Surgery around the Craniocervical Junction

Abstract

The craniocervical junction (CCJ) is a challenging region which may be approached from every direction: anteriorly through the transoral approach more or less extended with maxillotomy or mandibulotomy; posteriorly through the midline posterior approach; and laterally using either the posterolateral or the anterolateral approach. Lateral approaches take advantage of the fact that the condyle-C1 and C1-C2 joints are anteriorly located on both sides of the odontoid and before the neuraxis. Intradural lesions, mostly represented by foramen magnum meningiomas (N = 103), are better reached by a posterolateral route, while extradural and osseous pathologies (mostly chordomas) (N = 57), are preferentially exposed through the anterolateral approach. In all but 2 cases stability of the CCJ whenever preoperatively intact was able to be respected. Obviously in cases of tumoral bone involvement with preoperative instability, a fixation procedure must be associated with the tumor resection. In some cases fixation can be achieved through the same lateral approach as the one used for tumor resection. Pathologies at the CCJ level are various including tumors and pseudotumors. Preoperative planning is of utmost importance to define the best approach or combination of approaches to achieve as complete a resection as possible and to keep or to restore CCJ stability.