Neurosurgery
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Os odontoideum is an independent ossicle of variable size with smooth circumferential cortical margins separated from the foreshortened odontoid peg. The etiology of os odontoideum remains controversial, but there is now emerging consensus on the traumatic etiology of os odontoideum rather than a congenital source. ⋯ There is a role for conservative treatment of an asymptomatic incidentally found, radiologically stable, and noncompressive os odontoideum. Conversely, surgery has a definite role in symptomatic cases. The main method of surgical treatment today is posterior decompression after reduction and fusion via independent C1 and C2 instrumentation. Irreducible, persistent anterior compression from os odontoideum can be approached by a transoral route with good results in experienced hands.
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The transoral approach provides the most direct exposure to extradural lesions of the ventral craniovertebral junction. Lesions that extend beyond the exposure provided by the standard transoral approach require an extended transoral modification. The exposure can be expanded in the sagittal and axial planes by adding mandibulotomy, mandibuloglossotomy, palatotomy, and transmaxillary approaches to the standard transoral approach. Extended transoral approaches increase the surgical complexity and the risk of cosmetic and functional complications. Until recently, selection of an extended approach has been arbitrary and dependent on the surgeon's familiarity with the surgical approach. ⋯ Surgical decisions can be based on comprehensive preoperative evaluation of anatomy, pathology, and radiographic studies to maximize exposure while minimizing complications.
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Transarticular screw (TAS) fixation is our preferred method for stable internal fixation of the atlantoaxial joint because of its excellent outcomes, versatility, and cost-effectiveness. ⋯ The placement of TASs is safe and effective for stabilizing the atlantoaxial articulation. Refinements in technique, such as 3-dimensional stereotactic workstation for trajectory planning, have reduced the rate of serious complications. Clinical outcomes are excellent, with nearly 100% of patients achieving stable bony union.
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To describe the indications and techniques for occipitocervical (OC) fixation. ⋯ OC fixation systems have evolved from wire and cable techniques to plates, rods, and screws. Screw-rod constructs are easy to implant and biomechanically more rigid than wire techniques.
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This study reviews the relevant literature regarding the management of craniovertebral junction (CVJ) metastases. These rare tumors present significant diagnostic and treatment challenges. ⋯ Effective management of CVJ tumors using radiation and/or surgery results in significant pain and functional improvement in properly selected patients. Advanced surgical techniques and stereotactic radiation may improve outcomes with less morbidity.