Introduction: Feasibility of endoscopic transnasal odontoidectomy is dictated by anatomic variations of the location of the odontoid in relation to the nasopalatine line (NPL) and associated nasopalatine angle (NPA). We hypothesized a limited, dorsal transnasal hard palate resection would increase the NPA to allow for greater resection of the odontoid process for treatment of anterior craniocervical junction pathology.
Methods: Retrospective review of preoperative imaging of 119 patients treated for pathology of the craniocervical junction at our center over the past 8 years was performed to estimate the change of the NPA and increase in access to the C2 vertebral body if a transnasal approach was employed with a 5 mm distal hard palate resection. This was followed by a clinical review of 8 patients undergoing distal hard palate resection and odontoidectomy over the past 2 years at our institution. Change in NPA, rates of postoperative dysphagia, length of hospital stay, and rate of neurological decline were reviewed.
Results: A mean increase in NPA of 15.4° was noted with a hypothetical hard palate resection of 5 mm. This increased the potential caudal extent of resection by an average of 20%. Of the 8 patients in which hard palate resection was performed, no significant worsening of swallowing mechanics was noted on postoperative speech evaluation. One patient experienced worsening of neurological function postoperatively followed by early recovery. All patients were extubated immediately postoperatively without need for delayed reintubation. The average hospital stay was 5.4 days.
Conclusions: Resection of the posterior hard palate significantly increases the extent of resection that can be performed by transnasal odontoidectomy, possibly obviating the need for transoral resection in most ventral craniocervical pathology. The adjunctive procedure appears to be well tolerated in the sample of patients in which we treated.
Patient Care: This paper may provide evidence for a greater extent of use of transnasal approaches to the craniocervical junction.
Learning Objectives: By the conclusion of the session, participant should be able to 1) identify the limiting parameters to transnasal odontoidectomy, 2) consider modifying factors for these parameters, 3) and consider adjunctive procedures to maximize resection extent