specialists.
Dr. S h ab er is chief, d iv isio n o f o ra l an d m axillofacial su rg e ry service, a n d d ire c to r, m ax illo facial p a in u n it, V eterans A d m in is tra tio n M ed ic a l C enter, 4150 C lem en t S t, San F ran cisco , 94121. Dr. G ongloff is c h ie f, oral a n d m ax illo fa c ia l su rg e ry service, V eterans A d m in is tra tio n M edical C enter, Lom a L inda, C alif. Dr. E verett is in th e p riv a te p ra c tic e of n e u ro s u rg e ry in W h ittier, Calif. Dr. P o id m o re is chief, oral a n d m ax illo facial su rg e ry service, V eterans A d m in is tra tio n M edical C en ter, Long B each, C alif. A d d re ss re q u e sts fo r re p rin ts to Dr. Shaber. 1. A le x an d e r, E., Jr., a n d others. D islo ca tio n of th e a tla s o n th e axis. T h e v a lu e of e arly fu sio n of C -l, C-2, a n d C-3. J N eu ro su rg 15(4):353-371, 1958. 2. Fang, H .S. a n d O ng, G.B. D irect a n te rio r a p p ro a c h to th e u p p e r cervical sp in e. J B one Joint S u rg 44A :1588-1604, 1962. 3. Scoville, W.B., a n d S h e rm a n , I.J. P latybasia: re p o rt o f te n cases w ith c o m m e n ts o n fam ilial te n d e n cy , s p ec ia l d ia g n o stic sign, a n d e n d re s u lts of operatio n . A n n Surg 133:496-502, 1951. 4. S o uthw ick, W .O., a n d R ob in so n , R.A. S u rg ic a l a p p ro a c h e s to th e ve rte b ra l b o d ie s in th e cervical an d lu m b a r reg io n s. J B o n e Joint S u rg 39A (3):631-644, 1957. 5. M osberg, W .H., Jr., a n d L ip p m an , E.M. A n te rio r a p p ro a c h to th e cervical v erteb ral bo d ies. B ull Sch M ed U n iv M d 4 5 :1 0 -17,1960.