Skip to main content
SpringerLink
Log in

C1–C2 arthrodesis after transoral odontoidectomy and suboccipital craniectomy for ventral brain stem compression in Chiari I patients

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

Reference

  1. Alfieri A, Jho HD, Tschabitscher M (2002) Endoscopic endonasal approach to the ventral cranio-cervical junction: anatomical study. Acta Neurochir 144(3):219–225

    Article  CAS  Google Scholar 

  2. 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

    PubMed  CAS  Google Scholar 

  3. Bindal A, Dunsker S, Tew JJ (1995) Chiari I malformation: classification and management. Neurosurgery 37:1069–1074

    Article  PubMed  CAS  Google Scholar 

  4. Bogduk N, Mercer S (2000) Biomechanics of the cervical spine. I. Normal kinematics. Clin Biomech 15(9):633–648

    Article  CAS  Google Scholar 

  5. 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

    Article  PubMed  Google Scholar 

  6. DeBarros M, Farias W, Ataide L, Lins S (1968) Basilar impression and Arnold-Chiari malformation. J Neurol Neurosurg Psychiatr 31:596–605

    Google Scholar 

  7. 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

    Article  CAS  Google Scholar 

  8. 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

    Article  PubMed  Google Scholar 

  9. Dickman CA, Crawford NR, Brantley AG, VKl Sonntag (1995) Biomechanical effects of transoral odontoidectomy. Neurosurgery 36(6):1146–1152

    Article  PubMed  CAS  Google Scholar 

  10. 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

    Article  PubMed  CAS  Google Scholar 

  11. 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

    Article  PubMed  Google Scholar 

  12. 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

    PubMed  CAS  Google Scholar 

  13. 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

    PubMed  Google Scholar 

  14. 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

    PubMed  Google Scholar 

  15. Goel A, Achawal S (1995) The surgical treatment of Chiari malformation associated with atlantoaxial dislocation. Br J Neurosurg 9(1):67–72

    Article  PubMed  CAS  Google Scholar 

  16. Goel A, Bhatjiwale M, Desai K (1998) Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 88:962–968

    PubMed  CAS  Google Scholar 

  17. Goel A, Desai K (2000) Surgery for syringomyelia: an analysis based on 163 surgical cases. Acta Neurochir 142(3):293–301

    Article  CAS  Google Scholar 

  18. 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

    Google Scholar 

  19. 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

    Article  PubMed  CAS  Google Scholar 

  20. 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

    Article  PubMed  CAS  Google Scholar 

  21. Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26(22):2467–2471

    Article  PubMed  CAS  Google Scholar 

  22. 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

    Article  PubMed  Google Scholar 

  23. 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

    Article  PubMed  Google Scholar 

  24. 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

    PubMed  Google Scholar 

  25. Kandziora F, Kerschbaumer F, Starker M, Mittlmeier T (2000) Biomechanical assessment of transoral plate fixation for atlantoaxial instability. Spine 25(12):1555–1561

    Article  PubMed  CAS  Google Scholar 

  26. 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

    Article  PubMed  Google Scholar 

  27. 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

    Article  PubMed  CAS  Google Scholar 

  28. 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

    Article  PubMed  Google Scholar 

  29. 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)

    Article  PubMed  CAS  Google Scholar 

  30. 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

    Article  PubMed  Google Scholar 

  31. 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

    Article  PubMed  CAS  Google Scholar 

  32. Menezes AH, VanGilder JC, Graf CJ, McDonnell DE (1980) Craniocervical abnormalities: a comprehensive surgical approach. J Neurosurg 53(4):444–455

    PubMed  CAS  Google Scholar 

  33. 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

    PubMed  CAS  Google Scholar 

  34. 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

    Article  PubMed  CAS  Google Scholar 

  35. 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

    Article  PubMed  Google Scholar 

  36. 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

    Article  PubMed  CAS  Google Scholar 

  37. Paramore C, Dickman C, Sonntag V (1996) The anatomical suitability of the C1-2 complex for transarticular screw fixation. J Neurosurg 85:221–224

    PubMed  CAS  Google Scholar 

  38. 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

    PubMed  CAS  Google Scholar 

  39. 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

    Google Scholar 

  40. 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

    PubMed  Google Scholar 

  41. 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

    Article  PubMed  Google Scholar 

  42. 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

    Article  PubMed  CAS  Google Scholar 

  43. 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

    Article  PubMed  Google Scholar 

  44. Tuite GF, Veres R, Crockard HA, Sell D (1996) Pediatric transoral surgery: indications, complications, and long-term outcome. J Neurosurg 84(4):573–583

    Article  PubMed  CAS  Google Scholar 

  45. Vale FL, Oliver M, Cahill DW (1999) Rigid occipitocervical fusion. J Neurosurg 91(2 Suppl):144–150

    PubMed  CAS  Google Scholar 

  46. VanGilder JC, Menezes AH (1983) Craniovertebral junction abnormalities. Clin Neurosurg 30:514–530

    PubMed  CAS  Google Scholar 

  47. White A, Johnson R, Panjabi MM, Southwick W (1975) Biomechanical analysis of clinical stability in the cervical spine. Clin Orthop 105:85–96

    Google Scholar 

  48. White A, Panjabi MM (1978) The clinical biomechanics of the occipitoatlantoaxial complex. Orthop Clin North Am 9(4):867–878

    PubMed  Google Scholar 

  49. 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

    PubMed  CAS  Google Scholar 

  50. 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

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery #178, Tufts-New England Medical Center, 750 Washington Street, Boston, MA, 02111, USA

    Steven W. Hwang, Carl B. Heilman, Ron I. Riesenburger & James Kryzanski

Authors
  1. Steven W. Hwang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Carl B. Heilman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ron I. Riesenburger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. James Kryzanski
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Steven W. Hwang.

Rights and permissions

Reprints and permissions

About this article

Cite this article

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

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-008-0706-x

Keywords

Search

Navigation