Abstract
Chiari I malformations are often associated with congenital craniocervical anomalies such as platybasia, basilar invagination, and retroflexion of the odontoid process. Management of ventral brain stem compression associated with Chiari I malformations remains controversial, but several authors report a significant rate of failure with suboccipital decompression alone in the presence of pronounced ventral brain stem compression (VBSC). Treatment options described in the literature for these patients involve anterior, posterior, or combined decompressions with or without concurrent arthrodesis. A combined anterior and posterior approach provides a definitive circumferential decompression but also significantly disrupts the stability of the occipitocervical junction usually necessitating occipitocervical fixation. We describe an alternative surgical treatment for Chiari I patients with significant ventral brain stem compression where a combined anterior and posterior decompression was considered necessary. We report two patients who underwent transoral odontoidectomy with preservation of the anterior arch of the atlas and suboccipital craniectomy with C1 laminectomy followed by C1–C2 arthrodesis. Preservation of the anterior arch of the atlas in conjunction with C1–C2 arthrodesis stabilizes the occipito–atlanto-axial segments while conserving more cervical mobility as compared to an occipitocervical fusion.
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Alfieri A, Jho HD, Tschabitscher M (2002) Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir 144(3):219–225
Aronson DD, Kahn RH, Canady A, Bollinger RO, Towbin R (1991) Instability of the cervical spine after decompression in patients who have Arnold-Chiari malformation. J Bone Joint Surg Am 73(6):898–906
Bindal A, Dunsker S, Tew JJ (1995) Chiari I malformation: classification and management. Neurosurgery 37:1069–1074
Bogduk N, Mercer S (2000) Biomechanics of the cervical spine. I. Normal kinematics. Clin Biomech 15(9):633–648
Collignon FP, Cohen-Gadol AA, Krauss WE (2004) Circumferential decompression of the foramen magnum for the treatment of syringomyelia associated with basilar invagination. Neurosurg Rev 27(3):168–172
DeBarros M, Farias W, Ataide L, Lins S (1968) Basilar impression and Arnold-Chiari malformation. J Neurol Neurosurg Psychiatr 31:596–605
Di Lorenzo N (1992) Craniocervical junction malformation treated by transoral approach. A survey of 25 cases with emphasis on postoperative instability and outcome. Acta Neurochir 118(3–4):112–116
Dickerman RD, Lefkowitz M, Arinsburg SA, Schneider SJ (2005) Chiari malformation and odontoid panus causing craniovertebral stenosis in a child with Crouzon’s syndrome. J Clin Neurosci 12(8):963–966
Dickman CA, Crawford NR, Brantley AG, VKl Sonntag (1995) Biomechanical effects of transoral odontoidectomy. Neurosurgery 36(6):1146–1152
Dvorak J, Panjabi MM, Gerber M, Wichmann W (1987) CT-functional diagnostics of the rotatory instability of the upper cervical spine: an experimental study in cadavers. Spine 12:197–205
Dvorak MF, Fisher C, Boyd M, Johnson M, Greenhow R, Oxland TR et al (2003) Anterior occiput-to-axis screw fixation. I. A case report, description of a new technique, and anatomical feasibility analysis. Spine 28(3):E54–E60
Dyste GN, Menezes AH, VanGilder JC (1989) Symptomatic Chiari malformations An analysis of presentation, management, and long-term outcome. J Neurosurg 71(2):159–168
Frempong-Boadu AK, Faunce WA, Fessler RG (2002) Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction [see comment]. Neurosurgery 51(5 Suppl):S60–S66
Gluf W, Schmidt M, Apfelbaum R (2005) Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessonslearned in 67 pediatric patients. J Neurosurg Spine 2:155–163
Goel A, Achawal S (1995) The surgical treatment of Chiari malformation associated with atlantoaxial dislocation. Br J Neurosurg 9(1):67–72
Goel A, Bhatjiwale M, Desai K (1998) Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 88:962–968
Goel A, Desai K (2000) Surgery for syringomyelia: an analysis based on 163 surgical cases. Acta Neurochir 142(3):293–301
Gonzales L, Crawford NR, Chamberlain RH, Perez Garza L, Preul M, Sonntag VK et al (2003) Craniovertebral junction fixation with transarticular screws: biomechanical analysis of a novel technique. J Neurosurg 98(2 Suppl):202–209
Grabb P, Mapstone T, Oakes W (1999) Ventral brain stem compression in pediatric and young adult patients with Chiari I malformations. Neurosurgery 44(3):520–527
Grob D, Crisco JJIII, Panjabi MM, Wang P, Dvorak J (1992) Biomechanical evaluation of four different posterior atlantoaxial fixation techniques. Spine 17(5):480–490
Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26(22):2467–2471
Hartl R, Chamberlain RH, Fifield MS, Chou D, Sonntag VK, Crawford NR (2006) Biomechanical comparison of two new atlantoaxial fixation techniques with C1-2 transarticular screw-graft fixation. J Neurosurg Spine 5(4):336–342
Hong X, Dong Y, Yunbing C, Qingshui Y, Shizheng Z, Jingfa L et al (2004) Posterior screw placement on the lateral mass of atlas: an anatomic study. Spine 29(5):500–503
Hott JS, Lynch JJ, Chamberlain RH, Sonntag VK, Crawford NR (2005) Biomechanical comparison of C1-2 posterior fixation techniques. J Neurosurg Spine 2(2):175–181
Kandziora F, Kerschbaumer F, Starker M, Mittlmeier T (2000) Biomechanical assessment of transoral plate fixation for atlantoaxial instability. Spine 25(12):1555–1561
Kassam AB, Snyderman C, Gardner P, Carrau R, Spiro R (2005) The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 57(1 Suppl):E213
Kohno K, Sakaki S, Shiraishi T, Matsuoka K, Okamura H (1990) Successful treatment of adult Arnold-Chiari malformation associated with basilar impression and syringomyelia by the transoral anterior approach. Surg Neurol 33(4):284–287
Kuroki H, Rengachary SS, Goel VK, Holekamp SA, Pitkanen V, Ebraheim NA et al (2005) Biomechanical comparison of two stabilization techniques of the atlantoaxial joints: transarticular screw fixation versus screw and rod fixation. Neurosurgery 56(1 Suppl):151–159
McLaughlin MR, Wahlig JB, Pollack IF (1997) Incidence of postlaminectomy kyphosis after Chiari decompression. Spine 22(6):613–617 (erratum appears in Spine 1997 Jun 1;22(11):1276)
Melcher RP, Puttlitz CM, Kleinstueck FS, Lotz JC, Harms J, Bradford DS et al (2002) Biomechanical testing of posterior atlantoaxial fixation techniques. Spine 27(22):2435–2440
Menezes AH, Graf CJ, Hibri N (1980) Abnormalities of the cranio-vertebral junction with cervico-medullary compression. A rational approach to surgical treatment in children. Childs Brain 7(1):15–30
Menezes AH, VanGilder JC, Graf CJ, McDonnell DE (1980) Craniocervical abnormalities: a comprehensive surgical approach. J Neurosurg 53(4):444–455
Menezes AH, VanGilder JC (1988) Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 69(6):895–903
Milhorat T, Chou M, Trinidad E, Kula R, Mandell M, Wolpert C et al (1999) Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery 44(5):1005–1017
Nishikawa M, Ohata K, Baba M, Terakawa Y, Hara M (2004) Chiari I malformation associated with ventral compression and instability: one-stage posterior decompression and fusion with a new instrumentation technique. Neurosurgery 54(6):1430–1434
Panjabi MM, Dvorak J, Duranceau J, Yamamoto I, Gerber M, Rauschning W et al (1988) Three-dimensional movements of the upper cervical spine. Spine 13:726–730
Paramore C, Dickman C, Sonntag V (1996) The anatomical suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg 85:221–224
Pollack IF, Pang D, Albright AL, Krieger D (1992) Outcome following hindbrain decompression of symptomatic Chiari malformations in children previously treated with myelomeningocele closure and shunts. J Neurosurg 77(6):881–888
Puttlitz CM, Melcher RP, Kleinstueck FS, Harms J, Bradford DS, Lotz JC et al (2004) Stability analysis of craniovertebral junction fixation techniques. J Bone Joint Surg Am 86A(3):561–568
Quebada PB, Duhaime AC (2005) Chiari malformation Type I and a dolichoodontoid process responsible for sudden cardiorespiratory arrest: case report. J Neurosurg 103(6 Suppl):567–570
Richter M, Schmidt R, Claes L, Puhl W, Wilke HJ (2002) Posterior atlantoaxial fixation: biomechanical in vitro comparison of six different techniques. Spine 27(16):1724–1732
Steinbok P, Boyd M, Cochrane D (1989) Cervical spinal deformity following craniotomy and upper cervical laminectomy for posterior fossa tumors in children. Childs Nerv Syst 5(1):25–28
Tubbs S, Wellons J, Blount J, Grabb P, Oakes W (2003) Inclination of the odontoid process in the pediatric Chiari I malformation. J Neurosurg 98:43–49
Tuite GF, Veres R, Crockard HA, Sell D (1996) Pediatric transoral surgery: indications, complications, and long-term outcome. J Neurosurg 84(4):573–583
Vale FL, Oliver M, Cahill DW (1999) Rigid occipitocervical fusion. J Neurosurg 91(2 Suppl):144–150
VanGilder JC, Menezes AH (1983) Craniovertebral junction abnormalities. Clin Neurosurg 30:514–530
White A, Johnson R, Panjabi MM, Southwick W (1975) Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop 105:85–96
White A, Panjabi MM (1978) The clinical biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am 9(4):867–878
Wright N, Lauryssen C (1998) Vertebral artery injury in C1-2 trans-articular screw fixation: results of a survey of the AANS/CNS Section on Disorders of the Spine and Peripheral Nerves. J Neurosurg 88:634–640
Zileli M, Cagli S (2002) Combined anterior and posterior approach for managing basilar invagination associated with type I Chiari malformation. J Spinal Disord 15(4):284–289
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Hwang, S.W., Heilman, C.B., Riesenburger, R.I. et al. C1–C2 arthrodesis after transoral odontoidectomy and suboccipital craniectomy for ventral brain stem compression in Chiari I patients. Eur Spine J 17, 1211–1217 (2008). https://doi.org/10.1007/s00586-008-0706-x
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DOI: https://doi.org/10.1007/s00586-008-0706-x