Surgical Strategies in Craniovertebral Junction Lesions

Abstract

Objective: Outcome analysis of surgical management in craniovertebral junction (CVJ) lesions (trauma, congenital anomalies [CA], and rheumatoid arthritis [RA]). Methods: Sixty-three patients with CVJ pathology underwent surgery between 1998 and 2011. Trauma occurred in 49 cases, CA in 3, and RA in 11. Diagnostics consisted of neuro-orthopedic status assessment and neuroimaging. Patients were divided into two groups according to dominating clinical syndromes (DCSs): Group I was neurologically complicated with spinal cord compression, group 2 was orthopedically complicated with unstable injuries and high risk of secondary neuro-orthopedic lesions. Results: Group I (24 patients) with spinal cord compression had absolute indications for surgery, including myelopathic syndrome. These patients underwent single, two-stage surgery including spinal cord decompression and fixation. The first stage was decompression. The decompression target was chosen by compression direction as follows: Anterior decompression was done in cases with anterior compression (transoral-transpharyngeal approach), posterior decompression was done in cases with posterior compression. Group II (39 patients) had unstable injuries with high risk of secondary neuro-orthopedic lesions. The fixation method was chosen differentially. In cases of acute dental fracture, cannulated fixation was used; for atlanto-occipital dislocation, craniocervical fixation was used; for transarticular C1-C2, in case of Hangman's fracture, ACDF C2-C3 was used. Eighty-two percent of patients had follow-up from 1 year up to 5 years. We achieved positive outcome in 94.3% of patients. Three of 63 patients after surgery (4.6%) had complications. Conclusion: Spinal cord compression is an absolute indication for surgery. Wide bone resection requires safe internal fixation. Surgery in patients with instability without myelopathic manifestations provides possibilities for better functional outcomes in a shorter time.