Occipitocervical fusion after resection of craniovertebral junction tumors

2006 ◽  
Vol 4 (2) ◽  
pp. 137-144 ◽  
Author(s):  
Hyunchul Shin ◽  
Ignacio J. Barrenechea ◽  
Jonathan Lesser ◽  
Chandranath Sen ◽  
Noel I. Perin
Keyword(s):  
Neck Pain ◽  
Perioperative Complications ◽  
Craniovertebral Junction ◽  
Foramen Magnum ◽  
Occipitocervical Fusion ◽  
Glomus Tumors ◽  
Factors Associated ◽  
Presenting Symptoms ◽  
Surgical Access

Object Surgical access to tumors at the craniovertebral junction (CVJ) requires extensive bone removal. Guidelines for the use of occipitocervical fusion (OCF) after resection of CVJ tumors have been based on anecdotal evidence. The authors performed a retrospective study of factors associated with the use of OCF in 46 patients with CVJ tumors. The findings were used to develop recommendations for use of OCF in such patients. Methods The authors retrospectively reviewed the cases of 51 patients with CVJ tumors treated by their group between March 1991 and February 2004. Forty-six patients were available for follow up. Charts were reviewed to obtain data on demographic characteristics, presenting symptoms, and perioperative complications. Preoperative computerized tomography scans and magnetic resonance imaging studies were obtained in all patients. Occipitocervical fusion was performed in patients who had undergone a unilateral condyle resection in which 70% or more of the condyle was removed, a bilateral condyle resection with 50% removal, or C1–2 vertebral body destruction. Of the 46 patients, 16 had foramen magnum meningiomas, 17 had chordomas, one had a chondrosarcoma, two had Schwann cell tumors, two had glomus tumors, and eight had other types of tumors. Twenty-three (50%) of the 46 patients underwent OCF, including 15 of the 17 patients with chordomas (88%). None of the patients with meningiomas required fusion. Seventeen (71%) of the 24 patients presenting with neck pain preoperatively underwent OCF. Conclusions Patients presenting with neck pain had a 71% chance of undergoing OCF. Patients with chordomas and metastatic tumors were most likely to require OCF. One patient with a 50% unilateral condylar resection returned with OC instability for which OCF was required. Based on their clinical experience and published biomechanical studies, the authors recommend that OCF be performed when 50% or more of one condyle is resected.

scholarly journals Outcomes and effectiveness of posterior occipitocervical fusion for suboccipital spinal metastases

2017 ◽  
Vol 26 (5) ◽  
pp. 554-559 ◽  
Author(s):  
Panya Luksanapruksa ◽  
Jacob M. Buchowski ◽  
Neill M. Wright ◽  
Frank H. Valone ◽  
Colleen Peters ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Neck Pain ◽  
Cancer Patients ◽  
Perioperative Complications ◽  
Spinal Metastases ◽  
Vascular Anatomy ◽  
Scoring Systems ◽  
Occipitocervical Fusion ◽  
Primary Tumors

OBJECTIVEThe incidence of suboccipital spinal metastases is rare but has increased given cancer patients' longer life expectancies. Operative treatment in this region is often challenging because of limited fixation points due to tumor lysis, as well as adjacent neural and vascular anatomy. Few studies have reported on this population of cancer patients. The purpose of this study was to evaluate clinical outcomes and complications of patients with suboccipital spinal metastases who had undergone posterior occipitocervical fixation.METHODSA single-institution database was reviewed to identify patients with suboccipital metastases who had undergone posterior-only instrumented fusion between 1999 and 2014. Clinical presentation, perioperative complications, and postoperative results were analyzed. Pain was assessed using the visual analog scale. Survival analysis was performed using a Kaplan-Meier curve. The revised Tokuhashi and the Tomita scoring systems were used for prognosis prediction.RESULTSFifteen patients were identified, 10 men and 5 women with mean age of 64.8 ± 11.8 years (range 48–80 years). Severe neck pain without neurological deficit was the most common presentation. Primary tumors included lung, breast, bladder, myeloma, melanoma, and renal cell cancers. All tumors occurred in the axis vertebra. Preoperative Tokuhashi and Tomita scores ranged from 5 to 13 and 3 to 7, respectively. All patients had undergone occipitocervical fusion of a mean of 4.6 levels (range 2–7 levels). Median survival was 10.3 months. In all cases, neck pain markedly improved and patients were able to resume activities of daily living. The average postoperative pain score was significantly improved as compared with the average preoperative score (1.90 ± 2.56 and 5.50 ± 2.99, respectively, p = 0.01). Three patients experienced postoperative medical complications including urinary tract infection, deep vein thrombosis, myocardial infarction, and cardiac arrhythmia. In the follow-up period, no wound infections or reoperations occurred and no patients experienced spinal cord deficits from tumor recurrence.CONCLUSIONSPosterior-only occipitocervical stabilization was highly effective at relieving patients' neck pain. No instrumentation failures were noted, and no neurological complications or tumor progression causing spinal cord deficits was noted in the follow-up period.

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%.

Trombone tongue: a new clinical sign for significant medullary compression at the craniovertebral junction

2006 ◽  
Vol 5 (6) ◽  
pp. 550-553 ◽  
Author(s):  
Cheong H. Lee ◽  
Adrian T. H. Casey ◽  
James B. Allibone ◽  
Ramesh Chelvarajah
Keyword(s):  
Clinical Sign ◽  
Craniovertebral Junction ◽  
Basilar Invagination ◽  
Foramen Magnum ◽  
Occipitocervical Fusion ◽  
Repetitive Motion ◽  
Tongue Movements ◽  
Leg Weakness ◽  
Significant Compression ◽  
Spastic Tetraparesis

✓The authors describe a previously unreported clinical sign that may indicate the onset of significant compression of the medulla oblongata in cases of craniovertebral junction abnormalities. This 17-year-old boy presented with mild bilateral leg weakness. Imaging studies revealed severe basilar invagination and a marked Chiari malformation. While awaiting surgery, his tongue developed an involuntary constant protrusion–intrusion repetitive motion. The onset of this so-named “trombone tongue” sign was followed shortly afterward by rapidly progressive spastic tetraparesis. After the authors performed a transmaxillary clivectomy, foramen magnum decompression, and occipitocervical fusion, they noted that the abnormal tongue motion promptly resolved and the tetraparesis gradually improved. The authors discuss their current understanding of the central control of tongue movements and present a hypothesis on the pathogenesis of trombone tongue based on the neuroanatomical basis of another abnormal tongue movement sign, lingual myoclonus.

Radiosurgery for Primary Motor and Sensory Cortex Arteriovenous Malformations

Neurosurgery ◽  
2013 ◽  
Vol 73 (5) ◽  
pp. 816-824 ◽  
Author(s):  
Dale Ding ◽  
Chun-Po Yen ◽  
Zhiyuan Xu ◽  
Robert M. Starke ◽  
Jason P. Sheehan
Keyword(s):  
Arteriovenous Malformations ◽  
Cox Regression ◽  
Gamma Knife Radiosurgery ◽  
Intracranial Arteriovenous Malformations ◽  
Cox Regression Analysis ◽  
Factors Associated ◽  
Presenting Symptoms ◽  
Prescription Dose ◽  
Hemorrhage Risk

Abstract BACKGROUND: Eloquent intracranial arteriovenous malformations (AVMs) located in the primary motor or somatosensory cortex (PMSC) carry a high risk of microsurgical morbidity. OBJECTIVE: To evaluate the outcomes of radiosurgery on PMSC AVMs and compare them with radiosurgery outcomes in a matched cohort of noneloquent lobar AVMs. METHODS: Between 1989 and 2009, 134 patients with PMSC AVMs underwent Gamma Knife radiosurgery with a median radiographic and clinical follow-up of 64 and 80 months, respectively. Seizure (40.3%) and hemorrhage (28.4%) were the most common presenting symptoms. Pre-radiosurgery embolization was performed in 33.6% of AVMs. Median AVM volume was 4.1 mL (range, 0.1-22.6 mL), and prescription dose was 20 Gy (range, 7-30 Gy). Cox regression analysis was performed to identify factors associated with obliteration. RESULTS: The overall obliteration rate, including magnetic resonance imaging and angiography, after radiosurgery was 63%. Obliteration was achieved in 80% of AVMs with a volume less than 3 mL compared with 55% for AVMs larger than 3 mL. No previous embolization (P = .002) and a single draining vein (P = .001) were independent predictors of obliteration on multivariate analysis. The annual post-radiosurgery hemorrhage risk was 2.5%. Radiosurgery-related morbidity was temporary and permanent in 14% and 6% of patients, respectively. Comparing PMSC AVMs with matched noneloquent lobar AVMs, the obliteration rates and clinical outcomes after radiosurgery were not statistically different. CONCLUSION: For patients harboring PMSC AVMs, radiosurgery offers a reasonable chance of obliteration with a relatively low complication rate. Eloquent location does not appear to confer the same negative prognostic value for radiosurgery that it does for microsurgery.

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.

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 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.

Institutional experience of tuberculosis of craniovertebral junction

2017 ◽  
Vol 5 (4) ◽  
pp. 1294 ◽  
Author(s):  
Ravi Dasari ◽  
Kadali Satyavara Prasad ◽  
Phaneeswar Thota ◽  
Raman B. V. S.
Keyword(s):  
Neck Pain ◽  
Radical Surgery ◽  
Treatment Options ◽  
Craniovertebral Junction ◽  
Cord Compression ◽  
Basilar Invagination ◽  
Neurological Deficits ◽  
Occipitocervical Fusion ◽  
Bony Destruction ◽  
King George Hospital

Background: Craniovertebral junction tuberculosis (CVJ-TB) is a rare entity occurring in only 0.3 to 1% of tuberculous spondylitis. It causes severe instability and neurological deficits. Present study includes 16 cases of CVJ tuberculosis with neck pain and progressive quadriparesis. Radiological evaluation showed wide spread disease around clivus, C1, C2, C3 with extensive bony destruction, cord compression, basilar invagination and atlantoaxial dislocation.Methods: The study included all the cases admitted with cv junction tuberculosis in neurosurgery ward in King George hospital, Visakhapatnam during a period of three years from 2014 to 2016. Four cases were managed conservatively and four cases were treated by only posterior occipitocervical fusion. We performed two stage operation in single sitting i.e. transoral decompression and posterior occipitocervical fusion in 12 cases. The pathological findings confirmed tuberculosis.Results: Postoperatively all the patients had decreased neck pain and two third of the patients (10 of 16 patients) had improvement in motor power.Conclusions: In the available literature, the treatment options offered for cvj-tb have ranged from a purely conservative approach to radical surgery without well-defined guidelines. In this study, we followed a radical approach as the patients included in our study presented with extensive TB cv junction. So, we recommend radical surgery for extensive TB of cv junction.

Posterior occipitoaxial fusion for atlantoaxial dislocation associated with occipitalized atlas

1996 ◽  
Vol 84 (4) ◽  
pp. 559-564 ◽  
Author(s):  
Vijendra K. Jain ◽  
Piyush Mittal ◽  
Deepu Banerji ◽  
Sanjay Behari ◽  
Rajesh Acharya ◽  
...  
Keyword(s):  
Fusion Rate ◽  
Foramen Magnum ◽  
Atlantoaxial Dislocation ◽  
Posterior Fusion ◽  
Posterior Arch ◽  
Occipitocervical Fusion ◽  
Content Type ◽  
Transoral Odontoidectomy ◽  
Preoperative Status

✓ Between 1989 and 1994, 50 patients suffering from congenital atlantoaxial dislocation with either an assimilated atlas or a thin or deficient posterior arch of the atlas were treated with occipitocervical fusion using the technique described by Jain and colleagues in 1993 with a few modifications. An artificial bridge created from the occipital bone along the margin of the foramen magnum was fused to the axis using sublaminar wiring and interposed strut and lateral onlay bone grafts. Ten patients (20%) also underwent atlantoaxial lateral joint fusion by intraarticular instillation of bone chips. In 22 patients (44%) with irreducible dislocation, posterior fusion was preceded by transoral odontoidectomy. In seven patients (14%) with ventral compression, who showed marked clinical improvement on traction despite radiological evidence of persisting atlantoaxial dislocation, occipitocervical fusion was performed without ventral decompression. Seven patients (14%) underwent a single-stage transoral odontoidectomy and posterior fusion. There was no perioperative mortality and the osseous fusion rate was 88%. Of the 43 patients available at follow-up examination (range 3–12 months), 31 patients (72.09%) improved, seven (16.28%) remained the same, and five (11.6%) deteriorated in comparison with their preoperative status. Hence, this technique achieves a stable occipitocervical arthrodesis without supplemental external orthoses and facilitates early postoperative mobilization.

scholarly journals Observational outcome in surgery for Chiari malformation patients

2020 ◽  
Vol 7 (9) ◽  
pp. 3068
Author(s):  
Harisinh Parmar ◽  
Jaimin K. Shah ◽  
Jayant Gaud ◽  
Shailendra J. Solanki ◽  
Jatin Mavani ◽  
...  
Keyword(s):  
Chiari Malformation ◽  
Craniovertebral Junction ◽  
Presenting Symptoms ◽  
Cervical Portion ◽  
Suitable Treatment ◽  
Additional Procedure ◽  
Fluid Leak ◽  
Surgical Corrections ◽  
The Brain

Chiari malformation is the commonest anomaly of the craniovertebral junction involving both the skeletal as well as the neural structures. It is congenital anomaly of the hindbrain characterised by downward elongation of the brain stem and cerebellum into the cervical portion of spinal cord. Most common presenting symptoms was pain in the nape of neck with sub-occipital headache and weakness. If not intervened early in these cases they may progress to quadriparesis and respiratory failure. This study includes authors experience of 30 surgical corrections of Chiari malformation performed at civil hospital Ahmedabad from 2017 to 2019. The age and sex of the patient, the presence of syrinx, the type of surgical procedure and the clinical outcome were determined post-operatively and on follow up. Cerebro spinal fluid leak and collection were observed in patient who undergone duroplasty only with no leakage in patient undergone syringo-subarachnoid shunt. Overall, tingling/numbness had best improvement showed improvement in 13 out of 16 patients. Power showed improvement in 20 out of 27 patients and pain showed improvement in 18 patients. Wasting, clawing and cerebellar signs and bony deformity showed no improvement in any of the above procedures. Authors can conclude for Chiari malformation decompression with or without duroplasty with additional procedure with post-operative physiotherapy and analgesia is the suitable treatment.

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