|Year : 2019 | Volume
| Issue : 1 | Page : 92-98
The median labio-mandibulo-glossotomy approach to the upper cervical spine: A personal series and tips and pearls
K Venugopal Menon1, Hood Al Saqri2, Renjit Kumar2, Maruti Kambali3
1 Department of Orthopaedics, Sparsh Hospital, Bangalore, India
2 Department of Orthopaedics, Khoula Hospital, Mina Al Fahal, Muscat, Oman
3 Department of Orthopaedics, Sultan Qaboos Hospital, Salalah, Oman
|Date of Web Publication||11-Jan-2019|
Dr. K Venugopal Menon
Department of Orthopaedics, Sparsh Hospital, Tumkur Rd, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Wide exposure to the anterior part of the upper cervical spine is difficult due to anatomical constraints. The Labio-Mandibulo-Glossotomy (LMG) approach is considered a difficult approach with high morbidity. The objective of this study is to describe the authors experience with the approach and it's outcomes in six cases and offer tips and pearls to the surgical access. Methods: This is a retrospective review of a small series of six cases that were operated for upper cervical lesions by the LMG approach. Two had mandible fractures that needed fixation and in the others osteotomy of the mandible was performed. The patients were followed up for minimum two years or death (in malignancy). We specifically looked for cosmetic or functional problems related to osteotomy, glossotomy, and, hospital and ICU stay duration. Surgical access is described in detail. Results: The hospital stay was similar to other major spine trauma or tumour surgeries at our center (median 14 days) and mean ICU stay 2.8 days. There were no long-term issues related to the access. Several tips and tricks are offered to minimize intra and post-operative problems. Conclusions: The LMG approach, though apparently formidable, is quite a safe and simple procedure with few residual complications.
Keywords: Anterior cervical spine approaches, Labio-Mandibulo-Glossotomy approach, transoral-transpharyngeal approach, upper cervical spine approaches
|How to cite this article:|
Menon K V, Al Saqri H, Kumar R, Kambali M. The median labio-mandibulo-glossotomy approach to the upper cervical spine: A personal series and tips and pearls. Indian Spine J 2019;2:92-8
|How to cite this URL:|
Menon K V, Al Saqri H, Kumar R, Kambali M. The median labio-mandibulo-glossotomy approach to the upper cervical spine: A personal series and tips and pearls. Indian Spine J [serial online] 2019 [cited 2019 Jul 21];2:92-8. Available from: http://www.isjonline.com/text.asp?2019/2/1/92/249907
| Introduction|| |
The median labio-mandibulo-glossotomy (LMG) approach was originally described by Trotter in 1920 for lesions of the base of the tongue. Later, Hall et al. reinvented this approach for access to the upper cervical spine, and subsequently, Wood described it to approach the clivus region in the 1970s., Being an infrequently used approach, even large centers have limited numbers of cases demanding such extensile exposure to the anterior aspect of the upper cervical spine. Moreover, the current global trend towards minimal access surgery in all areas of surgical endeavor deplores the routine use of such extensive exposures. Nonetheless, there are still certain indications for the LMG approach, and it does have several advantages over the conventional approaches to the ventral side of the craniocervical spine (such as the transoral and the anterior retropharyngeal approaches). This paper describes our experience of six cases operated over the last decade utilizing this approach, and the authors' tips and tricks to perform this procedure safely and effectively.
| Patients and Methods|| |
Present series consists of six cases that were operated between 2004 and 2015 using the LMG approach. Two cases were of trauma to the upper cervical spine combined with mandible and orofacial injury, and four cases were tumours of the upper cervical spine. All the cases were operated by the senior author (KVM) in one of three centers (two in the Middle East and one in India). This study is a retrospective analysis of patient records along with imaging studies, clinical photographs, and technical modifications that we have evolved from our experience. No outcome measures were used. No ethics committee approval was mandated since informed consent was obtained from all the patients, and the data presented is retrospective and de-identified. The paper focuses on the description of the surgical approach along with tips and tricks of performing it safely. The authors also address the indications, advantages, disadvantages and the postoperative care of the approach.
The indications for the approach are lesions and pathologies at C0–C4 where extensive anterior exposure is indicated besides pathologies in the floor of the mouth and tongue. These include tumors, trauma, infections, degenerative, and rheumatoid pathologies of the craniocervical junction of the spine. The access can be modified to approach the clivus by splitting the soft palate in the midline though this has often lead to an increase in complication rate.
As a first stage, a tracheostomy was performed for anesthesia as well as immediate postoperative ventilatory care. This can be a percutaneous procedure or an open surgery (the authors prefer a systematically performed open procedure). Oral or nasal intubation interferes significantly with visualisation of the lesion and limits the operating space. In addition, postoperative swelling of the floor of the mouth can cause breathing difficulty, and tracheostomy for a few days is beneficial for ventilatory care.
The patient is positioned in a supine position. The head is fixed on the Mayfield head holder [Figure 1]. The oral cavity is rinsed with antiseptic mouthwash, and the skin is prepared and draped from the maxillae to the clavicles bilaterally. The skin incision is marked from the mucocutaneous junction of the lower lip to the hyoid bone. The skin and the lower lip are infiltrated with adrenaline solution (1:500,000) along the line of incision [Figure 2]. The same solution can also be used for the tongue along its superior and inferior surfaces where the incision is made. The skin incision from the lower lip to the hyoid bone is made first. The lower lip is then incised in the midline and both deepened to the bone. The vestibular mucosa is incised, and the periosteum is elevated at the mandibular symphysis medially to the mental nerve foramen laterally [Figure 3]. The space between the two central incisors on the gum, that is also previously infiltrated, is incised next and developed to the bone. Retention sutures are then placed on either side of the tongue to retract it upwards and outwards. The mandible is then osteotomized with a thin blade power saw. We do not recommend step-cut osteotomies and adhere to the central osteotomy. This modification obviates the need to sacrifice the central incisors that often happens with the step cuts. The cut bone surfaces are waxed. The undersurface of the tongue is first incised with a knife and carried through the muscle with electrocautery. The tongue incision is carried along the median raphe to the dorsum and posteriorly to the epiglottic vallecula [Figure 4]. The split surface of the tongue bleeds little since the incision is through largely avascular and aneural tissue., The mandible and the tongue halves are retracted laterally and held in place by the Crockard retractor system. This device, though originally designed for the transoral access, is eminently suitable for the LMG approach as well. A self-retaining Dingman retractor may be used instead. The posterior pharyngeal wall is infiltrated with adrenaline solution and incised along the midline. The mucosal flaps are reflected on either side to expose the C1–C3 vertebrae. The pharyngeal retractors provide additional exposure and allow for surgical resection of the lesion [Figure 5]. An operating microscope may be brought in at this stage to allow better visualization for the entire surgical team and also for magnification and illumination, although it has not been our practice to use it routinely. After excision of the infected or tumorous bone, it may be replaced with an appropriate expanding cage and reinforced with a plate. In this figure [Figure 6], the completed corpectomy and reconstruction of C2 are shown as an example of the achievement of wide exposure at a higher cervical level.
|Figure 1: The patient has been positioned supine in a Mayfield head-holding device. The tracheostomy anesthesia is given to the patient|
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|Figure 2: The upper half of the neck and lower half of the face including the mouth are draped in the surgical field. The skin and mucous membrane of the lip and tongue are infiltrated with 1:500,000 adrenaline solution|
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|Figure 3: After skin incision and mandible osteotomy held apart with self-retaining retractor. The tongue is held up and protracted out at this stage. The mucus membrane on the inferior surface of the tongue where the incision begins is visualized|
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|Figure 4: Line drawing of the exposed spine. Arrow No 1 depicts the split tongue retracted with sutures. Arrow 2 indicates the split lip and No 3 the split mandible. Arrows 4 and 5 points to the Uvula and the Epiglottis respectively|
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|Figure 5: Surgical microscope view into the field after removal of the C2 vertebral body lesion (white arrowhead). The tongue retractor (downward white arrow) and the pharyngeal wall retractors (diverging thin white arrows) of the Cloward's transoral retractor system are depicted|
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|Figure 6: White arrowhead shows the graft and plate reconstruction of the C2 completed. Note the two halves of the tongue and jaws retracted and the clear bloodless surgical field|
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For closure [Figure 7], the paraspinal musculature and prevertebral fascia are reapproximated with absorbable vicryl sutures. The posterior pharyngeal wall is also closed with continuous absorbable suture. Reconstruction of the dorsum of the tongue is started from posterior to anterior again with absorbable sutures in a continuous manner. The intrinsic lingual musculature is repaired next along the median raphae, followed by the ventral mucosa of the tongue. The mandibular osteotomy is repositioned and held temporarily by interdental wires across the lower incisors and pointed reduction clamps at the lower border of the mental bone. A 2.7-mm compression plate is applied along the anterior surface of the mandible and screwed in place taking care not to dissect laterally beyond the exit of the mental nerve. The ventral mucosa of the tongue and the floor of the mouth are brought together in a similar fashion and repaired next. The soft tissue of the lip, chin and mental region are closed in layers. The skin is closed preferably with subcuticular absorbable sutures.
|Figure 7: After completion of repair of the tongue, lip and mandible, and skin closure|
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Postoperative care is similar to all oral surgical procedures; strict oral hygiene with dilute hydrogen peroxide mouthwash alternating with povidone-iodine or chlorhexidine mouthwash, every 2–4 h. Dexamethasone 8 mg IV is given 8 hourly for the first 24 h to reduce laryngeal and floor of the mouth edema. We routinely maintain the tracheostomy for 24–48 h, and then remove it depending on the patient's comfort level. Nasogastric feeding is mandatory for the first 48–72 h, and oral feeds (starting with liquids) can be commenced thereafter depending on the recovery of the patient. Most patients are ready for discharge from the hospital between the 10th and 14th postoperative day. They will need to avoid hard foods for 3–6 weeks until the mandible osteotomy heals well.
| Case Reports|| |
A 35-year-old male sustained a fall from 15 meters height. He sustained extensive maxillofacial injuries that needed intubation and intensive care unit admission [Figure 8]. He also sustained multiple injuries including C2/C3 fracture dislocation [Figure 9]. After stabilizing him hemodynamically, he was operated through the LMG approach (through the mandibular fracture in this case). The C2–C3 dislocation was reduced after discectomy and iliac bone grafting, and plating was performed [Figure 10]. The mandible fracture was plated as described before. The tracheostomy and nasogastric tube were kept in place for 11 days due to his additional maxillofacial injuries that were treated surgically. He was discharged home after 2 weeks of surgery without any surgical site morbidity.
|Figure 8: Case 1: Preoperative three-dimensional computed tomography reconstruction of the first case described. Please note extensive faciomaxillary injuries|
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|Figure 9: Case 1: The T2-weighted magnetic resonance imaging scan of the same patient depicting Hangman's fracture of the C2 vertebra with C2–C3 subluxation|
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This case arguably might have been treated by posterior stabilization of the C2 fracture and anterior fixation of the mandible. However, given that he was already intubated and ventilated for his maxillofacial injuries and might have needed a tracheostomy anyway, it seemed an optimal case for resolving most injuries through the LMG approach.
A 38-year-old male presented with a history of neck pain and progressive quadriparesis of 5-month duration. On clinical examination, he had Grade 1/5 power in all four limbs. His imaging studies showed a destructive lesion in the C2 vertebral body that was compressing the spinal cord [Figure 11] and [Figure 12]. He underwent subtotal corpectomy of the C2 vertebra and stabilization through the LMG approach. In addition, posterior occipitocervical stabilization from C0 to C3 was performed in the same sitting [Figure 13]. His postoperative period was uneventful, and the tracheostomy was removed after 5 days of surgery. His neurological status recovered rapidly, and his histopathology was reported as metastatic paraganglioma. He was advised further treatment in the medical and radiation oncology services; however, he did not comply. At 18 months' follow-up, he was asymptomatic and was ambulant without support with muscle power of Grade 4/5 in all four limbs.
|Figure 12: Sagittal magnetic resonance image of the same case demonstrates C2 body tumor invading the posterior elements|
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|Figure 13: Postoperative image of the same case depicting resection and reconstruction of the C2 body with autograft and posterior occipitocervical instrumentation and fusion|
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The rationale for this approach in this case is self evident- to obtain maximum tumour clearance as well as neural decompression; alternate approaches such as the transoral and anterior retorpharyngeal approach would possibly achieve less with greater complications.
| Results|| |
The mean hospital stay in this series was 28.2 days. Four patients were discharged from inpatient care by 2 weeks; the two outliers in this series were due to the additional posterior surgery in case number 4 [Table 1] that developed superficial surgical site infection of the posterior surgical site and case number 5 who had significant preoperative neurological deficit and stayed on to complete his neuro rehabilitation regime. The stay in hospital was also determined by associated injuries and the need for medical and radiation oncology evaluation in the tumor cases.
|Table 1: Depicts the six cases operated through the labio-mandibulo-glossotomy approach|
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The mean intensive care unit (ICU) stay was 2.8 days though typically patients would stay for 2 days. One patient, who had severe craniomaxillofacial (CMF) injuries, was intubated and nursed in the ICU before and after the surgery due to his extensive facial injuries and surgery for these. This patient also needed blood transfusion for his hemodynamic instability. Typically, the surgery through the LMG approach itself does not need blood transfusions though the two cases with additional posterior access did have transfusions. This would also depend on the tumor vascularity in such cases.
The patients were followed up at 6 weeks, 3 months, 6 months, and yearly thereafter in the spine clinic. Oncology and CMF reviews were separate. The anterior surgical wounds healed well without infection or other complications. None of the patients complained about any cosmetic or functional impairment related to phonation or swallowing at 3 months' review [Figure 14] and [Figure 15]. One patient with metastatic malignancy expired at 4 months, another at 11 months, and the third at 24 months' postsurgery. The two trauma cases are fit and well till date. Case 2 described above is 18 months' postsurgery and is so far progressing well. He has Grade 4/5 power power in all muscle groups and is independently ambulant.
|Figure 14: Post operative outcome of case number 4 in the series. This image was taken 12 weeks after surgery and depicts the well healed lip and jaw|
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|Figure 15: Post operative outcome of case number 4 in the series. This image was taken 12 weeks after surgery and depicts the well healed tongue|
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| Discussion|| |
Anterior approach to the upper cervical spine has always been considered challenging. Several approaches have been described in literature but most have selective applications and are limited by anatomical structures posing either access morbidity or limited visibility for reconstruction purposes., Menezes and Foltz have collected one of the largest series of surgeries of the cranio-cervical junction; close to 700 patients. They describe the strategy for respiratory and nutritional support, antibiotic regime, pain management, and immobilization strategy for these cases that are quite similar to ours. However, these authors do not discuss the LMG approach. The anterior retropharyngeal (hypoglossal triangle) approach is the workhorse approach to this region but is plagued by access-related complications. Campbell et al., in a prospective study, have described 26.8% access-related complications in all anterior cervical surgeries. The upper cervical region is a conundrum of vessels, nerves, and the submandibular salivary glands.,,, Park et al. have described an alternate anterior approach avoiding the salivary gland and the neurovascular bundle to access the C2–C3 region ventrally. Watkins also describes the anterior, medial, and lateral approaches to the upper cervical spine though with limited accessibility that may not facilitate reconstructions in tumors and major trauma. The transoral approach is the procedure of choice for pathologies of the Dens and C1–C2 junction requiring limited access. However, the approach is limited by the mouth opening capacity of the patient and can at best offer a limited view of the pathology. Extensive dissection and instrumentation are difficult through the mouth and is also potentially complicated by higher infection rates. The transmastoid approach is essentially a unilateral approach to the C1–C2 facet joint and provides limited access with little scope for instrumentation. It is in this context that Nusrath et al. have called attention to the fact that in the endoscopic and robotic surgery era, the classic Trotter's approach may still have a role to play.
Typically, the LMG approach can be used for tumors [Figure 11], [Figure 12], [Figure 13], infections, and trauma of the upper cervical spine and cervicocranium and rheumatoid disease of this region when major reconstruction is envisaged. Not only is an extensive corpectomy envisaged but also reconstruction with cages and plate fixation extending from a level above to a level below is mandated in these situations. Despite the formidable and grotesque appearance of the approach, the results show that the surgical wound healing is excellent and the hospital stay is comparable to most tumor surgery and polytrauma cases. We have not had any major approach-related complications in this small series. Most series in literature are similarly small and do not report any access-related complications.,,,,,
There are many advantages to the LMG approach. It provides extensile anterior visibility from the clivus to C4 (C0–C4). The anatomy is easily discernable and amenable to dissection since it is completely avascular and aneural when one keeps to the midline and no vital structure is encountered during exposure. Postoperative healing is excellent with minimal residual disability. Tracheostomy is performed to provide an unobscured view of the posterior oropharynx, to provide a secure airway postoperatively, and to avoid complications secondary to significant lingual and oropharyngeal edema.
The disadvantages include that it is a radical and traumatic approach, needs tracheostomy anesthesia to be maintained postoperatively, needs tube feeds for 2–3 days, may need assistance of maxillofacial team if the surgeons are not familiar with mandible osteotomy, and fixation. These have prompted several surgeons to look for alternative methods of approaching this area., The glosstomy is seen by some authors as a limiting issue, and they have recommended a circumglossal approach after mandibulotomy. Nevertheless, this approach again exposes to injury the hypoglossal nerve and its accompanying vessels and the submandibular salivary glands and ducts. Malunions and nonunions of the mandible are known occur, and infection is a possibility. Some concern about the cosmetic impact of the approach has been expressed; however, this is not been well founded according to the present authors. Anterior pharyngeal wall necrosis is one of the dreaded complications of any of the transoral/transmandibular or transmastoid approaches. We have no experience with this problem; however, meticulous tissue dissection is advocated to prevent such disasters.
| Conclusions|| |
The LMG approach to the ventral aspect of the upper cervical spine is useful in selected cases when extensile exposure is mandated and is not associated with any major postoperative long-term access-related morbidity.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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