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Pediatric transoral surgery: indications, complications, and long-term outcome
G F Tuite1, R Veres, H A Crockard
1Department of Surgical Neurology, The National Hospital for Neurology and Neurosurgery, London, England.
Insights
Transoral surgery in children for craniovertebral junction compression shows effectiveness but carries significant neurological risks. Long-term swallowing and speech difficulties may occur, especially after resections above the foramen magnum.
Area of Science:
- Neurosurgery
- Pediatric Surgery
- Spinal Surgery
Background:
- Transoral surgery applications in pediatric patients are limited despite expanded knowledge in adults.
- Craniovertebral junction (CVJ) pathologies require specialized surgical approaches.
Purpose of the Study:
- To assess the safety and efficacy of transoral surgery in pediatric patients with CVJ pathologies.
- To evaluate neurological outcomes and long-term functional deficits following transoral surgery in children.
Main Methods:
- Retrospective study of 27 pediatric patients (ages 3-17) undergoing transoral surgery between 1985-1994.
- Analysis of preoperative neurological deficits, perioperative changes, and long-term follow-up (average 5.7 years).
- Assessment of neurological recovery using Frankel grading and evaluation of swallowing and speech function.
Main Results:
- 89% of patients presented with significant neurological deficits; no patient with normal strength deteriorated post-surgery.
- Of 16 patients with preoperative motor deficits, 9 improved, 3 were unchanged, and 4 worsened.
- Mobile atlantoaxial subluxation increased risk of neurological morbidity; 5 patients experienced long-term swallowing/speech difficulties.
Conclusions:
- Transoral surgery can be effective for pediatric CVJ compression but carries substantial neurological risks.
- Patients with mobile atlantoaxial subluxation are particularly vulnerable to neurological injury.
- Long-term swallowing and speech impairments are associated with transoral surgery, especially for lesions above the foramen magnum.
Abstract:
Knowledge of the role and hazards of transoral surgery has expanded rapidly, but the application of this technique in children has been limited. To assess its usefulness, 27 pediatric patients who underwent transoral surgery between 1985 and 1994 were studied. Transoral surgery was performed for irreducible anterior neuraxial compression at the craniovertebral junction caused by basilar impression, atlantoaxial subluxation with pseudotumor, or chordoma. The patients ranged in age from 3 to 17 years. Symptomatic presentation varied widely, but 89% had significant neurological deficits before surgery. No patient with normal strength deteriorated after surgery. Of the 16 patients with a preoperative motor deficit, nine improved rapidly, three were unchanged, and four significantly worsened in the perioperative period. Those with mobile atlantoaxial subluxation were most vulnerable to surgically related neurological morbidity. Twenty-four patients were alive for long-term follow-up study (average 5.7 years, range 1-9.2 years). Of those with preoperative weakness, nine improved one Frankel grade, four remained the same, and one deteriorated from Frankel Grade D to C. Swallowing and speech worsened in five patients; this occurred only after resection of lesions above the foramen magnum (p<0.05) when rostral pharyngeal disruption resulted in velopharyngeal dysfunction. This study, unlike previous reviews of pediatric transoral operations, leads the authors to suggest that although transoral surgery can be effective, it also carries a significant risk of neurological injury in patients with symptomatic spinal cord compression and it is also associated with long-term swallowing and speech difficulties.