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Exposure of the upper cervical spine for spinal decompression by a mandible and tongue-splitting approach. Case report.

Anterior decompression and fusion of the upper cervical spine may be mandatory if anterior compression of the spinal cord develops because of cervical kyphosis. The lateral approach to the bodies of the second through the fourth cervical vertebrae described by Whitesides and Kelly was not possible in the case reported here. We used a mandible and tongue-splitting approach described by Kochen for surgery to the pharynx and the base of the tongue. Our patient was a boy who had progressive quadriparesis following a wide posterior laminectomy and suboccipital decompression. He had a gradually increasing kyphosis with its apex at the third cervical vertebra. In a review of 1 15 children treated for intraspinal tumors at The Children’s Hospital Medical Center in Boston, Matson reported that thirty patients had postoperative progressive kyphosis. The paresis observed in our patient, however, did not develop in any of them. Malgaigne and Osler, as well as many others descnibed incisions of retropharyngeal abscesses via the transoral route. This exposure of the atlanto-axial area was reported by Southwick and Robinson and by Fang and Ong. It is a narrow exposure, as De Andrade and Macnab emphasized. Whitesides’ lateral approach requires that the head be rotated away from the side to be operated on. The subhyoid laryngotomy first described by Malgaigne “has the advantage of giving excellent access with little injury to the surrounding tissues’ ‘ . The transthyroid laryngotomy first described by Desault is a caudad extension of the previous subhyoid exposure. These two approaches allow access to the second, third, and fourth cervical vertebrae. We could not use this type of exposure in our patient for three reasons. First, we needed a wide cxposure to allow safe decompression of the spinal cord. Second, our patient had a severe kyphosis that increased the distance between the hyoid bone and the retropharynx. Third, he could not extend or rotate the cervical spine. Kocher’s technique, developed for resection of cancer of the tongue, was to split the mandible and tongue in the midline, thereby giving a good exposure of the entire postenon pharyngeal wall. This was the incision we used.