An observation on risk of infection in treatment of craniovertebral junction disorders by transoral approach operation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Yu ,  AI Fuzhi , YIN Qingshui , XIA Hong , WU Zenghui , MA Xiangyang , WANG Jianhua

Department of Spinal Surgery, General Hospital of Southern Theatre Command of Chinese PLA, Guangzhou Guangdong, 510010, P.R.China;

Corresponding author：

AI Fuzhi, Email: spine2000@126.com

Keywords：

Craniovertebral junction; transoral approach; infection prevention

DOI：

10.7507/1002-1892.201911006

Video：

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Objective To study the changes of bacterial flora after a series of preoperative oral disinfection and the postoperative recovery of patients with craniovertebral junction disorders who were treated with transoral approach operations. And to provide a theoretical basis for the prevention of postoperative complications such as infection.Methods The clinical data of 20 cases with craniovertebral junction disorders and treated with transoral approach operations between October 2009 and May 2010 were analyzed. There were 8 males and 12 females, aged 2-66 years (median, 34.5 years). According to the classification of American Spinal Injury Association (ASIA), there were 4 cases of grade B, 8 of grade C, 6 of grade D, and 2 of grade E. The Japanese Orthopedic Association (JOA) score was 10.3±3.0. The mucosa samples of the posterior pharyngeal wall were sent for bacteria culture. These samples were collected by sterile cotton swabs at four crucial points including 3 days before operation/before gargling (T1), 3 days after continuous gargling by chlorhexidine acetate/after anesthesia intubation on the day of operation (T2), after intraoperative cleaning and washing of the mouth (T3), and after intraoperative iodophor immersion for 5-10 minutes (T4). The microflora was stained by means of smear and further counted after an investigation by microscope. The ASIA classification and the JOA scores were applied to evaluate the postoperative nerve function of the patients. A regular reexamination of cervical vertebra with X-ray film, CT, and MRI was conducted after operation to evaluate the reduction of atlantoaxial dislocation, internal fixation position, bone graft fusion, inflammatory lesion, and tumor resection in the craniovertebral junction.Results After a series of oral disinfection, the mucosa of the posterior pharyngeal wall of all the patients was in a sterile state, which was considered as type Ⅰ incision. All these 20 patients were treated with successful operations, without any intraoperative injury in vertebral artery and spinal cord, or any postoperative complications such as plate loosening, incision infection, or intracranial infection. All the patients were followed up 3-23 months, with an average of 5.15 months. The symptoms such as neck pain, limb numbness and weakness, neural symptoms, etc. were improved to different degrees after operation. The JOA score was improved to 13.4±1.9 at 3 months after operation, showing significant difference when compared with preoperative score (t=8.677, P=0.000); and the atlantoaxial joints had been fused. At last follow-up, the ASIA grades were improved when compared with those before operation. Conclusion It is safe and effective to cut the posterior pharyngeal muscle layer and implant internal fixation by means of transoral approach in the treatment of craniovertebral junction disorders.

Citation： ZHANG Yu, AI Fuzhi, YIN Qingshui, XIA Hong, WU Zenghui, MA Xiangyang, WANG Jianhua. An observation on risk of infection in treatment of craniovertebral junction disorders by transoral approach operation. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(6): 769-774. doi: 10.7507/1002-1892.201911006 Copy

1.	尹庆水, 刘景发, 夏虹, 等. 寰枢椎经口咽前路手术预防感染之经验. 中华医院感染学杂志, 2002, 12(11): 829-830.
2.	Tanaka I, Suzuki K, Tanaka E, et al. Investigation of normal bacterial flora in the upper respiratory tract. Acta Otolaryngol Suppl, 1996, 525: 44-50.
3.	Rózalska M, Józefowicz-Korczyńska M. Microflora of the posterior pharyngeal wall, larynx and postoperative wounds in patients after laryngectomy. Med Dosw Mikrobiol, 2001, 53(1): 63-70.
4.	Humphreys GJ, McBain AJ. Continuous culture of sessile human oropharyngeal microbiotas. J Med Microbiol, 2013, 62(Pt 6): 906-916.
5.	Lopez AJ, Scheer JK, Leibl KE, et al. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus, 2015, 38(4): E2.
6.	Shkarubo AN, Kuleshov AA, Chernov IV, et al. Transoral decompression and stabilization of the upper cervical segments of the spine using custom-made implants in various pathologic conditions of the craniovertebral junction. World Neurosurg, 2018, 109: e155-e163.
7.	Visocchi M, Signorelli F, Liao C, et al. Transoral versus transnasal approach for craniovertebral junction pathologies: never say never. World Neurosurg, 2018, 110: 592-603.
8.	Kandziora F, Kerschbaumer F, Starker M, et al. Biomechanical assessment of transoral plate fixation for atlantoaxial instability. Spine (Phila Pa 1976), 2000, 25(12): 1555-1561.
9.	Ai F, Yin Q, Wang Z, et al. Applied anatomy of transoral atlantoaxial reduction plate internal fixation. Spine (Phila Pa 1976), 2006, 31(2): 128-132.
10.	Wang J, Zhu C, Xia H. Management of unique basilar invagination combined with C1 prolapsing into the foramen magnum in children: report of 2 cases. World Neurosurg, 2019, 127: 92-96.
11.	Ai FZ, Yin QS, Xu DC, et al. Transoral atlantoaxial reduction plate internal fixation with transoral transpedicular or articular mass screw of C2 for the treatment of irreducible atlantoaxial dislocation: two case reports. Spine (Phila Pa 1976), 2011, 36(8): E556-562.
12.	Yang J, Ma X, Xia H, et al. Transoral anterior revision surgeries for basilar invagination with irreducible atlantoaxial dislocation after posterior decompression: a retrospective study of 30 cases. Eur Spine J, 2014, 23(5): 1099-1108.
13.	夏虹, 王建华, 吴增晖, 等. 术前判别寰枢椎解剖类型对上颈椎后路置钉策略的意义. 中国脊柱脊髓杂志, 2017, 27(1): 17-24.
14.	Zhou J, Lu YT, Lu FY. Combined transoral and endoscopic approach for cervical spine tumor resection. Medicine (Baltimore), 2019, 98(22): e15822.
15.	Wang C, Yan M, Zhou HT, et al. Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine (Phila Pa 1976), 2006, 31(11): E306-E313.
16.	Mouchaty H, Perrini P, Conti R, et al. Craniovertebral junction lesions: our experience with the transoral surgical approach. Eur Spine J, 2009, 18(Suppl 1): 13-19.
17.	Amelot A, Terrier LM, Lot G. Craniovertebral junction transoral approach: predictive factors of complications. World Neurosurg, 2018, 110: 568-574.
18.	Yee S. Transoral Robotic Surgery. AORN J, 2017, 105(1): 73-84.
19.	Lin X, Ai FZ, Yin QS, et al. Application of three-dimensional model in the management of irreducible atlanto-axial dislocation. Acta Orthop Traumatol Turc, 2014, 48(3): 298-302.
20.	Jackson RS, Schmalbach CE. New frontiers in surgical innovation. Otolaryngol Clin North Am, 2017, 50(4): 733-746.
21.	禚汉杰, 周英杰, 柴旭斌, 等. 超声骨刀在椎管内肿瘤切除椎管成形术中的应用. 中国修复重建外科杂志, 2019, 33(1): 61-65.
22.	张宇, 李柯柯, 艾福志, 等. 颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜瘤. 中国修复重建外科杂志, 2019, 33(12): 1480-1485.
23.	Brook I. Microbiology and treatment of brain abscess. J Clin Neurosci, 2017, 38: 8-12.

1. 尹庆水, 刘景发, 夏虹, 等. 寰枢椎经口咽前路手术预防感染之经验. 中华医院感染学杂志, 2002, 12(11): 829-830.
2. Tanaka I, Suzuki K, Tanaka E, et al. Investigation of normal bacterial flora in the upper respiratory tract. Acta Otolaryngol Suppl, 1996, 525: 44-50.
3. Rózalska M, Józefowicz-Korczyńska M. Microflora of the posterior pharyngeal wall, larynx and postoperative wounds in patients after laryngectomy. Med Dosw Mikrobiol, 2001, 53(1): 63-70.
4. Humphreys GJ, McBain AJ. Continuous culture of sessile human oropharyngeal microbiotas. J Med Microbiol, 2013, 62(Pt 6): 906-916.
5. Lopez AJ, Scheer JK, Leibl KE, et al. Anatomy and biomechanics of the craniovertebral junction. Neurosurg Focus, 2015, 38(4): E2.
6. Shkarubo AN, Kuleshov AA, Chernov IV, et al. Transoral decompression and stabilization of the upper cervical segments of the spine using custom-made implants in various pathologic conditions of the craniovertebral junction. World Neurosurg, 2018, 109: e155-e163.
7. Visocchi M, Signorelli F, Liao C, et al. Transoral versus transnasal approach for craniovertebral junction pathologies: never say never. World Neurosurg, 2018, 110: 592-603.
8. Kandziora F, Kerschbaumer F, Starker M, et al. Biomechanical assessment of transoral plate fixation for atlantoaxial instability. Spine (Phila Pa 1976), 2000, 25(12): 1555-1561.
9. Ai F, Yin Q, Wang Z, et al. Applied anatomy of transoral atlantoaxial reduction plate internal fixation. Spine (Phila Pa 1976), 2006, 31(2): 128-132.
10. Wang J, Zhu C, Xia H. Management of unique basilar invagination combined with C1 prolapsing into the foramen magnum in children: report of 2 cases. World Neurosurg, 2019, 127: 92-96.
11. Ai FZ, Yin QS, Xu DC, et al. Transoral atlantoaxial reduction plate internal fixation with transoral transpedicular or articular mass screw of C2 for the treatment of irreducible atlantoaxial dislocation: two case reports. Spine (Phila Pa 1976), 2011, 36(8): E556-562.
12. Yang J, Ma X, Xia H, et al. Transoral anterior revision surgeries for basilar invagination with irreducible atlantoaxial dislocation after posterior decompression: a retrospective study of 30 cases. Eur Spine J, 2014, 23(5): 1099-1108.
13. 夏虹, 王建华, 吴增晖, 等. 术前判别寰枢椎解剖类型对上颈椎后路置钉策略的意义. 中国脊柱脊髓杂志, 2017, 27(1): 17-24.
14. Zhou J, Lu YT, Lu FY. Combined transoral and endoscopic approach for cervical spine tumor resection. Medicine (Baltimore), 2019, 98(22): e15822.
15. Wang C, Yan M, Zhou HT, et al. Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine (Phila Pa 1976), 2006, 31(11): E306-E313.
16. Mouchaty H, Perrini P, Conti R, et al. Craniovertebral junction lesions: our experience with the transoral surgical approach. Eur Spine J, 2009, 18(Suppl 1): 13-19.
17. Amelot A, Terrier LM, Lot G. Craniovertebral junction transoral approach: predictive factors of complications. World Neurosurg, 2018, 110: 568-574.
18. Yee S. Transoral Robotic Surgery. AORN J, 2017, 105(1): 73-84.
19. Lin X, Ai FZ, Yin QS, et al. Application of three-dimensional model in the management of irreducible atlanto-axial dislocation. Acta Orthop Traumatol Turc, 2014, 48(3): 298-302.
20. Jackson RS, Schmalbach CE. New frontiers in surgical innovation. Otolaryngol Clin North Am, 2017, 50(4): 733-746.
21. 禚汉杰, 周英杰, 柴旭斌, 等. 超声骨刀在椎管内肿瘤切除椎管成形术中的应用. 中国修复重建外科杂志, 2019, 33(1): 61-65.
22. 张宇, 李柯柯, 艾福志, 等. 颈后入路手术治疗寰枢椎硬膜下髓外神经鞘膜瘤. 中国修复重建外科杂志, 2019, 33(12): 1480-1485.
23. Brook I. Microbiology and treatment of brain abscess. J Clin Neurosci, 2017, 38: 8-12.

Chinese Journal of Reparative and Reconstructive Surgery

An observation on risk of infection in treatment of craniovertebral junction disorders by transoral approach operation

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