scholarly journals An investigation of craniocervical stability post-condylectomy

2021 ◽  
Vol 12 ◽  
pp. 380
Author(s):  
Brian Fiani ◽  
Ryan Jarrah ◽  
Erika Sarno ◽  
Athanasios Kondilis ◽  
Kory Pasko ◽  
...  
Keyword(s):  
Tumor Resection ◽  
Craniovertebral Junction ◽  
Surgical Approaches ◽  
Occipital Condyle ◽  
Neurosurgical Procedures ◽  
Occipitocervical Fusion ◽  
Surgical Access ◽  
Craniocervical Instability ◽  
Far Lateral ◽  
Occipital Condyles

Background: Occipital condylectomy is often necessary to gain surgical access to various neurological pathologies. As the lateral limit of the craniovertebral junction (CVJ), partial condylectomy can lead to iatrogenic craniocervical instability. What was once considered an inoperable location is now the target of various complex neurosurgical procedures such as tumor resection and aneurysm clipping. Methods: In this study, we will review the anatomical structure of the CVJ and provide the first comprehensive assessment of studies investigating craniovertebral stability following condylectomy with the transcondylar surgical approaches. Furthermore, we discuss future considerations that must be evaluated to optimize the chances of preserving craniocervical stability postcondylectomy. Results: The current findings postulate upward of 75% of the occipital condyle can be resected without significantly affecting mobility of the CVJ. The current findings have only examined overall dimensions and have not established a significant correlation into how the shape of the occipital condyles can affect mobility. Occipitocervical fusion should only be considered after 50% condyle resection. In terms of indicators of anatomical stability, components of range of motion (ROM) such as the neutral zone (NZ) and the elastic zone (EZ) have been discussed as potential measures of craniocervical mobility. These components differ by the sense that the NZ has little ligament tension, whereas the EZ does represent ROM where ligaments experience tension. NZ is a more sensitive indicator of instability when measuring for instability postcondylectomy. Conclusion: Various transcondylar approaches have been developed to access this region including extreme-lateral and far-lateral condylectomy, with hopes of preserving as much of the condyle as possible and maintaining postoperative craniocervical stability.

scholarly journals The far-lateral approach: destruction of the condyle does not necessarily result in clinically evident craniovertebral junction instability

2016 ◽  
Vol 125 (1) ◽  
pp. 196-201 ◽  
Author(s):  
Ehab Shiban ◽  
Elisabeth Török ◽  
Maria Wostrack ◽  
Bernhard Meyer ◽  
Jens Lehmberg
Keyword(s):  
Extent Of Resection ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipitocervical Fusion ◽  
Anterior Portion ◽  
Far Lateral Approach ◽  
Clinical Instability ◽  
Craniocervical Instability ◽  
Far Lateral

OBJECT Far-lateral or extreme-lateral approaches to the skull base allow access to the lateral and anterior portion of the lower posterior fossa and foramen magnum. These approaches include a certain extent of resection of the condyle, which potentially results in craniocervical junction instability. However, it is debated what extent of condyle resection is safe and at what extent of condyle resection an occipitocervical fusion should be recommended. The authors reviewed cases of condyle resection/destruction with regard to necessity of occipitocervical fusion. METHODS The authors conducted a retrospective analysis of all patients in whom a far- or extreme-lateral approach including condyle resection of various extents was performed between January 2007 and December 2014. RESULTS Twenty-one consecutive patients who had undergone a unilateral far- or extreme-lateral approach including condyle resection were identified. There were 10 male and 11 female patients with a median age of 61 years (range 22–83 years). The extent of condyle resection was 25% or less in 15 cases, 50% in 1 case, and greater than 75% in 5 cases. None of the patients who underwent condyle resection of 50% or less was placed in a collar postoperatively or developed neck pain. Two of the patients with condyle resection of greater than 75% were placed in a semirigid collar for a period of 3 months postoperatively and remained free of pain after this period. At last follow-up none of the cases showed any clear sign of radiological or clinical instability. CONCLUSIONS The unilateral resection or destruction of the condyle does not necessarily result in craniocervical instability. No evident instability was encountered even in the 5 patients who underwent removal of more than 75% of the condyle. The far- or extreme-lateral approach may be safer than generally accepted with regard to craniocervical instability as generally considered and may not compel fusion in all cases with condylar resection of more than 75%.

Lateral Transcondylar Approach for Tumors at the Anterior Aspect of the Craniovertebral Junction

Neurosurgery ◽  
2010 ◽  
Vol 66 (suppl_3) ◽  
pp. A104-A112 ◽  
Author(s):  
Chandranath Sen ◽  
Raj Shrivastava ◽  
Shuman Anwar ◽  
Aymara Triana
Keyword(s):  
Nerve Palsy ◽  
Tumor Resection ◽  
Complete Removal ◽  
Craniovertebral Junction ◽  
Occipital Condyle ◽  
Occipitocervical Fusion ◽  
Presenting Symptoms ◽  
Transcondylar Approach ◽  
Age Range ◽  
Headache And Neck Pain

Abstract BACKGROUND Tumors at the craniovertebral junction are difficult to remove because of their location and complex anatomic relations. The lateral transcondylar approach is a versatile approach to this area and allows access to a variety of intra- and extradural tumors. The lateral transcondylar approach has been used for a series of chordomas in this location. OBJECTIVE The nuances of this operation and its effectiveness in this group of patients are presented. METHODS There were 29 chordomas (1991–2007) in this region treated by one of the authors (CS) that were retrospectively reviewed. The imaging studies and medical records were evaluated. The location and extent of the tumor were defined, and the postoperative images were studied to determine the degree of resection. RESULTS There were 11 male and 18 female patients; their age range was 7 to 67 years. Headache and neck pain were the predominant presenting symptoms, and hypoglossal nerve palsy was the most common cranial nerve palsy. Twelve patients had previous surgery and 9 had previous radiation. Anterior midline and lateral approaches were used independently or in combination to treat these patients. Dural invasion was found in 27 patients requiring resection of the dura. Surgery was performed in 1 stage in 19 patients, and the tumor resection in the remaining patients was done in 2 stages. The lateral transcondylar approach was used in 19 patients. The occipital condyle was involved in all these patients. Radical tumor resection was achieved in 17 patients. Patients who had complete removal of the occipital condyle required occipitocervical fusion (20 patients) in the immediate postoperative period. CONCLUSION The lateral transcondylar approach is an effective approach to chordomas in this region. Most of the tumors were large and extended into multiple anatomic compartments. The approach allowed resection of all the involved tissues, intra- and extracranial, and afforded excellent neurovascular control.

scholarly journals Anatomical and Radiological study of the posterior cranial base in relationship to occipital condyles and Foramen magnum

2020 ◽  
Vol 11 (3) ◽  
pp. 3528-3532
Author(s):  
Sharmila Aristotle ◽  
Balaji Ramraj ◽  
Shantanu Patil ◽  
Sundarapandian Subramanian
Keyword(s):  
Clinical Importance ◽  
Diagnostic Procedures ◽  
Cranial Base ◽  
Ct Images ◽  
Foramen Magnum ◽  
Ct Scans ◽  
Surgical Approaches ◽  
Occipital Condyle ◽  
Mortality And Morbidity ◽  
Occipital Condyles

Detailed morphometric analysis is required for various surgical approaches in the craniovertebraljunction. High mortality and morbidity are anticipated for the surgical procedures when undertaken without in-depth anatomical knowledge. With so much clinical importance in this area, our study will present a thorough understanding in terms of skull and CT values. The main aim of this study is to give the morphometric details of occipital condyles and foramen magnum in cadaveric skulls and CT scans. Seventy dried human skulls and 70 CT images on the three-dimensional volume-rendered reconstruction of the skull base was used for this study. The length and width of the occipital condyle of right and the left side was 22.21 ±5.20 mm; 22.05±4.83 mm; 12.57 ± 2.50 and 12.68 ± 2.92mm respectively in cadaver skull. The length and width of occipital condyles in CT scans for right and left side was 21.61 ± 3.09 mm; 21.58 ± 3.50 mm; 13.04 ± 1.58 mm and 13.13 ± 2.54 mm respectively. The Anteroposterior and transverse diameters of the foramen magnum in cadaveric skulls and CT images was 33.17 ± 7.23; 29.22 ± 6.17; 34.15 ± 2.88 and 28.14 ± 2.43 mm respectively. Each surgical approach and the radiological diagnostic procedures have their limitations. Moreover, analysis of cranial base dimensions of occipital condyles and foramen magnum can be considered as a reliable method for sex determination. Hence this study will a useful guide for surgeons, radiologists, anthropologists and forensic experts.

Far Lateral Craniotomy Closure Technique for Preservation of Suboccipital Musculature

2020 ◽  
Author(s):  
Muhammad Salman Ali ◽  
Stephen T. Magill ◽  
Michael W. McDermott
Keyword(s):  
Muscle Atrophy ◽  
Craniovertebral Junction ◽  
Contralateral Side ◽  
Lateral Approach ◽  
Senior Author ◽  
Occipital Condyle ◽  
Closure Technique ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Initial Results

AbstractThe far lateral approach is used for accessing pathology at the craniovertebral junction but can be complicated by postoperative suboccipital muscle atrophy. In addition to significant cosmetic deformity, this atrophy can lead to head and neck pain and potentially could contribute to cranio-cervical instability. To address this issue, the senior author began using a single myocutaneous flap without a muscle cuff and securing it directly to the bone using predrilled holes in the bone that resemble a chevron. The method is described and illustrated with an example case. Results from seven consecutive cases are reported since the technique was adopted. Muscle atrophy was measured by calculating area at the level of the occipital condyle and compared with the contralateral side. No significant differences were noted. In conclusion, we have found this to be an excellent closure technique and wanted to present our initial results for consideration by other skull base surgeons.

Extreme lateral—transatlas approach for resection of the dens of the axis

2002 ◽  
Vol 96 (1) ◽  
pp. 73-82 ◽  
Author(s):  
Uğur Türe ◽  
M. Necmettin Pamir
Keyword(s):  
Craniovertebral Junction ◽  
Basilar Invagination ◽  
Clinical Experiences ◽  
Occipitocervical Fusion ◽  
Content Type ◽  
Advantages And Disadvantages ◽  
Alternative Approach ◽  
Craniocervical Instability ◽  
Fine Print

Object. Various approaches have been described for resection of the dens of the axis, each of which has potential advantages and disadvantages. Anterior approaches such as the transoral route or its modifications are the most commonly used for resection of this structure. The transcondylar approach, however, which allows the surgeon to view the craniovertebral junction (CVJ) from a lateral perspective, has been introduced by Al-Mefty, et al., as an alternative approach. In this report, the authors describe the surgical technique of the extreme lateral—transatlas approach and their clinical experiences. Methods. The authors first examined the surgical approach to the dens from a lateral perspective in five cadaveric heads. They found that removal of the lateral mass of the atlas provided adequate exposure for resection of the dens. Following this cadaveric study, the extreme lateral—transatlas approach was successfully performed at the authors' institution over a 1-year period (September 1998–August 1999) in five patients with basilar invagination due to congenital anomaly of the CVJ and rheumatoid arthritis. Furthermore, during the same procedure, unilateral occipitocervical fusion was performed following resection of the dens. In all cases complete resection of the dens was achieved using the extreme—lateral transatlas approach. This procedure provides a sterile operative field and the ability to perform occipitocervical fusion immediately following the resection. No postoperative complications or craniocervical instability were observed. The mean follow-up period was 17.2 months (range 13–24 months). Conclusions. The extreme lateral—transatlas approach for resection of the dens was found to be safe and effective. Knowledge of the anatomy of this region, especially of the V3 segment of the vertebral artery, is essential for the success of this procedure.

Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum

2005 ◽  
Vol 103 (5) ◽  
pp. 783-788 ◽  
Author(s):  
Joshua M. Ammerman ◽  
Russell R. Lonser ◽  
Edward H. Oldfield
Keyword(s):  
Tumor Resection ◽  
National Institutes Of Health ◽  
Surgical Approaches ◽  
Content Type ◽  
Surgical Access ◽  
Operative Findings ◽  
Transtentorial Approach ◽  
Complete Tumor ◽  
Fine Print

Object. To overcome the limitations associated with surgical approaches that have been described for accessing intraparenchymal lesions of the anteromedial region of the superior cerebellum, the authors used a posterior subtemporal transtentorial approach to remove tumors in this region. In this paper they describe the surgical technique that they used as well as the operative findings and clinical outcomes observed in patients who underwent resection of tumors in the anteromedial superior cerebellum. Methods. The consecutive patients with anteromedial superior cerebellar tumors who underwent resection performed using the posterior subtemporal transtentorial approach at the National Institutes of Health were included in this study. Clinical, neuroimaging, and operative results were analyzed. Three patients (two men and one woman) with anteromedial superior cerebellar tumors (two hemangioblastomas and one pilocytic astrocytoma) underwent resection via this approach. All the tumors were larger than 3 cm in diameter (range 3.1–3.5 cm). This approach provided excellent surgical access and permitted complete tumor resection in each case. The patients remained neurologically unchanged compared with preoperative baseline findings at the last follow-up examination (conducted at 4, 18, and 42 months postoperatively). One patient displayed a mild transient confusion immediately after surgery, but it resolved within 6 days. Conclusions. The posterior subtemporal transtentorial approach provides excellent access to the anteromedial superior cerebellar region. This approach permits resection of large lesions in this location, while avoiding many of the limitations associated with other approaches to this site.

Posterior occipitocervical (C0–3) fusion using polyaxial occipital condyle to cervical spine screw and rod fixation: a radiographic and cadaveric analysis

2010 ◽  
Vol 12 (5) ◽  
pp. 509-516 ◽  
Author(s):  
Bruce M. Frankel ◽  
Michael Hanley ◽  
Alex Vandergrift ◽  
Timothy Monroe ◽  
Steven Morgan ◽  
...  
Keyword(s):  
Sagittal Plane ◽  
Craniovertebral Junction ◽  
Basilar Invagination ◽  
Atlantoaxial Instability ◽  
Occipital Condyle ◽  
Anatomical Studies ◽  
Occipitocervical Fixation ◽  
Polyaxial Screws ◽  
Occipital Condyles ◽  
Ct Studies

Numerous conditions affect the occipitocervical junction requiring treatment with occipitocervical fixation. In this paper the authors present their technique of craniocervical fixation achieved with the cephalad extension of posterior C1–3 polyaxial screw and rods to polyaxial screws placed in the occipital condyles. They retrospectively analyzed occipital condyle morphology obtained from CT analyses of 40 patients with normal cervical spines, evaluated occipital condyle screw placement feasibility in 4 cadavers, and provided a case report of a 70-year-old woman with rheumatoid arthritis, basilar invagination, and atlantoaxial instability who was treated with this novel technique. Based on radiographic analysis of occipital condyle anatomy, they concluded that on average a 3.5-mm-diameter × 20- to 30-mm-long screw can be safely placed at an angle of 20–33° from the sagittal plane. Overall, measuring the condylar heights (mean [± SD] 10.8 ± 1.5 mm, range 8.1–15.0 mm), widths (mean 11.1 ± 1.4 mm, range 8.5–14.2 mm), lengths (20.3 ± 2.1 mm, range 15.4–24.6 mm), and angles (mean 32.8 ± 5.2°, range 20.2–45.8°) by using CT studies is an accurate and precise method. This finding correlates with the results of prior anatomical studies of occipital condyles and is important in the planning of craniovertebral junction surgery.

The far-lateral approach for foramen magnum meningiomas

2013 ◽  
Vol 35 (6) ◽  
pp. E12 ◽  
Author(s):  
Bruno C. Flores ◽  
Benjamin P. Boudreaux ◽  
Daniel R. Klinger ◽  
Bruce E. Mickey ◽  
Samuel L. Barnett
Keyword(s):  
Skull Base ◽  
Cervical Spinal Cord ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Surgical Approaches ◽  
Confined Space ◽  
Far Lateral Approach ◽  
Far Lateral

Foramen magnum meningiomas (FMMs) are slow growing, most often intradural and extramedullary tumors that pose significant challenges to the skull base neurosurgeon. The indolent clinical course of FMMs and their insidious onset of symptoms are important factors that contribute to delayed diagnosis and relative large size at the time of presentation. Symptoms are often produced by compression of surrounding structures (such as the medulla oblongata, upper cervical spinal cord, lower cranial nerves, and vertebral artery) within a critically confined space. Since the initial pathological description of a FMM in 1872, various surgical approaches have been described with the aim of achieving radical tumor resection. The surgical treatment of FMMs has evolved considerably over the last 4 decades due to the progress in microsurgical techniques and development of a multitude of skull base approaches. Posterior and posterolateral FMMs can be safely resected via a standard midline suboccipital approach. However, controversy still exits regarding the optimal management of anterior or anterolateral lesions. Independently of technical variations and the degree of bone removal, all modern surgical approaches to the lower clivus and anterior foramen magnum derive from the posterolateral (or far-lateral) craniotomy originally described by Roberto Heros and Bernard George. This paper is a review of the surgical management of FMMs, with emphasis on the far-lateral approach and its variations. Clinical presentation, imaging findings, important neuroanatomical correlations, recurrence rates, and outcomes are discussed.

Temporomandibular Joint-preserving Preauricular Subtemporal-Infratemporal Fossa Approach: Surgical Technique and Clinical Application

Neurosurgery ◽  
2004 ◽  
Vol 55 (1) ◽  
pp. 143-154 ◽  
Author(s):  
Marcelo D. Vilela ◽  
Robert C. Rostomily
Keyword(s):  
Carotid Artery ◽  
Internal Carotid Artery ◽  
Temporomandibular Joint ◽  
Internal Carotid ◽  
Infratemporal Fossa ◽  
Tumor Resection ◽  
Occipital Condyle ◽  
Computed Tomographic ◽  
Surgical Access ◽  
Lower Clivus

Abstract OBJECTIVE: The preauricular subtemporal-infratemporal (PSI) approach is commonly used to resect clival tumors and other lesions anterior to the brainstem. One of the surgical steps in this approach is a condylar osteotomy or a condylectomy, which often leads to temporomandibular joint dysfunction. We describe a modification of the PSI approach that preserves the temporomandibular joint without sacrificing the ability to mobilize the petrous internal carotid artery or gain surgical access to the clivus and anterior brainstem. METHODS: Anatomic studies in cadaveric specimens were performed, and the extent of exposure of critical skull base and intradural structures was documented with postdissection fine-cut computed tomographic scans. This modification of the PSI approach was subsequently used in three consecutive patients with a clival chondrosarcoma, and the completeness of tumor resection was documented with postoperative magnetic resonance imaging and computed tomographic scans. RESULTS: This approach allowed complete mobilization of the petrous internal carotid artery and surgical access to the mid-lower clivus, jugular tubercle, hypoglossal canal, occipital condyle, anterior brainstem, and the origin of the trigeminal through hypoglossal nerves. It also proved to be safe and feasible in the three patients who underwent surgical resection of a clival chondrosarcoma, allowing a complete tumor removal. CONCLUSION: This variation of the PSI approach is practical, has no additional morbidity, and provides complete access to critical cranial base regions and tumor margins. It can certainly be used as an alternative to the standard PSI approach when dealing with clival tumors and other lesions anterior to the brainstem.

scholarly journals Resection of Foramen Magnum Meningioma through Modified Far Lateral Approach: Surgical Principles and Technical Nuances

2020 ◽  
Author(s):  
Vinayak Narayan ◽  
Fareed Jumah ◽  
Anil Nanda
Keyword(s):  
Spinal Cord ◽  
Tumor Resection ◽  
Cranial Nerves ◽  
Surgical Techniques ◽  
Foramen Magnum ◽  
Lateral Approach ◽  
Occipital Condyle ◽  
Far Lateral Approach ◽  
Far Lateral ◽  
Neurovascular Structures

Abstract Objectives Safe maximal resection is the basic principle of cranial base surgery and the grade of resection is an important factor influencing the prognostic outcome. This operative video highlights the surgical principles and technical nuances in the microsurgical resection of foramen magnum meningioma (FMM). Case Description The surgery was performed in a 45-year-old lady who presented with hoarseness of voice and spastic quadriparesis (grade 4/5). On imaging, FMM with mass effect on brainstem and spinal cord was identified. The tumor was gross totally resected through modified far lateral approach with minimal occipital condyle drilling. This video demonstrates the surgical techniques of tumor resection including early devascularization, operating in the arachnoid plane to dissect the neurovascular structures, piecemeal decompression, sharp dissection to separate tumor from lower cranial nerves (LCN), identifying the brainstem veins, and resecting the lesion from tumor–brainstem interface. Postoperatively, she had significant neurological improvement and the magnetic resonance imaging revealed excellent radiological outcome (Figs. 1 and 2). Conclusion The surgery of FMM is challenging due to the deep surgical corridor, critical location, close proximity with various neurovascular structures, firm consistency, and high vascularity of the tumor. The modified far lateral approach by preserving the occipital condyle may prevent the postoperative incidence of craniovertebral junction instability. The key operative principles to achieve the best surgical outcome include careful dissection along the arachnoid plane, gentle handling of cranial nerves, veins, and perforator vessels, avoidance of traction on brainstem and spinal cord, intraoperative neurophysiological monitoring, proper hemostasis, and meticulous dural closure.The link to the video can be found at: https://youtu.be/1qvAeUmNIUw.

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