Intraoperative magnetic resonance imaging and neuronavigation for transoral approaches to upper cervical pathology

Background: The transoral transpharyngeal surgical approach is a recognized technique for management of ventral lesions at the clivus and upper cervical spine. This report examines the use of neuronavigation and intraoperative magnetic resonance imaging as surgical adjuncts for lesions in this region. Methods: A retrospective review of patients undergoing transoral transpharyngeal surgery in the intraoperative magnetic resonance imaging (iMRI) unit from 1997 to present was performed. Preoperative demographic data, clinical history, physical examination, and imaging studies were reviewed. Data were collected on surgical approach, pathology, postoperative management, and adverse events. Results: Twenty patients underwent resection of ventral lesions at the craniovertebral junction through a transoral approach in the iMRI suite. Mean age at time of surgery was 50 years. A variety of pathologies were identified including neoplasms (n = 7), congenital anomalies (n = 7), and degenerative disease (n = 6). Intraoperative imaging and neuronavigation allowed for tailoring of the surgical approach in each of our patients: 11 patients underwent transoral surgery without a palatal split or mandibulotomy; 9 patients underwent a palatal split and of these, 5 required a mandibulotomy. Interdissection images allowed for immediate confirmation of gross total resection in all cases. Postoperatively, patients were managed in the intensive care unit for an average of 7 days. Ninety-two percent of patients had neurological improvement at a mean of 1.8 years of follow-up (range 0.4-6 years). Two patients died from tumor progression and one died from renal failure. Conclusions: Intraoperative MRI and neuronavigation are valuable adjuncts that allow selective surgical exposure and confirmation of surgical objectives within the narrow surgical corridor provided by a transoral approach to the craniovertebral junction.