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Vazquez S, Dominguez JF, Das A, Soldozy S, Kinon MD, Ragheb J, Hanft SJ, Komotar RJ, Morcos JJ. Treatment of Chiari malformations with craniovertebral junction anomalies: Where do we stand today? World Neurosurg X 2023; 20:100221. [PMID: 37456684 PMCID: PMC10338356 DOI: 10.1016/j.wnsx.2023.100221] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/14/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Chiari malformation type 1 (CM-1) is characterized by cerebellar tonsil herniation through the foramen magnum and can be associated with additional craniovertebral junction anomalies (CVJA). The pathophysiology and treatment for CM-1 with CVJA (CM-CVJA) is debated. Objective To evaluate the trends and outcomes of surgical interventions for patients with CM-CVJA. Methods A systematic review of the literature was performed to obtain articles describing surgical interventions for patients with CM-CVJA. Articles included were case series describing surgical approach; reviews were excluded. Variables evaluated included patient characteristics, approach, and postoperative outcomes. Results The initial query yielded 403 articles. Twelve articles, published between 1998-2020, met inclusion criteria. From these included articles, 449 patients underwent surgical interventions for CM-CVJA. The most common CVJAs included basilar invagination (BI) (338, 75.3%), atlantoaxial dislocation (68, 15.1%) odontoid process retroflexion (43, 9.6%), and medullary kink (36, 8.0%). Operations described included posterior fossa decompression (PFD), transoral (TO) decompression, and posterior arthrodesis with either occipitocervical fusion (OCF) or atlantoaxial fusion. Early studies described good results using combined ventral and posterior decompression. More recent articles described positive outcomes with PFD or posterior arthrodesis in combination or alone. Treatment failure was described in patients with PFD alone that later required posterior arthrodesis. Additionally, reports of treatment success with posterior arthrodesis without PFD was seen. Conclusion Patients with CM-CVJA appear to benefit from posterior arthrodesis with or without decompressive procedures. Further definition of the pathophysiology of craniocervical anomalies is warranted to identify patient selection criteria and ideal level of fixation.
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Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Merritt D. Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - John Ragheb
- Department of Neurosurgery, Brian Institute, Nicklaus Children's Hospital, Miami, FL, USA
| | - Simon J. Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Ricardo J. Komotar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jacques J. Morcos
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Yakdan SM, Greenberg JK, Krishnaney AA, Mroz TE, Spiessberger A. Transcervical, retropharyngeal odontoidectomy - Anatomical considerations. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:393-398. [PMID: 38268697 PMCID: PMC10805156 DOI: 10.4103/jcvjs.jcvjs_112_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/19/2023] [Indexed: 01/26/2024] Open
Abstract
Context Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications. Aims This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process. Methods and Surgical Technique To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach. Results The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas. Conclusions For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.
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Affiliation(s)
- Salim M. Yakdan
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University, St. Louis, MO, USA
| | - Ajit A. Krishnaney
- Center for Spine Health, Cleveland Clinic, Neurologic Institute, Cleveland, OH, USA
| | - Thomas E. Mroz
- Center for Spine Health, Cleveland Clinic, Neurologic Institute, Cleveland, OH, USA
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Joaquim AF, Evangelista Santos Barcelos AC, Daniel JW, Botelho RV. Chamberlain's Line Violation in Basilar Invagination Patients Compared with Normal Subjects: A Systematic Literature Review and Meta-Analysis. World Neurosurg 2023; 173:e364-e370. [PMID: 36822399 DOI: 10.1016/j.wneu.2023.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To compare the measured odontoid tip violation above Chamberlain's line described in the literature to diagnose basilar invagination (BI) and to establish the normal placement of the dens tip defining individuals without BI (normal subjects). METHODS A systematic literature review was performed to identify clinical or radiological studies that expressed the amount of odontoid violation above Chamberlain's line in patients with a BI diagnosis. In addition, a meta-analysis was performed to evaluate normal subjects' values of Chamberlain's line violation (CLV). RESULTS There were 23 studies included (13 radiological and 10 clinical). Most studies used computed tomography and/or magnetic resonance imaging. Eight different cutoff values were used to measure dislocated odontoid apexes above Chamberlain's line regardless of the radiological modality. The mean measured amount of CLV was 3.95 mm (median 5 mm; range, 0-9 mm). The meta-analysis included 8 studies (1233 patients) with a normal sample population with a mean normal CLV of -0.63 mm (below the line) (95% confidence interval [-0.8, 1.18 mm], random effects model). CONCLUSIONS Different values were found in the assessed studies used for CLV in BI diagnosis. This variability is especially important for type B BI, as type A BI has other craniocervical diagnostic parameters. Considering the results obtained in this meta-analysis, BI should be diagnosed in the case of any dens violation >1.18 mm.
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Affiliation(s)
- Andrei F Joaquim
- Department of Neurology, Discipline of Neurosurgery, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil.
| | | | - Jefferson Walter Daniel
- Division of Neurosurgery, Santa Casa de Sao Paulo - School of Medical Sciences, Sao Paulo, São Paulo, Brazil
| | - Ricardo Vieira Botelho
- Department of Neurosurgery, Hospital Servidor Público Estadual (IAMSPE-SP), São Paulo, São Paulo, Brazil
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Hou Z, Fan T, Fan W, Jian Q, Wang Y. Basilar invagination without atlantoaxial dislocation: treatment by correction of clivus canal angle with interfacet distraction and fixation. BMC Musculoskelet Disord 2022; 23:1138. [PMID: 36581884 PMCID: PMC9798678 DOI: 10.1186/s12891-022-06102-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND This study reports on the surgical technique used and clinical outcomes obtained during the treatment of basilar invagination (BI) without atlantoaxial dislocation (AAD) through the correction of the clivus canal angle (CCA) using interfacet distraction and fixation. METHODS Nineteen cases with BI without AAD treated by the correction of the clivus canal angle were retrospectively analyzed. Pre- and postoperative computed tomography scans and three-dimensional reconstruction views were obtained to measure the size of the CCA, pB-C2 distance, and degree of BI. Chiari malformation and syringomyelia were evaluated by magnetic resonance imaging (MRI). The clinical outcomes for all patients were measured using the Japanese Orthopedic Association (JOA) scale. The CCA was corrected by using interfacet distraction and fixation techniques. The Wilcoxon test was used to compare pre- and postoperative measurements. RESULTS All the patients were followed up for 24.95 ± 5.22 months (range 12-36 months); no patient suffered intraoperative nerve or vascular injury. Clinical symptoms improved in 17 patients (89.5%). The mean JOA score increased from 12.32 ± 1.89 to 14.37 ± 1.30 (Z = -3.655, P < 0.001). The mean CCA improved from 129.34 ± 8.52° preoperatively to 139.75 ± 8.86° postoperatively (Z = -3.824, P < 0.001). The mean pB-C2 decreased from 7.47 ± 2.21 to 5.68 ± 3.13 (Z = -3.060, P = 0.002). Syringomyelia was significantly reduced in 10 out of 13 patients by the first follow-up year. All patients achieved bony fusion. CONCLUSION Posterior interfacet distraction and fixation to correct the CCA is a feasible and effective method for treating BI without AAD.
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Affiliation(s)
- Zhe Hou
- grid.478016.c0000 0004 7664 6350Department of Neurosurgery, Beijing Luhe Hospital, Capital Medica University, Beijing, People’s Republic of China ,grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tao Fan
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wayne Fan
- grid.17091.3e0000 0001 2288 9830Faculty of Science, The University of British Columbia, Vancouver, BC Canada
| | - Qiang Jian
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yinqian Wang
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
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Palmisciano P, Al Fawares Y, Woodhouse C, Yang G, Xu A, d'Herbemont S, Hoang S, McGuire JL, Phillips KM, Cheng J, Forbes JA. The Impact of C1 Anterior Arch Preservation on Spine Stability After Odontoidectomy: Systematic Review and Meta-Analysis. World Neurosurg 2022; 167:165-175.e2. [PMID: 36049722 DOI: 10.1016/j.wneu.2022.08.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Odontoidectomy for symptomatic irreducible ventral brainstem compression at the craniovertebral junction may result in spine instability requiring subsequent instrumentation. There is no consensus on the importance of C1 anterior arch preservation in prevention of iatrogenic instability. We conducted a systematic review of the impact of C1 anterior arch preservation on postodontoidectomy spine stability. METHODS PubMed, Embase, Scopus, Web of Science, and Cochrane were searched following the PRISMA guidelines to include studies of patients undergoing odontoidectomy. Random-effect model meta-analyses were performed to compare spine stability between C1 anterior arch preservation versus removal and posttreatment outcomes between transoral approaches (TOAs) versus endoscopic endonasal approaches (EEAs). RESULTS We included 27 studies comprising 462 patients. The most common lesions were basilar invagination (73.3%) and degenerative arthritis (12.6%). Symptoms included myelopathy (72%) and neck pain (43.9%). Odontoidectomy was performed through TOA (56.1%) and EEA corridors (34.4%). The C1 anterior arch was preserved in 16.7% of cases. Postodontoidectomy stabilization was performed in 83.3% patients. Median follow-up was 27 months (range, 0.1-145). Rates of spine instability were significantly lower (P = 0.004) when the C1 anterior arch was preserved. Postoperative clinical improvement and pooled complications were reported in 78.8% and 12.6% of patients, respectively, with no significant differences between TOA and EEA (P = 0.892; P = 0.346). Patients undergoing EEA had significantly higher rates of intraoperative cerebrospinal fluid leaks (P = 0.002). CONCLUSIONS Odontoidectomy is safe and effective for treating craniovertebral junction lesions. Preservation of the C1 anterior arch seems to improve maintenance of spine stability. TOA and EEA show comparable outcomes and complication rates.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Yara Al Fawares
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Cody Woodhouse
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, USA
| | - George Yang
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alice Xu
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sophie d'Herbemont
- Department of Neurological Surgery, Centro Médico Nacional 20 de Noviembre, ISSSTE, Mexico City, Mexico
| | - Stanley Hoang
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Jennifer L McGuire
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Katie M Phillips
- Department of Otolaryngology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joseph Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jonathan A Forbes
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
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Rennert RC, Stephens ML, Palmer AW, Rodriguez A, Kazemi N, Morris TW, Pait TG, Day JD. Basilar decompression via a far lateral transcondylar approach: technical note. Acta Neurochir (Wien) 2022; 164:2563-2572. [PMID: 35867183 DOI: 10.1007/s00701-022-05312-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/05/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Treatments for symptomatic or unstable basilar invagination (BI) include posterior decompression, distraction/fusion, trans-nasal or trans-oral anterior decompression, and combined techniques, with the need for occipitocervical fusion based on the degree of craniocervical instability. Variations of the far lateral transcondylar approach are described in limited case series for BI, but have not been widely applied. METHODS A single-institution, retrospective review of consecutive patients undergoing a far lateral transcondylar approach for odontoidectomy (± resection of the inferior clivus) followed by occipitocervical fusion over a 6-year period (1/1/2016 to 12/31/2021) is performed. Detailed technical notes are combined with images from cadaveric dissections and patient surgeries to illustrate our technique using a lateral retroauricular incision. RESULTS Nine patients were identified (3 males, 6 females; mean age 40.2 ± 19.6 years). All patients had congenital or acquired BI causing neurologic deficits. There were no major neurologic or wound-healing complications. 9/9 patients (100%) experienced improvement in preoperative symptoms. CONCLUSIONS The far lateral transcondylar approach provides a direct corridor for ventral brainstem decompression in patients with symptomatic BI. A comprehensive knowledge of craniovertebral junction anatomy is critical to the safe performance of this surgery, especially when using a lateral retroauricular incision.
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Affiliation(s)
- Robert C Rennert
- Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA
| | - Marcus L Stephens
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - Angela W Palmer
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - Analiz Rodriguez
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - Noojan Kazemi
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - Thomas W Morris
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - T Glen Pait
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA
| | - J D Day
- Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA.
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Arslan A, Olguner SK, Acik V, İstemen İ, Arslan B, Ökten Aİ, Gezercan Y. Surgical Outcomes of C1-2 Posterior Stabilization in Patients With Chiari Malformation Type 1. Global Spine J 2022; 12:37-44. [PMID: 32787628 PMCID: PMC8965300 DOI: 10.1177/2192568220945293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY DESIGN Retrospective chart review. OBJECTIVES Chiari malformation (CM) is characterized by a downward displacement of the cerebellar tonsils through the foramen magnum. This tonsillar herniation may sometimes be accompanied by syringomyelia and/or basilar invagination (BI). In this study, we examined the surgical outcomes of patients by underwent C1-2 reduction + fixation (C1-2RF), which is a new method defined by Goel, in the literature. METHODS Between 2015 and 2018, 21 patients (mean age and duration of follow-up: 39 years and 20 months, respectively) with CM were treated with atlantoaxial fixation. We found syringomyelia in all patients and BI in 9 of them. In all cases, radiography, computed tomography, and magnetic resonance imaging were performed radiologically. C1-2RF was performed in all patients. Preoperative and postoperative clinical Japanese Orthopaedic Association scores were obtained. Syrinx size and cerebrospinal fluid flow rate were compared radiologically. RESULTS All patients were treated with C1-2RF. None of the patients underwent foramen magnum decompression or intervention for the syrinx. Occipital bone and subaxial spinal structures were not included in the fixation. In addition to significant clinical improvement, significant improvement in syringomyelia and cerebrospinal fluid flow rate was seen on the radiographs of all patients. CONCLUSIONS Although posterior fossa decompression and/or duraplasty is a common treatment modality in CM, we propose that the C1-2RF method described by Goel is a radiologically and clinically effective treatment method, whether or not BI and/or syringomyelia in CM are present. This article is the first article of central and axial atlantoaxial dislocation, except for Goel's writings in the literature.
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Affiliation(s)
- Ali Arslan
- Adana City Training and Research Hospital, Adana, Turkey,Ali Arslan, Department of Neurosurgery, Adana City Training and Research Hospital, Dr. Mithat Özsan Bulvarı Kışla Mah. 4522 Sok. No:1 Yüreğir, Adana, Turkey.
| | | | - Vedat Acik
- Adana City Training and Research Hospital, Adana, Turkey
| | - İsmail İstemen
- Adana City Training and Research Hospital, Adana, Turkey
| | - Barış Arslan
- Adana City Training and Research Hospital, Adana, Turkey
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Zileli M, Akıntürk N. Complications of occipitocervical fixation: retrospective review of 128 patients with 5-year mean follow-up. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 31:311-326. [PMID: 34725722 DOI: 10.1007/s00586-021-07037-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/18/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Occipitocervical fusion is necessary for many pathologies of the craniocervical junction. The anatomy of the region is unique, and fusion can cause significant morbidity. This retrospective review aims to investigate the complication rates and outcomes of occipitocervical fixation. MATERIAL AND METHODS This is a retrospective review of 128 patients with occipitocervical fixation operated between 1994 and 2020. The average follow-up is 63 months. RESULTS The indications of occipitocervical fixation were basilar invagination (53 patients; 41.4%), trauma (25 patients; 19.5%), tumor (23 patients; 18%), instability due to rheumatoid arthritis (13 patients; 10.2%), cervical deformity (7 patients; 5.5%) and os odontoideum (7 patients; 5.5%). There were six early postoperative (1st month) deaths. We observed complications in 67 patients (52%). Most common complication was implant-related (32%), followed by wound problems (23.4%), systemic and other complications (11.7%), neurologic complications (6.2%). Implants are removed in 31 patients (24%) for different reasons: deep wound infection (7), local pain and restriction of head movements (21), respiratory distress and swallowing problems (2), screw fracture and local pain (1). CONCLUSIONS Occipitocervical fixation has quite large number of complications and significantly restricts head movements. With the advent of our biomechanical concepts, indications should be limited, and shorter cervical fixations should be preferred. LEVEL OF EVIDENCE Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.
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Affiliation(s)
- Mehmet Zileli
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey.
| | - Nevhis Akıntürk
- Ege University Neurosurgery Department, Bornova, Izmir, Turkey
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Vidal CHF, Fonseca RB, Leimig B, Matias-Filho WF, Carneiro-Filho GS. Increase of the clivus-canal angle in patients with basilar invagination, without atlantoaxial displacement, treated with a simple maneuver of indirect decompression of the odontoid with the head clamp, during posterior occipitocervical arthrodesis. Surg Neurol Int 2021; 12:260. [PMID: 34221591 PMCID: PMC8247686 DOI: 10.25259/sni_284_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Basilar invagination (BI) can be defined as the insinuation of the content of the craniovertebral junction through the foramen magnum toward the posterior fossa. BI is a prevalent condition in Northeast Brazil. The present study describes the changes in the clivus-canal angle (CCA) in the postoperative period in patients with symptomatic BI operated by a posterior approach, using a simple technique of indirect reduction of the odontoid associated with occipitocervical fixation. Methods: Patients underwent radiological evaluations by magnetic resonance imaging in the pre and postoperative periods, where the height of the odontoid tip was measured in relation to the Chamberlain line and the ACC. All patients underwent posterior occipitocervical fixation with specific maneuvers of distraction and extension of the cephalic segment with the aid of a head clamp with three fixation points for anterior reduction of the odontoid. Results: Among the 8 patients evaluated in the series, all had increased ACC in the postoperative period, with a mean of 14.81 ± 1.54°, and statistically significant difference between the pre and postoperative periods (P < 0.05). Conclusion: The indirect surgical reduction of the odontoid process by a posterior approach through the manipulation (distraction-extension) of a “Mayfield” type of head clamp followed by occipitocervical fixation proved to be effective in improving the ACC, being easily reproducible.
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Affiliation(s)
| | - Ricardo Brandao Fonseca
- Department of Neurosurgery, Universidade Federal do Vale do São Francisco, Petrolina, Pernambuco, Brazil
| | - Bruno Leimig
- Department of Neurosurgery, Hospital Getulio Vargas, Recife, Pernambuco, Brazil
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Sai Kiran NA, Vidyasagar K, Sivaraju L, Raj V, Aryan S, Thakar S, Mohan D, Hegde AS. Outcome of Surgery for Congenital Craniovertebral Junction Anomalies with Atlantoaxial Dislocation/Basilar Invagination: A Retrospective Study of 94 Patients. World Neurosurg 2020; 146:e313-e322. [PMID: 33096283 DOI: 10.1016/j.wneu.2020.10.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the results of surgery for congenital craniovertebral junction (CVJ) anomalies with atlantoaxial dislocation (AAD)/basilar invagination (BI) and compare the results of transoral odontoidectomy and posterior fusion (TOO+PF) with only posterior fusion (PF) in patients with irreducible AAD/BI. METHODS AND RESULTS All 94 patients with congenital CVJ anomalies with AAD/BI operated on during the 3-year study period (June 2013-May 2016) were included. Of these patients, 55 had irreducible AAD/BI and the remaining 39 had reducible AAD/BI. TOO+PF was restricted to patients (34/94; 36.2%) with irreducible AAD/BI when reduction and realignment by intraoperative C1-C2 facet joint manipulation were considered technically difficult and risky. The remaining patients with irreducible AAD/BI and all the patients with reducible AAD/BI (60/94; 63.8%) were managed with only posterior fusion. Poor preoperative Nurick grade, preoperative dyspnea/lower cranial nerve deficits, and syringomyelia were associated with significantly higher incidence of postoperative pulmonary complications. Follow-up ≥3 months (final follow-up) was available for 87 patients. Good outcome (Nurick grade 0-3) at final follow-up was noted in 90% (45/50) of the patients with irreducible AAD/BI and 91.9% (34/37) of the patients with reducible AAD/BI. Preoperative poor Nurick grade (4-5) was the only factor associated with poor outcome. No significant difference in perioperative complications, outcome, and fusion was noted between patients who underwent TOO+PF or only PF for irreducible AAD/BI. CONCLUSIONS Many of the patients with congenital AAD/BI showed remarkable recovery after surgery. Preoperative poor Nurick grade (4-5) is associated with poor outcome. TOO+PF is a safe alternative treatment option for irreducible AAD/BI when only PF techniques are technically difficult/risky.
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Affiliation(s)
- Narayanam Anantha Sai Kiran
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Kanneganti Vidyasagar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India.
| | - Laxminadh Sivaraju
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Vivek Raj
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Saritha Aryan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Sumit Thakar
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Dilip Mohan
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
| | - Alangar S Hegde
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, India
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Duan W, Du Y, Qi T, Jiang B, Wang K, Liu Z, Guan J, Wang X, Wu H, Chen Z, Jian F. The Value and Limitation of Cervical Traction in the Evaluation of the Reducibility of Atlantoaxial Dislocation and Basilar Invagination Using the Intraoperative O-Arm. World Neurosurg 2019; 132:e324-e332. [PMID: 31476460 DOI: 10.1016/j.wneu.2019.08.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the value and limitation of cervical traction in the evaluation of the reducibility of atlantoaxial dislocation (AAD) and basilar invagination (BI) using the intraoperative O-arm. METHODS A total of 22 patients with hyperextensive, irreducible AAD were included. The cervical traction test under general anesthesia was performed, and the degree of reduction was evaluated using the O-arm before the operation started. The traction effects both vertically and horizontally were evaluated. All cases then underwent modified direct posterior reduction and fixation. Clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scale. Radiologic measurements included the anterior atlantodental interval, the distance of odontoid tip above Chamberlain line, and the clivus-canal angle. Magnetic resonance imaging signal changes, size of syringomyelia, and the space ventral to medulla also were used to evaluate the postoperative reduction result. RESULTS After the cervical traction test, 7 patients achieved incomplete reduction, 5 achieved only vertical reduction, 6 achieved only horizontal reduction, and 4 achieved complete reduction in both horizontal and vertical orientations as assessed by the O-arm. All patients underwent a direct reduction technique. The mean JOA score increased from 11.1 to 14.5. Complete reduction of AAD and BI were achieved in 19 patients (86.4%), with partial reduction achieved in 3 (13.6%). Sufficient cerebrospinal fluid space anterior to the medulla with improved JOA score was achieved in the 3 partially reduced patients. CONCLUSIONS With the innovations of direct posterior reduction techniques, cervical traction under anesthesia may not sufficiently predict the reducibility of BI and AAD. Cervical traction still plays an important role during the direct posterior reduction procedure.
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Affiliation(s)
- Wanru Duan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yueqi Du
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Tengfei Qi
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhenlei Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Guan
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xingwen Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zan Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Fengzeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
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12
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Zileli M. Chiari I Malformation: Is It the Result of an instability, and Should We Perform a Fusion Surgery? Neurospine 2019; 16:221-222. [PMID: 31261460 PMCID: PMC6603838 DOI: 10.14245/ns.19edi.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
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13
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Alalade AF, Ogando-Rivas E, Forbes J, Ottenhausen M, Uribe-Cardenas R, Hussain I, Nair P, Lehner K, Singh H, Kacker A, Anand VK, Hartl R, Baaj A, Schwartz TH, Greenfield JP. A Dual Approach for the Management of Complex Craniovertebral Junction Abnormalities: Endoscopic Endonasal Odontoidectomy and Posterior Decompression with Fusion. World Neurosurg X 2019; 2:100010. [PMID: 31218285 PMCID: PMC6580888 DOI: 10.1016/j.wnsx.2019.100010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ventral brainstem compression secondary to complex craniovertebral junction abnormality is an infrequent cause of neurologic deterioration in pediatric patients. However, in cases of symptomatic, irreducible ventral compression, 360° decompression of the brainstem supported by posterior stabilization may provide the best opportunity for improvement in symptoms. More recently, the endoscopic endonasal corridor has been proposed as an alternative method of odontoidectomy associated with less morbidity. We report the largest single case series of pediatric patients using this dual-intervention surgical technique. The purpose of this study was to evaluate the surgical outcomes of pediatric patients who underwent posterior occipitocervical decompression and instrumentation followed by endoscopic endonasal odontoidectomy performed to relieve neurologic impingement involving the ventral brainstem and craniocervical junction. METHODS Between January 2011 and February 2017, 7 patients underwent posterior instrumented fusion followed by endonasal endoscopic odontoidectomy at our unit. Standardized clinical and radiological parameters were assessed before and after surgery. A univariate analysis was performed to assess clinical and radiologic improvement after surgery. RESULTS A total of 14 operations were performed on 7 pediatric patients. One patient had Ehlers-Danlos syndrome, 1 patient had a Chiari 1 malformation, and the remaining 5 patients had Chiari 1.5 malformations. Average extubation day was postoperative day 0.9. Average day of initiation of postoperative feeds was postoperative day 1.0. CONCLUSIONS The combined endoscopic endonasal odontoidectomy and posterior decompression and fusion for complex craniovertebral compression is a safe and effective procedure that appears to be well tolerated in the pediatric population.
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Affiliation(s)
- Andrew F. Alalade
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neurosurgery, The Walton Centre, Liverpool, United Kingdom
| | - Elizabeth Ogando-Rivas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jonathan Forbes
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Malte Ottenhausen
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Rafael Uribe-Cardenas
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Prakash Nair
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Kurt Lehner
- Zucker School of Medicine, Hofstra-Northwell Health School of Medicine, New York, USA
| | - Harminder Singh
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Ashutosh Kacker
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Vijay K. Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Ali Baaj
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Theodore H. Schwartz
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, USA
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Complications in Craniovertebral Junction Instrumentation: Hardware Removal Can Be Associated with Long-Lasting Stability. Personal Experience. ACTA NEUROCHIRURGICA. SUPPLEMENT 2017. [PMID: 28120073 DOI: 10.1007/978-3-319-39546-3_29] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
BACKGROUND The causes of craniovertebral junction (CVJ) instabilities include trauma, rheumatological diseases, tumors, infections, congenital malformations, and degenerative disease processes; these complex pathologies often require CVJ instrumentation. Hardware complications were analyzed in a personal series of 48 treated patients. In light of the analysis of very unusual radiological and clinical findings, the authors tried to better investigate the related mechanisms and to reach possible useful conclusions. METHODS In a series of 48 patients who underwent CVJ instrumentation and fusion procedures in our Institution, we describe three cases of hardware failure, due to: (1) infection; (2) radio- and chemotherapy; and (3) incorrect surgical procedure. RESULTS 1. A stable bone CVJ fusion can occur after instrumentation removal for infection, since this removal can enhance bone fusion mechanisms; 2. Radio- and chemotherapy can cause hardware failure due to interference with local bone metabolism; 3. Although old-fashioned, wiring techniques still deserve consideration, mostly in CVJ re-do surgery after screwing technique failures; nevertheless, although the procedure is simple, safe, and effective, care must be taken in the preparation of the cranial holes in order to avoid sliding complications of the U-shaped rods. CONCLUSIONS CVJ instrumentations provide reasonably good mechanical stabilization with a high rate of bony fusion. Complications, such as dislocation or rupture of the fixation system, screw loosening, dural fistula, neural or vascular damage, and wound infection, are relatively infrequent. Knowledge and prevention of these complications is fundamental to improve surgical results and outcomes.
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15
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Shkarubo AN, Kuleshov AA, Chernov IV, Vetrile MS. Transoral Decompression and Anterior Stabilization of Atlantoaxial Joint in Patients with Basilar Impression and Chiari Malformation Type I: A Technical Report of 2 Clinical Cases. World Neurosurg 2017; 102:181-190. [DOI: 10.1016/j.wneu.2017.02.113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023]
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16
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The effect of posterior fossa decompression in adult Chiari malformation and basilar invagination: a systematic review and meta-analysis. Neurosurg Rev 2017; 41:311-321. [DOI: 10.1007/s10143-017-0857-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/15/2017] [Accepted: 04/13/2017] [Indexed: 02/06/2023]
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17
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He X, Meng Y, Zhang J, Hang Y, Yang J, Wu Q, Hao D. Bone Grafting of Atlantoaxial Joints and Occipitocervical or Atlantoaxial Fusion for the Reduction and Fixation of Basilar Invagination with Atlantoaxial Dislocation by a Posterior Approach: A Preliminary Study. World Neurosurg 2017; 100:230-235. [DOI: 10.1016/j.wneu.2016.12.131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 11/15/2022]
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18
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Wei G, Shi C, Wang Z, Xia H, Yin Q, Wu Z. Surgical Outcome and Prognostic Analysis of Transoral Atlantoaxial Reduction Plate System for Basilar Invagination: A Voxel-Based Morphometry Study. J Bone Joint Surg Am 2016; 98:1729-1734. [PMID: 27869624 DOI: 10.2106/jbjs.15.01151] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of a transoral atlantoaxial reduction plate (TARP) system is an effective surgical approach for the treatment of basilar invagination. With the aim of improving the therapeutic efficacy of the TARP operation, we conducted a voxel-based morphometric study to quantitatively investigate the descent of the odontoid process and craniocervical volume changes. METHODS We enrolled 20 patients with basilar invagination who underwent a TARP procedure. Craniocervical computed tomography (CT) scanning and a 3-dimensional (3-D) reconstruction of the craniocervical junction were performed. Craniocervical volumes and odontoid process descent distances were measured preoperatively and postoperatively. Individual neurological function was evaluated according to the Japanese Orthopaedic Association (JOA) scoring system for cervical disorders. Pearson correlation analysis was applied for statistical testing. RESULTS Surgical efficacy (the JOA-score improvement rate) was significantly associated with the craniocervical volume improvement rate, the odontoid descent distance, and the absolute craniocervical volume changes (p < 0.01 for all), with correlation coefficients (r) of 0.83, 0.80, and 0.61, respectively. No significant correlation was noted between surgical efficacy and age, symptom duration, preoperative neurological function, odontoid process displacement, or change in clivus-odontoid angle (p > 0.05). The craniocervical volume improvement rate was significantly associated with the odontoid descent distance (r = 0.8; p < 0.01), but it was not associated with the odontoid displacement or the change in the clivus-odontoid angle (p > 0.05). CONCLUSIONS We found that the odontoid descent distance predicted the craniocervical volume improvement rate following TARP procedures in patients with basilar invagination, and we believe that both can serve as predictors of surgical efficacy. We believe that planning the odontoid descent distance preoperatively may help to improve the efficacy of TARP operations. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Gejin Wei
- Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China.,No. 303 Hospital of People's Liberation Army, Nanning, People's Republic of China
| | - Chenglong Shi
- Southern Medical University, Guangzhou, People's Republic of China
| | - Zhiyun Wang
- Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China.,Institute of Traumatic Orthopaedics of People's Liberation Army, Guangzhou, People's Republic of China
| | - Hong Xia
- Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China .,Southern Medical University, Guangzhou, People's Republic of China.,Institute of Traumatic Orthopaedics of People's Liberation Army, Guangzhou, People's Republic of China
| | - Qingshui Yin
- Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China.,Institute of Traumatic Orthopaedics of People's Liberation Army, Guangzhou, People's Republic of China
| | - Zenghui Wu
- Department of Orthopedics, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, People's Republic of China.,Institute of Traumatic Orthopaedics of People's Liberation Army, Guangzhou, People's Republic of China
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19
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Maurer AJ, Duong NQ, Bonney PA, Cheema AA, Glenn CA, Safavi-Abbasi S, Stoner JB, Mapstone TB. Clinical significance of changes in pB-C2 distance in patients with Chiari Type I malformations following posterior fossa decompression: a single-institution experience. J Neurosurg Pediatr 2016; 17:336-42. [PMID: 26613273 PMCID: PMC4821417 DOI: 10.3171/2015.7.peds15261] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The coexistence of Chiari malformation Type I (CM-I) and ventral brainstem compression (VBSC) has been well documented, but the change in VBSC after posterior fossa decompression (PFD) has undergone little investigation. In this study the authors evaluated VBSC in patients with CM-I and determined the change in VBSC after PFD, correlating changes in VBSC with clinical status and the need for further intervention. METHODS Patients who underwent PFD for CM-I by the senior author from November 2005 to January 2013 with complete radiological records were included in the analysis. The following data were obtained: objective measure of VBSC (pB-C2 distance); relationship of odontoid to Chamberlain's, McGregor's, McRae's, and Wackenheim's lines; clival length; foramen magnum diameter; and basal angle. Statistical analyses were performed using paired t-tests and a mixed-effects ANOVA model. RESULTS Thirty-one patients were included in the analysis. The mean age of the cohort was 10.0 years. There was a small but statistically significant increase in pB-C2 postoperatively (0.5 mm, p < 0.0001, mixed-effects ANOVA). Eleven patients had postoperative pB-C2 values greater than 9 mm. The mean distance from the odontoid tip to Wackenheim's line did not change after PFD, signifying postoperative occipitocervical stability. No patients underwent transoral odontoidectomy or occipitocervical fusion. No patients experienced clinical deterioration after PFD. CONCLUSIONS The increase in pB-C2 in patients undergoing PFD may occur as a result of releasing the posterior vector on the ventral dura, allowing it to relax posteriorly. This increase appears to be well-tolerated, and a postoperative pB-C2 measurement of more than 9 mm in light of stable craniocervical metrics and a nonworsened clinical examination does not warrant further intervention.
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Affiliation(s)
- Adrian J. Maurer
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ngoc Quyen Duong
- Department of Biostatistics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Phillip A. Bonney
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ahmed A. Cheema
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sam Safavi-Abbasi
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Julie B. Stoner
- Department of Biostatistics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Timothy B. Mapstone
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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20
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Chang PY, Yen YS, Wu JC, Chang HK, Fay LY, Tu TH, Wu CL, Huang WC, Cheng H. The importance of atlantoaxial fixation after odontoidectomy. J Neurosurg Spine 2016; 24:300-308. [DOI: 10.3171/2015.5.spine141249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Although anterior odontoidectomy has been widely accepted as a procedure for decompression of the craniovertebral junction (CVJ), postoperative biomechanical instability has not been well addressed. There is a paucity of data on the necessity for and choice of fixation.
METHODS
The authors conducted a retrospective review of consecutively treated patients with basilar invagination who underwent anterior odontoidectomy and various types of posterior fixation. Posterior fixation included 1 of 3 kinds of constructs: occipitocervical (OC) fusion with atlantoaxial (AA) fixation, OC fusion without AA fixation, or AA-only (without OC) fixation. On the basis of the use or nonuse of AA fixation, these patients were assigned to either the AA group, in which the posterior fixation surgery involved both the atlas and axis simultaneously, regardless of whether the patient underwent OC fusion, or the non-AA group, in which the OC fusion construct spared the atlas, axis, or both. Clinical outcomes and neurological function were compared. Radiological results at each time point (i.e., before and after odontoidectomy and after fixation) were assessed by calculating the triangular area causing ventral indentation of the brainstem in the CVJ.
RESULTS
Data obtained in 14 consecutively treated patients with basilar invagination were analyzed in this series; the mean follow-up time was 5.75 years. The mean age was 53.58 years; there were 7 males and 7 females. The AA and non-AA groups consisted of 7 patients each. The demographic data of both groups were similar. Overall, there was significant improvement in neurological function after the operation (p = 0.03), and there were no differences in the postoperative Nurick grades between the 2 groups (p = 1.00). According to radiological measurements, significant decompression of the ventral brainstem was achieved stepwise in both groups by anterior odontoidectomy and posterior fixation; the mean ventral triangular area improved from 3.00 ± 0.86 cm2 to 2.08 ± 0.51 cm2 to 1.68 ± 0.59 cm2 (before and after odontoidectomy and after fixation, respectively; p < 0.05). The decompression gained by odontoidectomy (i.e., reduction of the ventral triangular area) was similar in the AA and non-AA groups (0.66 ± 0.42 cm2 vs 1.17 ± 1.42 cm2, respectively; p = 0.38). However, the decompression achieved by posterior fixation was significantly greater in the AA group than in the non-AA group (0.64 ± 0.39 cm2 vs 0.17 ± 0.16 cm2, respectively; p = 0.01).
CONCLUSIONS
Anterior odontoidectomy alone provides significant decompression at the CVJ. Adjuvant posterior fixation further enhances the extent of decompression after the odontoidectomy. Moreover, posterior fixation that involves AA fixation yields significantly more decompression of the ventral brainstem than OC fusion that spares AA fixation.
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Affiliation(s)
- Peng-Yuan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Yu-Shu Yen
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Jau-Ching Wu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Hsuan-Kan Chang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Li-Yu Fay
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 4Institute of Pharmacology, National Yang-Ming University; and
| | - Tsung-Hsi Tu
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
- 5Molecular Medicine Program, Taiwan International Graduate Program, Academia Sinica, Taipei, Taiwan
| | - Ching-Lan Wu
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
| | - Wen-Cheng Huang
- 1Department of Neurosurgery, Neurological Institute, and
- 3School of Medicine and
| | - Henrich Cheng
- 1Department of Neurosurgery, Neurological Institute, and
- 2Department of Radiology, Taipei Veterans General Hospital
- 3School of Medicine and
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Ma H, Dong L, Liu C, Yi P, Yang F, Tang X, Tan M. Modified technique of transoral release in one-stage anterior release and posterior reduction for irreducible atlantoaxial dislocation. J Orthop Sci 2016; 21:7-12. [PMID: 26686772 DOI: 10.1016/j.jos.2015.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 09/07/2015] [Accepted: 09/21/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND One-stage anterior release and posterior reduction is one of the most effective methods for irreducible atlantoaxial dislocation. However, the criteria of appropriate tissue release for successful posterior reduction is yet to be confirmed. Hence, an assistant technique using the transoral approach to verify satisfactory release is required. To evaluate the efficacy of the modified technique of transoral release for irreducible atlantoaxial dislocation (IAAD) with patients underwent one-stage anterior release and posterior reduction. METHODS Between January 2009 and June 2014, 23 consecutive patients diagnosed with IAAD free from bony union between the C1-C2 facet joints on reconstructive computed tomography scan underwent one-stage anterior release and posterior reduction after no response to 2 weeks of skull traction. During transoral release, an elevator was used as a lever repeatedly to confirm a 3-5 mm bilateral joint space between the lateral masses of the atlas and axis. The release was accomplished since a 3-5 mm joint space was achieved. After anterior release, posterior reduction and instrumented fusion were subsequently performed. RESULTS All patients were observed for an average of 18 (range 6-50) months. Nineteen of 23 patients achieved complete reduction while four had an incomplete reduction. Significant differences in pre- and postoperative JOA scores and cervicomedullary angle (CMA) were found. Twenty-one patients presenting with myelopathy had a JOA score of 12.9 at final follow-up, improved from 7.8 before surgery. The mean CMA improved to 143.5° postoperatively from 101.8° preoperatively. Bony fusion was confirmed in all cases under radiologic assessment during follow-up; there were no instrument failures. CONCLUSION The modified technique of transoral release provides appropriate criteria for anterior release, to achieve good posterior reduction without excessive tissue release or intraspinal manipulation, proving its value as an assistant technique in one-stage anterior release and posterior reduction for IAAD.
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Affiliation(s)
- Haoning Ma
- Graduate School of Peking Union Medical College, 100005, Beijing, China; Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China
| | - Liang Dong
- Graduate School of Peking Union Medical College, 100005, Beijing, China; Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China
| | - Chuyin Liu
- Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China; Graduate School of Beijing University of Chinese Medicine, 100029, Beijing, China
| | - Ping Yi
- Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China
| | - Feng Yang
- Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China
| | - Xiangsheng Tang
- Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China
| | - Mingsheng Tan
- Graduate School of Peking Union Medical College, 100005, Beijing, China; Department of Spine Surgery, China-Japan Friendship Hospital, 100029, Beijing, China.
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22
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Xu ZW, Liu TJ, He BR, Guo H, Zheng YH, Hao DJ. Transoral anterior release, odontoid partial resection, and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoid fracture malunion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015; 24:694-701. [PMID: 25563198 DOI: 10.1007/s00586-014-3747-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Zheng-wei Xu
- Department of Spinal Surgery, Xi'an Red Cross Hospital, No. 76 Nanguo Road, Xi'an, 710054, People's Republic of China
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Kim KH, Lee DB, Kim HJ, Riew KD, Kim BS, Chang BS, Lee CK, Yeom JS. Indirect decompression for a prior severe C1–2 dislocation causing progressive quadriparesis. J Neurosurg Spine 2014; 20:709-13. [DOI: 10.3171/2014.2.spine1352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Combined anterior and posterior surgery is frequently chosen for the treatment of prior, severe C1–2 dislocations that occurred during early childhood because of the difficulty in achieving reduction and satisfactory decompression. The authors treated a prior, severe C1–2 dislocation that was causing progressive quadriparesis. The patient was a 14-year-old boy who had suffered a C1–2 fracture-dislocation at 3 years of age and had been treated with a Minerva body jacket cast. The treatment involved posterior C1–2 segmental screw fixation, without direct bone decompression or additional surgery. Satisfactory neural decompression was achieved with the techniques used, and complete bone union was confirmed. The patient showed satisfactory neurological recovery at the 5-year follow-up assessment.
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Affiliation(s)
- Kyeong Hwan Kim
- 1Spine Center and Department of Orthopaedic Surgery, Hyundae General Hospital, Namyangju, Korea
| | - Dong Bong Lee
- 2Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam, Korea
| | - Ho-Joong Kim
- 2Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam, Korea
| | - K. Daniel Riew
- 3Department of Orthopaedic Surgery, Washington University in St. Louis, Missouri; and
| | - Boo Seop Kim
- 1Spine Center and Department of Orthopaedic Surgery, Hyundae General Hospital, Namyangju, Korea
| | - Bong-Soon Chang
- 4Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Choon-Ki Lee
- 4Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Jin S. Yeom
- 2Spine Center and Department of Orthopaedic Surgery, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Sungnam, Korea
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Occipitocervical fusion with relief of odontoid invagination: atlantoaxial distraction method using cylindrical titanium cage for basilar invagination—case report. Neurosurg Rev 2014; 37:519-24; discussion 524-5. [DOI: 10.1007/s10143-014-0531-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 12/10/2013] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
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Chandra PS, Kumar A, Chauhan A, Ansari A, Mishra NK, Sharma BS. Distraction, Compression, and Extension Reduction of Basilar Invagination and Atlantoaxial Dislocation. Neurosurgery 2013; 72:1040-53; discussion 1053. [DOI: 10.1227/neu.0b013e31828bf342] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The management of basilar invagination (BI) and atlantoaxial dislocation (AAD) is a challenge.
OBJECTIVE:
To describe a new innovative method to reduce BI and AAD through a single-stage posterior approach.
METHODS:
Thirty-five patients had irreducible BI and AAD (May 2010 to April 2012). In all patients, reduction of AAD and BI was achieved by using an innovative method of distraction and spacer placement, followed by compression and extension. A C1 lateral mass/C2 translaminar screw was performed in cases where the C1 arch was not assimilated, and occipito-C2 translaminar screw fixation was performed in cases where the C1 arch was assimilated.
RESULTS:
Thirty-two of 35 (94%) patients improved clinically and 2 patients had stable symptoms (mean Nurick postoperative score = 1.4; preoperative score = 3.7). AAD reduced completely in 33/35 patients and >50% in 2. BI improved significantly in all patients. Solid bone fusion was demonstrated in 24 patients with at least 1-year follow-up (range, 12-39 months; mean, 19.75 + 7.09 months). The duration of surgery was 80 to 190 minutes, and blood loss was 90 to 500 mL (mean, 170 ± 35 mL). There was 1 death because of cardiac etiology and 1 morbidity (wound infection).
CONCLUSION:
Distractive compressive extension and reduction of BI and AAD seems to be an effective and safe method of treatment. It is different from the earlier described techniques, because it is the first procedure that uses a spacer not, only for distraction, but also as a pivot to perform extension to reduce the AAD.
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Affiliation(s)
- P. Sarat Chandra
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Amandeep Kumar
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Avnish Chauhan
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Abuzar Ansari
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nalin K. Mishra
- Department of Neuroradiology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Bhawani S. Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Endoscopic transnasal odontoidectomy to treat basilar invagination with congenital osseous malformations. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2012; 22:1127-36. [PMID: 23224062 DOI: 10.1007/s00586-012-2605-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 10/30/2012] [Accepted: 11/24/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Transoral resection of the odontoid has been accepted as a standard procedure to decompress the cervicomedullary junction during the past several decades. The endoscopic transnasal odontoidectomy is emerging as a feasible surgical alternative to conventional microscopic transoral approach. In this article, we describe several operative nuances and pearls from our experience about this approach, which provided successful decompression. METHODS From September 2009 to April 2010, three consecutive patients with basilar invagination, of which the etiology was congenital osseous malformations, underwent endoscopic transnasal odontoidectomy. All patients presented with myelopathy. The last two cases also received occipitocervical fixation and bone fusion during the same surgical episode to ensure stability. RESULTS All the patients were extubated after recovery from anesthesia and allowed oral food intake the next day. Cerebrospinal fluid rhinorrhea was found in the second case and cured by continuous lumber drainage of cerebrospinal fluid. No infection was noted. The average follow-up time was more than 24 months. Remarkable neurological recovery was observed postoperative in all patients. CONCLUSION The endoscopic transnasal odontoidectomy is a feasible approach for anterior decompression of pathology at the cervicomedullary junction. The advantages over the standard transoral odontoidectomy include elimination of risk of tongue swelling and teeth damaging, improvement of visualization, alleviation of prolonged intubation, reduction of need for enteral tube feeding and less risk of affecting phonation. The minimally invasive access and faster recovery associated with this technique make it a valid alternative for decompression of the ventral side of the cervicomedullary junction.
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Bollo RJ, Riva-Cambrin J, Brockmeyer MM, Brockmeyer DL. Complex Chiari malformations in children: an analysis of preoperative risk factors for occipitocervical fusion. J Neurosurg Pediatr 2012; 10:134-41. [PMID: 22725652 DOI: 10.3171/2012.3.peds11340] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECT Chiari malformation Type I (CM-I) is a congenital anomaly often treated by decompressive surgery. Patients who fail to respond to standard surgical management often have complex anomalies of the craniovertebral junction and brainstem compression, requiring reduction and occipitocervical fusion. The authors hypothesized that a subgroup of "complex" patients defined by specific radiographic risk factors may have a higher rate of requiring occipitocervical fusion. METHODS A retrospective review was conducted of clinical and radiographic data in pediatric patients undergoing surgery for CM-I between 1995 and 2010. The following radiographic criteria were identified: scoliosis, syringomyelia, CM Type 1.5, medullary kinking, basilar invagination, tonsillar descent, craniocervical angulation (clivoaxial angle [CXA] < 125°), and ventral brainstem compression (pB-C2 ≥ 9 mm). A multivariate Cox regression analysis was used to determine the independent association between occipitocervical fusion and each variable. RESULTS Of the 206 patients who underwent CM decompression with or without occipitocervical fusion during the study period, 101 had preoperative imaging available for review and formed the study population. Mean age at surgery was 9.1 years, and mean follow-up was 2.3 years. Eighty-two patients underwent suboccipital decompression alone (mean age 8.7 years). Nineteen patients underwent occipitocervical fusion (mean age 11.1 years), either as part of the initial surgical procedure or in a delayed fashion. Factors demonstrating a significantly increased risk of requiring fusion were basilar invagination (HR 9.8, 95% CI 2.2-44.2), CM 1.5 (HR 14.7, 95% CI 1.8-122.5), and CXA < 125° (HR 3.9, 95% CI 1.2-12.6). CONCLUSIONS Patients presenting with basilar invagination, CM 1.5, and CXA < 125° are at increased risk of requiring an occipitocervical fusion procedure either as an adjunct to initial surgical decompression or in a delayed fashion. Patients and their families should be counseled in regard to these findings as part of a preoperative CM evaluation.
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Affiliation(s)
- Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113, USA
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Dasenbrock HH, Clarke MJ, Bydon A, Sciubba DM, Witham TF, Gokaslan ZL, Wolinsky JP. Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination. Neurosurgery 2012; 70:351-9; discussion 359-60. [PMID: 21826033 DOI: 10.1227/neu.0b013e318230e59a] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Ventral decompression with posterior stabilization is the preferred treatment for symptomatic irreducible basilar invagination. Endoscopic image-guided transcervical odontoidectomy (ETO) may allow for decompression with limited morbidity. OBJECTIVE To describe the perioperative outcomes of patients undergoing anterior decompression of basilar invagination with the use of ETO. METHODS Fifteen patients who had a follow-up of at least 16 months were retrospectively reviewed. Intraoperatively, the vertebral body of C2 was removed and the odontoid was resected in a "top-down" manner using endoscopic visualization and frameless stereotactic navigation. Posterior instrumented stabilization was subsequently performed. RESULTS The average (± standard deviation) age of the patients was 42.6 ± 24.5 (range, 11-72) years. Postoperative complications occurred in 6 patients, including a urinary tract infection (n = 2), upper airway swelling (n = 2), dysphagia (n = 2), gastrostomy tube placement (n = 1), and an asymptomatic pseudomeningocele (n = 1). No patients required a tracheostomy, had bacterial meningitis, or developed a venous thromboembolic event; only 1 patient was intubated for more than 48 hours postoperatively. With a mean follow-up of 41.9 ± 14.4 (range, 16-59) months, myelopathy improved in all patients and no patient experienced late neurological deterioration. The mean modified Japanese Orthopedic Association (JOA) score increased from 11.2 ± 4.2 to 15.9 ± 1.4 (P = .002). Patients with a diagnosis other than rheumatoid arthritis or who had a higher preoperative JOA score had a significantly better postoperative neurological recovery (P = .005). CONCLUSION ETO may be a valid treatment for patients with symptomatic irreducible basilar invagination that avoids some of the morbidity of transoral surgery and leads to long-term improvement in myelopathy.
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Surgical treatment of chronic C1-C2 dislocation with absence of odontoid process using C1 hooks with C2 pedicle screws: a case report and review of literature. Spine (Phila Pa 1976) 2011; 36:E1245-9. [PMID: 21358484 DOI: 10.1097/brs.0b013e318205620a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A case report. OBJECTIVE.: A rare case of chronic C1-C2 dislocation with absence of odontoid process that underwent posterior C1-C2 arthrodesis using C1 hooks and C2 pedicle screws. SUMMARY OF BACKGROUND DATA C1-C2 dislocation is a rare but fatal upper cervical injury. To date, there have been many reports about C1-C2 dislocation of traumatic origin. However, very few C1-C2 dislocation cases of congenital odontoid deformities had been presented. This was particularly the case when the odontoid process was absent. METHODS Plain radiograph of his cervical spine revealed a C1-C2 dislocation, and subsequent computed tomographic scan as well as magnetic resonance imaging (MRI) detected absence of odontoid process and cord compression. Upon admission, the patient was placed on skull traction and the weight increased from 3.5 to 5.5 kg. After 10 days of traction, reduction was achieved radiographically and the posterior C1-C2 arthrodesis by C1 hooks with C2 pedicle screws was performed. RESULTS After surgery, the patient showed significant improvement in gait function despite slightly raised muscle tone in his lower extremities. Four-month postoperative radiographs indicated restoration of C1-C2 alignment and bony fusion. No residual cord compression was present. CONCLUSION In clinical evaluation of patients who present with neck pain and limited cervical motion with or without neurologic deficits, C1-C2 dislocation should be considered. If the patient has no history of trauma or infection, congenital C1-C2 deformity, especially odontoid malformation, has to be included as a possible factor. Once the diagnosis is confirmed, posterior C1-C2 arthrodesis may become necessary for stabilizing C1-C2 and preventing it from deterioration or new development of neurologic symptoms.
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Revision surgery of irreducible atlantoaxial dislocation: a retrospective study of 16 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20:2187-94. [PMID: 21912831 DOI: 10.1007/s00586-011-1865-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 05/08/2011] [Accepted: 05/22/2011] [Indexed: 10/17/2022]
Abstract
There is lack data concerning anterior cervical spine revision surgeries; even more data are missing concerning posterior cervical revision surgeries, to determine the feasibility, safety, and clinical efficacy of revision surgery for irreducible atlantoaxial dislocation (RS-IAAD). Patients with IAAD-FS underwent one-stage transoral release and posterior reduction. Their medical history was documented in detail. The JOA score system was used to evaluate each patient's neurological status pre and postoperatively, and serial MRI and radiographs were used to determine the status of the reduction and the autografts. 16 patients (average age, 36 years old) underwent successful surgery. There was no intraoperative or postoperative neurological deficit except in two cases that suffered transient neurological deficit that alleviated after conservative treatment. Solid bony union was seen at the end of 3 months after surgery in all patients. The mean follow-up period was 28.8 months (range 18-66 months). No pseudarthrosis was noted. Anterior transoral release and posterior instrumented fusion remain significant surgeries with the potential for serious complications, but in the current series there were no major complications.
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Combination of skull traction with posterior C1-2 fusion for old C1-2 dislocations. J Clin Neurosci 2011; 18:768-73. [PMID: 21507654 DOI: 10.1016/j.jocn.2010.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2010] [Revised: 10/04/2010] [Accepted: 10/10/2010] [Indexed: 11/21/2022]
Abstract
Between January 2003 and December 2009, 23 patients who had suffered old C1-2 dislocations, were surgically treated in our orthopedics department. Fifteen patients underwent direct posterior C1-2 fusion following pre-operative reduction by skull traction. In eight patients, reduction was achieved only by skull traction under general anesthesia, facilitated by manual hyperextension of the cervical spine and maintained by simultaneous posterior C1-2 fusion. Intra-operative traction was monitored using C-arm fluoroscopy and cortical somatosensory-evoked potentials. Posterior C1-2 fixation was achieved in nine patients using C1-2 laminar hooks and in 14 patients using C1 laminar hooks with C2 pedicle screws. During the follow-up of 5 to 72 months (mean: 42.8 months), solid bony fusion was accomplished in all patients. Using Di Lorenzo's grades and Japanese Orthopedics Association scores, there was significant improvement (p<0.05). The cervical medullary angle exhibited a significant improvement of 31.7°, from 121.6° to 153.3° (p<0.05). There were no complications, including dural tears, spinal cord damage, vertebral artery damage, or breakage or loosening of implants.
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Abstract
The diagnosis of Chiari type I malformation (CIM) is more and more frequent in clinical practice due to the wide diffusion of magnetic resonance imaging. In many cases, such a diagnosis is made incidentally in asymptomatic patients, as including children investigated for different reasons such as mental development delay or sequelae of brain injury. The large number of affected patients, the presence of asymptomatic subjects, the uncertainties surrounding the pathogenesis of the malformation, and the different options for its surgical treatment make the management of CIM particularly controversial.This paper reports on the state of the art and the recent achievements about CIM aiming at providing further information especially on the pathogenesis, the natural history, and the management of the malformation, which are the most controversial aspects. A historial review introduces and explains the current classification. Furthermore, the main clinical, radiological, and neurophysiological findings of CIM are described to complete the picture of this heterogeneous and complex disease.
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Affiliation(s)
- L Massimi
- Pediatric Neurosurgery, Catholic University Medical School, Rome, Italy
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Miao EY. Basilar invagination managed with electroacupuncture and Chinese herbal medicine: the report of a rare case in a pediatric patient. J Altern Complement Med 2010; 15:197-200. [PMID: 19183070 DOI: 10.1089/acm.2008.0057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND A 13-year-old girl who suffered from basilar invagination managed with electroacupuncture and Chinese Herbal medicine is presented in this report. This is a rare disease. The condition was misdiagnosed by many biomedical specialists over a period of 5 years. There has been no literature ever recorded in Traditional Chinese Medicine (TCM) history for the treatment of this rare condition. METHODS The patient has a secondary condition, hydrocephalus, which was categorized as Jie Lu from a Chinese Medicine perspective. Jie Lu has also been used to form the rational base of the TCM treatment. RESULTS This patient's condition stabilized for a period of 3 years. As bone growth continued, the severity of the patient's symptoms increased. The patient has turned 19; her symptoms have become more severe and she is unable to walk for a short distance. CONCLUSIONS Finally, a diagnosis of basilar invagination was confirmed by a private health service provider team separate from several public hospitals' specialist teams.
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Jian FZ, Chen Z, Wrede KH, Samii M, Ling F. Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery 2010; 66:678-87; discussion 687. [PMID: 20305492 DOI: 10.1227/01.neu.0000367632.45384.5a] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report the surgical technique and clinical results for the treatment of basilar invagination (BI) with atlantoaxial dislocation (AAD) by direct posterior reduction and fixation using intraoperative distraction between the occiput and C2 pedicle screws. METHODS From May 2004 to June 2008, 29 patients who had BI with AAD were surgically treated in our department. Pre- and postoperative dynamic cervical x-rays, computed tomographic scans, and 3-dimensional reconstruction views were performed to assess the degree of dislocation. Ventral compression of the cervicomedullary junction was evaluated by magnetic resonance imaging. For all patients, reduction of the AAD was conducted by intraoperative distraction between the occiput and C2 pedicle screws using a direct posterior approach. RESULTS Follow-up ranged from 6 to 50 months in 28 patients. Clinical symptoms improved in 26 patients (92.9%) and were stable in 2 patients (7.1%) without postoperative deterioration. Radiologically, complete or more than 50% reduction was achieved in 27 of 28 patients (96.4%). In 1 patient, the reduction was less than 50% because the direction of the facets on 1 side of the C1-C2 joint was vertically oriented, instead of horizontal. Overall, good decompression and bone fusion were shown on postoperative magnetic resonance imaging, computed tomography, or x-ray scans for all patients. There was 1 death in the series because of basilar artery thrombosis 1 week after the operation. CONCLUSION The direct posterior distraction technique between occiput and C2 pedicle screws is an effective, simple, fast, and safe method for the treatment of BI with AAD. Transoral odontoidectomy and cervical traction for the treatment of BI with AAD should be reconsidered.
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Affiliation(s)
- Feng-Zeng Jian
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, China
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Abstract
BACKGROUND Basilar invagination is a developmental anomaly of the craniovertebral junction in which the odontoid abnormally prolapses into the foramen magnum. It is often associated with other osseous anomalies of the craniovertebral junction, including atlanto-occipital assimilation, incomplete ring of C1, and hypoplasia of the basiocciput, occipital condyles, and atlas. Basilar invagination is also associated with neural axis abnormalities, including Chiari malformation, syringomyelia, syringobulbia, and hydrocephalus. Patients frequently present with neurologic symptoms and deficits and warrant surgical treatment to prevent progression. OBJECTIVE To review the management of basilar invagination. METHODS The literature was reviewed in reference to the evaluation and management of basilar invagination, with particular emphasis on the surgical treatment. RESULTS Reducible basilar invagination may be treated with posterior decompression and stabilization. Ventral decompression may be necessary for basilar invagination with neural compression that is not reducible with axial cervical traction. Posterior cervical stabilization is necessary after ventral decompression. Modern rod and screw systems combined with autogenous bone graft enable correction of deformity, immediate stabilization, and high fusion rates. CONCLUSION Basilar invagination is a developmental anomaly and commonly presents with neurologic findings. Treatment is typically surgical and involves anterior decompression followed by posterior stabilization for irreducible invagination and posterior decompression and stabilization for reducible invagination.
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Affiliation(s)
- Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia 22908, USA
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Congenital Diseases of the Craniocervical Junction in the Dog. Vet Clin North Am Small Anim Pract 2010; 40:121-41. [DOI: 10.1016/j.cvsm.2009.10.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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CERDA-GONZALEZ SOFIA, DEWEY CURTISW, SCRIVANI PETERV, KLINE KARENL. IMAGING FEATURES OF ATLANTO-OCCIPITAL OVERLAPPING IN DOGS. Vet Radiol Ultrasound 2009; 50:264-8. [DOI: 10.1111/j.1740-8261.2009.01531.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Landeiro JA, Boechat S, Christoph DDH, Gonçalves MB, Castro ID, Lapenta MA, Ribeiro CH. Transoral approach to the craniovertebral junction. ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 65:1166-71. [PMID: 18345423 DOI: 10.1590/s0004-282x2007000700014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 09/04/2007] [Indexed: 11/22/2022]
Abstract
The transoral approach provides a safe exposure to lesions in the midline and the ventral side of the craniovertebral junction. The advantages of the transoral approach are 1) the impinging bony pathology and granulation tissue are accessible only via the ventral route; 2) the head is placed in the extended position, thus decreasing the angulation of the brainstem during the surgery; and 3) surgery is done through the avascular median pharyngeal raphe and clivus. We analyzed the clinical effects of odontoidectomy after treating 38 patients with basilar invagination. The anterior transoral operation to treat irreducible ventral compression in patients with basilar invagination was performed in 38 patients. The patients ages ranged from 34 to 67 years. Fourteen patients had associated Chiari malformation and eight had previously undergone posterior decompressive surgery. The main indication for surgery was significant neurological deterioration. Symptoms and signs included neck pain, myelopathy, lower cranial nerve dysfunction, nystagmus and gait disturbance. Extended exposure was performed in 24 patients. The surgery was beneficial to the majority of patients. There was one death within 10 days of surgery, due to pulmonary embolism. Postoperative complications included two cases of pneumonia, three cases of oronasal fistula with regurgitation and one cerebrospinal fluid leak. In patients with marked ventral compression, the transoral approach provides direct access to the anterior face of the craniovertebral junction and effective means for odontoidectomy.
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Hwang SW, Heilman CB, Riesenburger RI, Kryzanski J. C1-C2 arthrodesis after transoral odontoidectomy and suboccipital craniectomy for ventral brain stem compression in Chiari I patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2008; 17:1211-7. [PMID: 18629549 PMCID: PMC2527411 DOI: 10.1007/s00586-008-0706-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Revised: 04/05/2008] [Accepted: 06/02/2008] [Indexed: 02/02/2023]
Abstract
Chiari I malformations are often associated with congenital craniocervical anomalies such as platybasia, basilar invagination, and retroflexion of the odontoid process. Management of ventral brain stem compression associated with Chiari I malformations remains controversial, but several authors report a significant rate of failure with suboccipital decompression alone in the presence of pronounced ventral brain stem compression (VBSC). Treatment options described in the literature for these patients involve anterior, posterior, or combined decompressions with or without concurrent arthrodesis. A combined anterior and posterior approach provides a definitive circumferential decompression but also significantly disrupts the stability of the occipitocervical junction usually necessitating occipitocervical fixation. We describe an alternative surgical treatment for Chiari I patients with significant ventral brain stem compression where a combined anterior and posterior decompression was considered necessary. We report two patients who underwent transoral odontoidectomy with preservation of the anterior arch of the atlas and suboccipital craniectomy with C1 laminectomy followed by C1-C2 arthrodesis. Preservation of the anterior arch of the atlas in conjunction with C1-C2 arthrodesis stabilizes the occipito-atlanto-axial segments while conserving more cervical mobility as compared to an occipitocervical fusion.
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Affiliation(s)
- Steven W Hwang
- Department of Neurosurgery #178, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111, USA.
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40
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McGirt MJ, Attenello FJ, Sciubba DM, Gokaslan ZL, Wolinsky JP. Endoscopic transcervical odontoidectomy for pediatric basilar invagination and cranial settling. Report of 4 cases. J Neurosurg Pediatr 2008; 1:337-42. [PMID: 18377313 DOI: 10.3171/ped/2008/1/4/337] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pediatric basilar invagination and cranial settling have traditionally been approached through a transoral-transpharyngeal route with or without extended maxillotomy or mandibulotomy for resection of the anterior portion of C-1 and the odontoid. The authors hypothesize that application of a recently described endoscopic transcervical odontoidectomy (ETO) technique would allow an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients. The authors performed ETO in a consecutive series of pediatric patients presenting with myelopathy or bulbar dysfunction resulting from basilar invagination or cranial settling. All clinical, radiographic, surgical, and follow-up data were prospectively collected. The initial experience with ETO in the pediatric population is analyzed and outcomes are reported. Three patients required ETO for basilar invagination and 1 required ETO with anterior C-1 arch and distal clivus resection for cranial settling. All patients presented with myelopathy. One patient was wheelchair bound with severe quadriparesis. The mean age was 14 +/- 3 years (mean +/- standard deviation [SD]) in the 2 male and 2 female patients. The ETO and posterior fusion were performed as a 2-stage procedure in 2 (50%) and as a single-stage procedure in 2 (50%) cases. Prolonged intubation or postoperative placement of a gastrostomy tube was not needed in any case. The postoperative hospitalization lasted 9 +/- 4 days (mean +/- SD). At last follow-up (mean 5 months), head and neck pain had resolved and motor strength had improved or stabilized in all cases. All 4 children were independently functioning and ambulatory at the last follow-up. In the authors' initial experience, ETO has allowed ventral brainstem decompression without the need for prolonged intubation, worsening dysphagia requiring enteral tube feeding, or prolonged hospitalization, and has resulted in cosmetically appealing results. The ETO technique allows an alternative approach for the treatment of ventral pathological entities at the craniocervical junction in pediatric patients.
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Affiliation(s)
- Matthew J McGirt
- Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland 21287, USA
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Kotil K, Kalayci M, Bilge T. Management of cervicomedullary compression in patients with congenital and acquired osseous–ligamentous pathologies. J Clin Neurosci 2007; 14:540-9. [PMID: 17336528 DOI: 10.1016/j.jocn.2006.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Revised: 03/06/2006] [Accepted: 03/07/2006] [Indexed: 11/25/2022]
Abstract
We present our experience in the diagnosis, surgical management and long-term follow-up of congenital and acquired osseous-ligamentous abnormalities or pathologies of the craniovertebral junction. The purpose of this study was: (i) to determine the incidence and degree of cervicomedullary compression in pediatric and young adult patients with congenital and acquired abnormalities, and (ii) to correlate cervicomedullary compression with other imaging and clinical factors to determine to what extend cervicomedullary compression is successfully treated with a posterior decompressive procedure, transoral decompression, and medical management. Between January 1995 and December 2004, 26 cases were managed in our department. These patients had: rheumatoid arthritis (RA) (3); traumatic injury (2); congenital basilar impression (5, in 2 cases a posteriorly oriented or retroflexed odontoid); infection (10); craniovertebral junction Pott's disease (9); os odonteideum (3); condylus tertius (1); and tumor (2). Six of the patients (23.1%) had syringomyelia. Only three (11.3%) were in the pediatric age group. Symptoms and signs included headache (72%), ataxia (38%), lower cranial nerve dysfunction (54%), quadriparesis (44%), hyperreflexia (76%), Hoffman positivity (72%), achilles clonus (72%) nystagmus (33%) and dysphagia (22%). The mean follow-up time was 44 months (range 3-85). Twelve (46.2%) had undergone posterior fossa decompression; seven (26.6%) had ventral decompression. Seven of the patients (26.6%) had medical management. The major morbidity included pharyngeal wound sepsis leading to dehiscence (3.8%), valopharyngeal insufficiency (3.8%), cerebrospinal fluid leakage (3.8%), postoperative macroglossia (3.8%) and inadequate anterior decompression (3.8%). Transient neurological deterioration occurred in two patients (7.6%). Our management paradigm will result in some neurologic improvements and limit the progression of symptoms. Patients with these pathologies are likely to show a good neurologic outcome when treatment, whether with or without surgery, is administered early in the course of the disease.
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Affiliation(s)
- Kadir Kotil
- Haseki Educational and Research Hospital, Department of Neurosurgery, Istanbul, Turkey.
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Wolinsky JP, Sciubba DM, Suk I, Gokaslan ZL. Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. J Neurosurg Spine 2007; 6:184-91. [PMID: 17330590 DOI: 10.3171/spi.2007.6.2.184] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓Symptomatic irreducible basilar invagination has traditionally been approached through a transoral–transpharyngeal route with resection of the anterior portion of C-1 and the odontoid. Modification of this exposure with either a Le Fort osteotomy or a transmandibular osteotomy and circumglossal approach has increased the access to pathological conditions in this region. These traditional routes all require traversing the oral cavity and accepting the associated potential complications. The authors have developed a novel surgical approach, an endoscopic transcervical odontoidectomy, which allows access for resection of the odontoid and for brainstem and spinal cord decompression without traversing the oral cavity. In this paper they describe the technique and its advantages and present three cases in which patients underwent the endoscopic transcervical odontoidectomy for basilar invagination.
Three consecutive patients (age range 42–74 years) who had irreducible basilar invagination underwent the endoscopic transcervical odontoidectomy. All were symptomatic and had neck pain and myelopathy. All were evaluated preoperatively and postoperatively with computed tomography and magnetic resonance imaging. In all cases the procedure resulted in complete decompression. There were no serious complications. No patient required prolonged intubation, tracheostomy, or enteral tube feeding. One patient had an intraoperative cerebrospinal fluid leak, which had no postoperative sequelae.
The authors present an alternative surgical approach for treating ventral compression of the brainstem and spinal cord. The technique is safe and effective for decompression and provides a surgical route that can be added to the armamentarium of treatments for pathological conditions in this region.
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Affiliation(s)
- Jean-Paul Wolinsky
- Department of Neurosurgery, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Guo F, Wang M, Long J, Wang H, Sun H, Yang B, Song L. Surgical management of Chiari malformation: analysis of 128 cases. Pediatr Neurosurg 2007; 43:375-81. [PMID: 17786002 DOI: 10.1159/000106386] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Accepted: 02/14/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVE A variety of surgical interventions have been recommended for patients with Chiari malformations (CMs). In this study, we have evaluated the intraoperative findings and clinical outcome in different-aged patients with CMs undergoing posterior fossa decompression. METHODS Sixteen pediatric and 112 adult cases with CMs underwent suboccipital craniectomy and wide duraplasty as well as autogenous bone grafting in selected cases. The clinical outcome was assessed by evaluation of postoperative signs and symptoms and magnetic resonance imaging of the craniocervical junction. RESULTS The most striking intraoperative finding was the presence of a very thin membrane over the opening of the central canal; the occurrence of this membrane in pediatric patients was significantly higher than that in adults (94 and 43%, respectively; p < 0.05, Fisher's exact probability test). During the immediate postoperative period, 81% of pediatric CMs and 90% of adult CMs showed improved symptomatology and magnetic resonance imaging revealed favorable findings comprising syrinx collapse or reduction of the syrinx diameter in 14 (88%) pediatric and 92 (82%) adult CMs. During discharge from hospital, 103 (90%) patients with CMs type I and 11 (85%) with CMs type II achieved good results. However, there was a statistically significant difference in the occurrence of poor results between patients treated with bony fusion and those without fusion (24 vs. 6%;p < 0.05, Fisher's exact probability test). The incidence of vertebral instability was markedly augmented in pediatric CMs in comparison to adult CMs (19 vs. 2%; p < 0.01, Fisher's exact probability test). CONCLUSIONS Suboccipital decompression and duraplasty with autogenous bone grafts in selected cases are effective treatments for most patients with CMs. A higher incidence of a special membrane over the obex and atlantoaxial instability were closely associated with childhood CMs.
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Affiliation(s)
- Fuyou Guo
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
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Simsek S, Yigitkanli K, Belen D, Bavbek M. Halo traction in basilar invagination: technical case report. ACTA ACUST UNITED AC 2006; 66:311-4; discussion 314. [PMID: 16935643 DOI: 10.1016/j.surneu.2005.12.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2005] [Accepted: 12/19/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND In the management of basilar invagination, traction therapy may help by pulling down the odontoid process away from the brain stem that may result in clinical and radiological improvement. We aimed to discuss the role of the halo vest apparatus traction on the reduction of severe anterior compression pathologies in basilar invagination. CASE DESCRIPTION We describe a simple and safe cervical traction method by the halo vest apparatus that is followed by rigid posterior occipitocervical fixation and foramen magnum decompression in a patient who presented with basilar invagination and symptoms of severe brain stem compression. An MR-suitable halo vest apparatus was used for reduction of the deformity. The reduction of the basilar invagination was achieved gradually by distracting the halo crown in stages. CONCLUSION The halo vest apparatus can be safely used in complex craniocervical junction anomalies. An effective cervical traction can be performed in basilar invagination, and reduction of the deformity may be achieved without the risk of overdistraction. In some cases, even partial reduction of the deformity may facilitate brain stem and spinal cord relief without any need of posterior decompression. Patients may benefit from ambulatory functions because bed rest is eliminated in this procedure. Neurovascular structures and the degree of the reduction can be observed on MRIs when an MR-suitable device is used.
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Affiliation(s)
- Serkan Simsek
- Neurosurgery Department, Ministry of Health, Diskapi Educational and Research Hospital, Ankara 06110, Turkey
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Wang C, Yan M, Zhou HT, Wang SL, Dang GT. Open reduction of irreducible atlantoaxial dislocation by transoral anterior atlantoaxial release and posterior internal fixation. Spine (Phila Pa 1976) 2006; 31:E306-13. [PMID: 16688020 DOI: 10.1097/01.brs.0000217686.80327.e4] [Citation(s) in RCA: 148] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study of surgical outcome of 33 patients with irreducible atlantoaxial dislocation (IAAD). OBJECTIVE To evaluate the safety efficacy of one stage anterior release and posterior fixation and fusion to reduce and stabilize IAAD. SUMMARY OF BACKGROUND DATA The traditional treatment of symptomatic IAAD is ventral decompression by transoral approach. This procedure is accompanied with high morbidity and mortality. It does not correct the swan neck deformity, which could precipitate the degenerative changes in the lower cervical spine. Our hypotheses were that it is the contraction of the muscles, ligaments, and capsules of atlantoaxial joint that prevent reduction, and that most of IAADs might be reduced by anterior atlantoaxial joint release without the odontoid resection, and that further reduction and stabilization might be achieved by special posterior fixation. METHODS A consecutive series of 33 patients with IAAD were surgically treated. Dislocation or reduction was assessed before surgery, immediately after surgery, and at the final fol5786-up. Etiology, instrumentation, levels fused, and complications were documented. All patients were assessed clinically for neurologic recovery by Odom's method. RESULTS The mean age was 32 years (range, 7-63 years). The pathology included os odontoideum in 8 patients, occipitalization of C1 in 19 patients, malunion of odontoid fracture in 5, and relaxation of transverse ligament of atlas in 1. Twenty five patients presented neurologic signs and symptoms. Anterior release was performed without odontoid resection in all cases. Four patients underwent transarticular C1-C2 screw fixation, 3 had C1-C2 pedicle screw and plate fixation, and 26 required occipitocervical fixation. Twenty-five cases resulted in an anatomic reduction, 8 had partial reduction. Complication included one dysphagia and two nasal phonations. The mean follow-up period was 33.7 months (range, 24-55 months). There was no pseudarthrosis, and all but 1 of the patients with neurologic deficit showed improvement. CONCLUSION This series has demonstrated the safety and efficacy of the transoral anterior atlantoaxial release in the reduction of IAAD. Most of the so-called irreducible/fixed AAD could become reducible after anterior release without odontoid resection. The posterior short-segment atlantoaxial or occipitocervical fixation, especially the plate screw instrumentation, could achieve further reduction and provide immediate stabilization. One-stage anterior release and posterior instrumentation and fusion are a safe and reliable operation in experienced hands.
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Affiliation(s)
- Chao Wang
- Department of Orthopaedics, Peking University Third Hospital, Beijing, China.
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Dickerman RD, Lefkowitz M, Arinsburg SA, Schneider SJ. Chiari malformation and odontoid panus causing craniovertebral stenosis in a child with Crouzon's syndrome. J Clin Neurosci 2005; 12:963-6. [PMID: 16242933 DOI: 10.1016/j.jocn.2004.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 11/23/2004] [Indexed: 11/18/2022]
Abstract
Crouzon's disease is a well-known disorder affecting multiple organ systems, specifically a craniofacial disorder with highly variable penetrance and severity of deformity. Crouzon's patients typically have anomalies of the skull base leading to gross distortion of the cranium and in some cases the cervicocranium. We present a 5-year-old girl with Crouzon's disease who suffered from an acquired Chiari I malformation after insertion of a ventriculoperitoneal shunt and a coexistent ventral odontoid panus. Both these lesions were causing cervicomedullary compression. The literature is controversial on the surgical management of anterior and posterior compression at the craniocervical junction. We review the literature on surgical options for decompression at the craniocervical junction and offer our surgical case as a treatment option for patients in this rare clinical situation.
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Affiliation(s)
- Rob D Dickerman
- Denton Regional Medical Center and Plano Presbyterian Hospitals, Plano, Texas, USA.
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Inamasu J, Kim DH, Klugh A. Posterior Instrumentation Surgery for Craniocervical Junction Instabilities: an Update. Neurol Med Chir (Tokyo) 2005; 45:439-47. [PMID: 16195642 DOI: 10.2176/nmc.45.439] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The surgical treatment of craniocervical junction (CCJ) instability has recently undergone significant development and change. Posterior instrumentation surgery has been the mainstay of treatment of CCJ instability, and is the focus of this review. For the treatment of atlantoaxial instability, C1-2 transarticular screw fixation has shown good stability, and has been regarded as the "gold standard" procedure. Because of potentially hazardous complications including vertebral artery injury, however, C-1 lateral mass-C-2 pedicle screw fixation is gaining popularity. For treatment of atlantooccipital instability, occipitocervical fixation using screw constructs (combined with either rods or plates) has shown more stability than sublaminar wiring techniques, and has been utilized more frequently. Both innovation in material engineering and in vitro biomechanical studies have contributed significantly to the development of more rigid internal fixation devices, and as a result, many patients who would have been treated conservatively with external orthosis are treated nowadays with instrumentation surgery, resulting in earlier ambulation, shortened hospital stay, and earlier recovery into social activities. New surgical techniques and instruments, however, need to stand the test of time to see whether they are free from long-term adverse events. The rapid turnover of new surgical techniques and hardware has made it difficult for less experienced surgeons to keep up with the latest developments. Conventional techniques can be safer and less technically demanding than newer techniques for those who are not familiar with them.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
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