Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation

✓ The upward odontoid displacement observed in basilar invagination (BI) is generally associated with a horizontal clivus and craniocervical kyphosis, conditions that exert ventral compression at the spinomedullary junction. Ventral brainstem decompression by reduction or elimination of the odontoid invagination is part of the desired treatment. The authors describe a case of BI in an adult, who was effectively treated with the easy and safe reduction of odontoid invagination via cervical traction. Normalization of kyphosis at the craniovertebral junction and the vertical position of both a previously horizontal clivus and the cerebellar tentorium demonstrated that these conditions were not part of the original malformation but instead were caused by a reducible craniovertebral instability.

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

Journal of Neurosurgery Spine ◽

10.3171/spi.2002.96.1.0073 ◽

2002 ◽

Vol 96 (1) ◽

pp. 73-82 ◽

Cited By ~ 12

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.

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

Journal of Neurosurgery Spine ◽

10.3171/2009.11.spine09172 ◽

2010 ◽

Vol 12 (5) ◽

pp. 509-516 ◽

Cited By ~ 23

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.

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Endoscopic Endonasal Transclival Odontoidectomy for Basilar Invagination: Operative Video and Technical Nuances

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715522 ◽

2020 ◽

Author(s):

James K. Liu ◽

Vincent N. Dodson ◽

Kevin Zhao ◽

Jean Anderson Eloy

Keyword(s):

Odontoid Process ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Foramen Magnum ◽

Endoscopic Endonasal ◽

Motor Weakness ◽

Cervicomedullary Junction ◽

Unsteady Gait ◽

Cervical Traction ◽

Motor Strength

AbstractBasilar invagination is a congenital or acquired craniovertebral junction abnormality where the tip of the odontoid process projects through the foramen magnum which can cause severe symptomatic compression of the brainstem and spinal cord. If left untreated, patients can develop progressive quadriparesis. Traditionally, basilar invagination can be treated with cervical traction and posterior stabilization. However, in irreducible cases, anterior decompression via a transoral or endonasal approach may be necessary. In this operative video, we demonstrate an endoscopic endonasal transclival approach for odontoidectomy to successfully treat a 37-year-old female with severe basilar invagination causing symptomatic compression on the cervicomedullary junction resulting in unsteady gait and motor weakness. The patient had Klippel–Feil syndrome where the C1 arch was assimilated to the foramen magnum and transclival drilling was needed to adequately access the odontoid process for removal. A second-stage posterior occipitocervical stabilization and fusion was performed the following day. Immediate postoperative imaging showed excellent decompression of the cervicomedullary junction. Postoperatively, the patient had significant improvement in gait and motor strength in all extremities, and was ambulating independently without assistance at 1 year after surgery. The endoscopic endonasal transclival odontoidectomy is a useful strategy to treat severe irreducible basilar invagination causing symptomatic neural compression. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video.The link to the video can be found at: https://youtu.be/HL4K7KqJEJM.

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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

Surgical Neurology International ◽

10.25259/sni_284_2021 ◽

2021 ◽

Vol 12 ◽

pp. 260

Author(s):

Claudio Henrique F. Vidal ◽

Ricardo Brandao Fonseca ◽

Bruno Leimig ◽

Walter F. Matias-Filho ◽

Geraldo Sa Carneiro-Filho

Keyword(s):

Postoperative Period ◽

Posterior Approach ◽

Odontoid Process ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Foramen Magnum ◽

Occipitocervical Fixation ◽

Significant Difference ◽

Indirect Decompression ◽

Head Clamp

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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Basilar Invagination

Neurosurgery ◽

10.1227/01.neu.0000365770.10690.6f ◽

2010 ◽

Vol 66 (suppl_3) ◽

pp. A39-A47 ◽

Cited By ~ 85

Author(s):

Justin S. Smith ◽

Christopher I. Shaffrey ◽

Mark F. Abel ◽

Arnold H. Menezes

Keyword(s):

Surgical Treatment ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Foramen Magnum ◽

Developmental Anomaly ◽

Autogenous Bone ◽

Posterior Decompression ◽

Neural Axis ◽

Cervical Traction ◽

Occipital Condyles

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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Endoscopic Transnasal Transclival Odontoidectomy: A New Approach to Decompression: Technical Case Report

Operative Neurosurgery ◽

10.1227/01.neu.0000313115.51071.d5 ◽

2008 ◽

Vol 63 (suppl_1) ◽

pp. ONSE92-ONSE94 ◽

Cited By ~ 20

Author(s):

Jau-Ching Wu ◽

Wen-Cheng Huang ◽

Henrich Cheng ◽

Muh-Lii Liang ◽

Ching-Yin Ho ◽

...

Keyword(s):

Clinical Presentation ◽

Odontoid Process ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

New Approach ◽

Prolonged Intubation ◽

Less Invasive ◽

Transoral Odontoidectomy ◽

Occipitocervical Fixation ◽

Lateral Mass Screws

Abstract Objective: Endoscopic transnasal transclival resection of the odontoid process is less invasive than the standard transoral odontoidectomy. In this article, we describe our techniques, which are less invasive but provide successful decompression. Clinical Presentation: From September 2004 to April 2007, three consecutive patients with basilar invagination and instability in the craniovertebral junction were enrolled. The causes for the invagination and instability included rheumatoid arthritis in two patients and trauma in one patient, and all patients presented with myelopathy and quadriparesis before intervention. Intervention: All three patients underwent an endoscopic transnasal transclival approach for anterior decompression and resection of the displaced odontoid process and pannus to decompress the underlying medulla. Subsequently, they received occipitocervical fixation by lateral mass screws and bone fusion to ensure stability. Remarkable neurological recovery was observed after surgery in all patients, and no adverse effects were noted. Conclusion: Compared with the standard transoral approach, the transnasal transclival endoscopic approach for decompressing basilar invagination is a feasible and effective alternative that avoids common disadvantages like prolonged intubation, excessive tongue retraction, and the need for palatal incision.

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Further cranial settling of the upper cervical spine following odontoidectomy

Journal of Neurosurgery Spine ◽

10.3171/spi.2001.95.2.0246 ◽

2001 ◽

Vol 95 (2) ◽

pp. 246-249 ◽

Cited By ~ 11

Author(s):

Sait Naderi ◽

M. Necmettin Pamir

Keyword(s):

Craniovertebral Junction ◽

Basilar Invagination ◽

Upper Cervical Spine ◽

Rigid Fixation ◽

Content Type ◽

Fusion Procedure ◽

Transoral Odontoidectomy ◽

Occipitocervical Fixation ◽

Additional Surgery ◽

Upper Cervical

✓ A variety of diseases may affect the craniovertebral junction and require a decompressive and fusion procedure. Craniovertebral junction instability is expected after a fusion procedure. The authors describe two patients with basilar invagination who underwent transoral odontoidectomy and occipitocervical fixation. Despite an uneventful immediate postoperative course, further cranial settling of the C-2 vertebral body (VB) was demonstrated. One patient experienced neurological deterioration and required a second decompressive procedure, whereas the second patient was asymptomatic and required no additional surgery. It was concluded that the odontoidectomy may have led to horizontal separation of the C-1 lateral masses, resulting in further cranial settling of the C-2 VB. Preservation of one aspect of the C-1 anterior arch minimizes C-1 lateral mass offset and, in turn, further cranial settling of the C-2 VB. In addition, a more rigid fixation of C-2 may minimize the possibility of horizontal separation of the C-1 lateral masses after transoral odontoidectomy.

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Immediate postoperative regression of retroodontoid pannus after lateral mass reconstruction in a patient with rheumatoid disease of the craniovertebral junction

Journal of Neurosurgery Spine ◽

10.3171/spi/2008/9/9/273 ◽

2008 ◽

Vol 9 (3) ◽

pp. 273-276 ◽

Cited By ~ 36

Author(s):

Atul Goel ◽

Nitin Dange

Keyword(s):

Bone Graft ◽

Craniovertebral Junction ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Postoperative Phase ◽

Complete Disappearance ◽

Lateral Mass ◽

Rheumatoid Disease ◽

Mass Reconstruction

The authors report the case of a 35-year-old man who had polyarthritic affliction with rheumatoid disease. He presented with complaints of quadriparesis that had progressed over the course of 2 years. Investigations revealed telltale evidence of rheumatoid disease of the craniovertebral junction with retroodontoid pannus, basilar invagination, and “fixed” atlantoaxial dislocation. The patient underwent lateral mass reconstruction with distraction of the facets and impaction of a spiked metal spacer and bone graft within the joint. Investigations done in the immediate postoperative phase showed complete disappearance of retroodontoid pannus in addition to reduction of basilar invagination and atlantoaxial dislocation. He had remarkable and sustained relief from symptoms. The authors also review the pathogenesis and treatment of retroodontoid pannus.

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Surgical treatment for basilar invagination with irreducible atlantoaxial dislocation: transoral atlantoaxial reduction plate fixation vs occipitocervical fixation

BMC Musculoskeletal Disorders ◽

10.1186/s12891-020-03838-6 ◽

2020 ◽

Vol 21 (1) ◽

Author(s):

Xiaobao Zou ◽

Bieping Ouyang ◽

Haozhi Yang ◽

Binbin Wang ◽

Su Ge ◽

...

Keyword(s):

Surgical Treatment ◽

Early Stage ◽

Plate Fixation ◽

Japanese Orthopaedic Association ◽

Odontoid Process ◽

Basilar Invagination ◽

Atlantoaxial Dislocation ◽

Clinical Effects ◽

Occipitocervical Fixation ◽

Irreducible Atlantoaxial Dislocation

Abstract Background Transoral atlantoaxial reduction plate (TARP) fixation or occipitocervical fixation (OF) is an effective treatment for basilar invagination (BI) with irreducible atlantoaxial dislocation (IAAD). But, all current clinical studies involved a single surgical procedure. The clinical effects of TARP and OF operation for BI with IAAD have yet to be compared. We therefore present this report to compare the treatment of TARP and OF procedure for BI with IAAD. Methods Fifty-six patients with BI with IAAD who underwent TARP or OF operation from June 2011 to June 2017 were retrospectively analyzed. Among these, 35 patients underwent TARP operation (TARP group), and 21 patients underwent OF operation (OF group). We compared the difference of clinical, radiological, and surgical outcomes between the TARP and OF groups postoperatively. Results Compared with OF group, the operative time and blood loss in TARP group were lower. There was no statistical difference in the atlantodental interval (ADI), clivus canal angle (CCA), cervicomedullary angle (CMA), distance between the top of the odontoid process and the Chamberlain line (CL) and Japanese Orthopaedic Association (JOA) score between the TARP and OF groups preoperatively, but the improvements of these parameters in the TARP group were superior to those in the OF group postoperatively. The fusion rates were higher in the TARP group than those in the OF group at the early stage postoperatively. Conclusions TARP and OF operations are effective surgical treatment for BI with IAAD, but the performance of reduction and decompression and earlier bone fusion rates of TARP procedure are superior to those of OF.

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