Transoral Decompression and Posterior Stabilization in Fixed Anterior Pathology of the Craniocervical Junction

Abstract

Introduction Management of the anterior compressive pathology of the craniovertebral junction (CVJ) is complex and demanding. We review our experience with the transoral surgical decompression of fixed anterior CVJ lesions, with particular attention to the decision making and to the indication for a consecutive stabilization. Patients and Methods Retrospective study (2000–2013) of 47 consecutive patients (14 males and 13 females). Mean age was 59.2 years (range, 32–82 years). Encountered lesions were rheumatoid arthritis with pannus (29, 9 of which with associated cranial settling), ankylosing spondylitis (four), tumors (seven: six extradural chordomas/chondrosarcomas and one metastasis), odontoid fractures with hypoporosis, and rotational instability (seven). Patients presented with a variety of following symptoms: high cervical pain (82%), varying degrees of quadriparesis (64%), lower cranial nerve deficits (23%), and central cord syndrome with neurogenic bladder (14%). All patients underwent one-stage transoral decompression and consecutive posterior atlantoaxial or occipitocervical stabilization. Clinical evaluation was made pre- and postoperatively using the Ranawat score. Follow-up period ranged between 6 and 48 months (average, 22 months). Results According to the Ranawat score, we had 21 grade I patients, in 20 of which pain was eradicated, 10 grade II patients, 8 of which passed to grade I, 11 grade IIIA patients, of which 6 passed to grade I and 5 to grade II, and 5 grade IIIB patients of which 4 passed to grade IIIA. In seven patients, the transarticular screws crossed the anterior cortex of the atlas, without clinical manifestations. In five patients, complete reduction of the C1–C2 rotation was not possible, because of the chronic nature of the defect. Surgical morbidity occurred in five cases (three dural tears and two occipital wound infections). There were two perioperative deaths ([a] dural rupture, pneumoencephaly, meningitis, and massive pulmonary embolism, [b] pulmonary infection, and cardiorespiratory arrest). Conclusion Successful and stable decompression of the CVJ requires extensive preoperative evaluation, appropriate tailoring, and adequate expertise. The transarticular C1–C2 fixation is a safe and effective stabilization method when the atlanto-occipital joints remain competent. Complications appear mostly in patients with rotational deformity of the C1–C2 complex. Patients with clinical and radiological findings of myelopathy improve less even if surgery is successful.