title: Combined pre- and retrovascular extraoral approach for tumors at lateral mass of the atlas.
abstract: METHODS
  a series of 9 patients surgically treated with a novel combined pre-and retrovascular extraoral approach to lateral mass of the atlas (LMA) is examined.
  
  
  OBJECTIVE
  to describe the efficacy of combined pre- and retrovascular extraoral approach in achieving a wide exposure and aggressive resection of tumors at the LMA.
  
  
  BACKGROUND
  the anatomic complexity and closeness to vital neurovascular structures raise technical difficulties in the surgical access to the LMA. Although various approaches, such as transoral approach, high anterior cervical approach, anterior lateral approach, and far lateral approach, have been reported in literature, wide exposure for the tumors at the LMA remains a unique challenge.
  
  
  METHODS
  for our experience in the surgical exposure of the upper cervical spine, we have developed a combined pre- and retrovascular extraoral approach to the atlas since 2001. Nine patients with neoplastic lesions at the LMA were surgically treated through this combined approach. Reconstruction of stability was achieved by a posterior occipitocervical fusion through a posterior approach under the same anesthesia.
  
  
  RESULTS
  this combined approach provided an excellent surgical field exposure to ensure the successful tumor resection while preventing the vertebral artery or nerve from injury. There was no operative mortality or severe morbidity in this series. Complications included 1 instance of transient dysphagia and 2 instances of transient trouble swallowing liquids. The symptoms of local pain and pharyngeal discomfort relieved, and patients suffering from spinal cord compression recovered well with 1 level of the Frankel scale when reevaluated 3 months after operation. With a follow-up period of 16 to 100 months, 1 patient with chondrosarcoma developed local recurrence at the 14th month of postoperation and died of respiratory and circulatory failure 39 months after surgery. No evidence of local recurrence was found in other patients.
  
  
  CONCLUSIONS
  the combined pre- and retrovascular extraoral approach provides an advantageous alternative to previous reported approaches. For selected cases with tumor lesions at the LMA, this combined approach offers more benefits, through which a wide exposure with well-protected vertebral artery favoring radical excision could be achieved without complications normally associated with transoral surgery.
authors.affiliation: Spine Center, Changzheng Hospital, The Second Military Medical University, Shanghai, China.
authors.forename: Xinghai
authors.initials: X
authors.lastname: Yang
authors.forename: Wengding
authors.initials: W
authors.lastname: Huang
authors.forename: Jianru
authors.initials: J
authors.lastname: Xiao
authors.forename: Zhipeng
authors.initials: Z
authors.lastname: Wu
authors.forename: Dapeng
authors.initials: D
authors.lastname: Feng
authors.forename: Wei
authors.initials: W
authors.lastname: Zheng
authors.forename: Huajiang
authors.initials: H
authors.lastname: Chen
authors.forename: Tielong
authors.initials: T
authors.lastname: Liu
authors.forename: Ning
authors.initials: N
authors.lastname: Xie
authors.forename: Wen
authors.initials: W
authors.lastname: Yuan
mesh_terms: D000328:Adult; D001270:Cervical Atlas / Q000098:blood supply / Q000473:pathology / Q000601:surgery*; D002574:Cervical Vertebrae / Q000098:blood supply / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods*; D013125:Spinal Neoplasms / Q000098:blood supply / Q000601:surgery*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D055815:Young Adult