Complications of surgery at the craniovertebral junction--avoidance and management

The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach

BACKGROUND

Surgical access to the ventral pontomedullary junction (PMJ) can be achieved through various corridors depending on the location and extension of the lesion. The jugular tubercle (JT), a surgically challenging obstacle to access the PMJ, typically needs to be addressed in transcranial exposures. We describe the endoscopic endonasal transclival approach (EETCA) and its inferolateral transtubercular extension to assess the intradural surgical field gained through JT removal. We also complement the dissections with an illustrative case.

METHODS

EETCA was surgically simulated, and the anatomical landmarks were assessed in eight cadaveric heads. Microsurgical dissections were additionally performed along the endoscopic surgical path. Lastly, we present an intraoperative video of the trans-JT approach in a patient with lower clival chordoma.

RESULTS

The EETCA allowed adequate extracranial visualization and removal of the JT. The surgical bony window-obtained along the clivus and centered at the JT via the EETCA-measured 11 × 9 × 7 mm. Removal of the JT provided an improved intradural field within the lower third of the cerebellopontine cistern to expose an area bordered by the cranial nerves VII/VIII and flocculus superior and anterior margin of the lateral recess of the fourth ventricle and cranial nerves IX-XI inferiorly, centered on the foramen of Luschka.

CONCLUSIONS

Removal of the JT via EETCA improves exposure along the lower third of the cerebellopontine and upper cerebellomedullary cisterns. The inferolateral transtubercular extension of the EETCA provides access to the lateral recess of the fourth ventricle, in combination with the ventral midline pontomedullary region.

LABIOMANDIBULAR GLOSSOTOMY APPROACH FOR CRANIOCERVICAL PATHOLOGIES - SPINE RECONSTRUCTION

ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 – C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.

Muscle Sparing C1-C2 Laminoplasty: Cadaveric Feasibility Study

BACKGROUND

Posterior cervical approaches for atlantoaxial and craniovertebral junction pathologies with or without instrumentation are often associated with excessive soft tissue dissection and bleeding consequent with disruption of the venous plexus. A few minimally invasive approaches to this region have been reported from clinical and cadaveric studies in an effort to minimize blood loss, reduce soft tissue dissection, and decrease postoperative pain; however, unilateral minimally invasive approaches have not been described. Here, we describe a minimally invasive atlantoaxial and craniovertebral approach.

METHODS

Using fresh cadavers, we performed a novel, right-sided, muscle-sparing minimally invasive C1-C2 laminotomy with laminoplasty for access to the atlantoaxial level and craniovertebral junction and used the traditional approach on left sides.

RESULTS

Using this approach, the atlantoaxial space and craniovertebral junction with wide and generous exposure via unilateral soft tissue dissection and muscle splitting was achieved. After exposure, the musculoosseous unit was easily repositioned, thus allowing for C1-C2 laminoplasty. Grossly, no damage to the vertebral artery or regional nerves was noted.

CONCLUSIONS

We present a novel, unilateral minimally invasive approach to reach the atlantoaxial and craniovertebral junction. This could allow for faster postoperative recovery, less pain and opioid requirement, and increased maintenance of atlantoaxial stability. Such a technique, after being confirmed in patients, could optimize this surgical technique.

Surgical, clinical, and radiological outcomes of occipitocervical fusion using the plate-screw-rod system with allograft in craniocervical instability

Objective:

We evaluated surgical, clinical, and radiological outcomes of posterior occipitocervical fusion (OCF) using plate–rod–screw construct supplemented with allograft in cases of occipitocervical instability.

Study Design:

This was a retrospective analysis of prospective collected data.

Methods:

Data of 52 patients who underwent posterior OCF using plate–screw–rod construct supplemented with allograft at a single institute from 2009 to 2014 were analyzed. Demographics, clinical parameters (Visual Analog Score [VAS], ODI, and mJOA score), functional status (McCormick scale), radiological parameters – mean atlantodens interval, posterior occipitocervical angle, occipitocervical 2 angle, and surgical parameters (operative time, blood loss, hospital stay, and fusion) with complications were evaluated.

Results:

The mean age of the patients was 54.56 ± 16.21 years with male: female was 28:24. The mean operative time was 142.2 min (90–185 min) and mean blood loss was 250.8 ml. The mean duration of hospital stay was 6.7 days and mean follow-up period was 65.17 ± 5.39 months. There was significant improvement in clinical parameters (modified JOA score, VAS, and Oswestry Disability Index values) postoperatively. Forty patients showed recovery in neurological status at least in Grade 1 in McCormick scale with no neurological deterioration in any patient. Furthermore, radiological parameters at cervicomedullary junction got into acceptable range. Implant-related complications noted in 1 patient and 1 patient had vertebral artery injury. We had dural tear in 3 patients and infection in 2 patients. Fusion was achieved in 46 cases with mean time for fusion was 11.039 months.

Conclusion:

Patients with occipitocervical instability can successfully undergo posterior OCF using plate–screw–rod construct supplemented with allograft with high fusion rate, good clinical and functional outcomes, and low complication rate.

Application of neuromuscular blockade and intraoperative 3D imaging in the reduction of basilar invagination

OBJECT

The treatment of basilar invagination in the pediatric age group is dependent on the possibility of preoperative reduction. Reducible lesions obviate a ventral decompression and require a dorsal-only approach for stabilization with or without a suboccipital decompression.

METHODS

The authors describe a technique of intraoperative reduction of basilar invagination with the use of general anesthesia and neuromuscular blockade in the presence of crown halo traction. Using the O-arm device, a 3D CT scan is generated in the sagittal plane to demonstrate the reduction intraoperatively. This technique was successful in 6 pediatric patients with basilar invagination.

RESULTS

The average age of the patients was 10.8 years, and they were followed for a mean period of 8.5 months. The patients had mild basilar invagination or partial reduction in extension on preoperative MR imaging. Intraoperative reduction was demonstrated in all patients by using the reported technique with intraoperative CT. All patients underwent occipitocervical fusion, and all but one underwent a suboccipital decompression. There were no complications related to the operation, and all but one reported improvement of symptoms on the last postoperative visit.

CONCLUSIONS

Intraoperative reduction performed using neuromuscular blockade and intraoperative traction is an effective method for further reduction of basilar invagination in the pediatric age group. This is the first reported application of intraoperative CT imaging performed using the O-arm device in craniocervical surgery in which successful reduction is demonstrated in detail.

Comparison of endoscopic transnasal and transoral approaches to the craniovertebral junction

OBJECTIVE

The study compared the endoscopic anatomy of the transnasal and transoral approaches to the craniovertebral junction (CVJ).

METHODS

Structures examined and compared with both the straight and angled telescopes in 10 cadaveric specimens included the pharyngeal walls and adjacent musculature, resected anterior arch of the axis and odontoid, cruciform, axial, and apical ligaments, clival and dural openings, and the intradural exposure.

RESULTS

There is considerable overlap at the pharyngeal level in the structures that can be viewed by the transoral and transnasal routes. The transoral approach provides a wider corridor with less restricted manipulation of instruments than the transnasal approach, but the transnasal approach provides a better view of the clivus, upper part of the CVJ, and the structures posterior to the removed odontoid and anterior arch of C1. Combining the two approaches provides significantly better access to the midline anterior CVJ than either approach alone, allows the scopes to be advanced in one cavity and the surgical instruments in the other cavity, and reduces the need to split the palate, tongue, or mandible in order to reach the target area. The transnasal approach also allows access to the superior part of the occipital condyles, paraclival areas, and hypoglossal canals without removal of the condyles, but these structures can be exposed by the transoral route only after at least partial removal of the condyles.

CONCLUSION

The endoscopic transoral and transnasal approaches to the CVJ should be viewed as complementary routes as opposed to strict alternatives.

Posterior instrumentation for occipitocervical fusion

Since 1995, 29 consecutive patients with craniocervical spine instability due to several pathologies were managed with posterior occipitocervical instrumentation and fusion. Laminectomy was additionally performed in nineteen patients. The patients were divided in two groups: Group A which included patients managed with screw-rod instrumentation, and Group B which included patients managed with hook-and-screw-rod instrumentation. The patients were evaluated clinically and radiographically using the following parameters: spine anatomy and reconstruction, sagittal profile, neurologic status, functional level, pain relief, complications and status of arthrodesis. The follow-up was performed immediately postoperatively and at 2, 6, 12 months after surgery, and thereafter once a year. Fusion was achieved in all but one patient. One case of infection was the only surgery related complication. Neurological improvement and considerable pain relief occurred in the majority of patients postoperatively. There were neither intraoperative complications nor surgery related deaths. However, the overall death rate was 37.5% in group A, and 7.7% in group B. There were no instrument related failures. The reduction level was acceptable and was maintained until the latest follow-up in all of the patients. No statistical difference between the outcomes of screw-rod and hook-and-screw-rod instrumentation was detected. Laminectomy did not influence the outcome in either group. Screw-rod and hook-and-screw-rod occipitocervical fusion instrumentations are both considered as safe and effective methods of treatment of craniocervical instability.

Chiari type I malformation in children

The diagnosis of Chiari type I malformation (CIM) is more and more frequent in clinical practice due to the wide diffusion of magnetic resonance imaging. In many cases, such a diagnosis is made incidentally in asymptomatic patients, as including children investigated for different reasons such as mental development delay or sequelae of brain injury. The large number of affected patients, the presence of asymptomatic subjects, the uncertainties surrounding the pathogenesis of the malformation, and the different options for its surgical treatment make the management of CIM particularly controversial.This paper reports on the state of the art and the recent achievements about CIM aiming at providing further information especially on the pathogenesis, the natural history, and the management of the malformation, which are the most controversial aspects. A historial review introduces and explains the current classification. Furthermore, the main clinical, radiological, and neurophysiological findings of CIM are described to complete the picture of this heterogeneous and complex disease.

Dorsal approaches to intradural extramedullary tumors of the craniovertebral junction

Tumors of the craniovertebral junction (CVJ) pose significant challenges to cranial and spine surgeons. Familiarity with the complex anatomy and avoidance of injury to neurologic and vascular structures are essential to success. Multiple surgical approaches to address lesions at the CVJ have been promoted, including ventral and dorsal-based trajectories. However, optimal selection of the surgical vector to manage the pathology requires a firm understanding of the limitations and advantages of each approach. The selection of the best surgical trajectory must include several factors, such as obtaining the optimal exposure of the region of interest, avoiding injury to critical neurologic or vascular structures, identification of normal anatomical landmarks, the familiarity and comfort level of the surgeon to the approach, and the need for fixation. This review article focuses on dorsal approaches to the CVJ and the advantages and limitations in managing intradural extramedullary tumors.

Basilar invagination

BACKGROUND

Basilar invagination is a developmental anomaly of the craniovertebral junction in which the odontoid abnormally prolapses into the foramen magnum. It is often associated with other osseous anomalies of the craniovertebral junction, including atlanto-occipital assimilation, incomplete ring of C1, and hypoplasia of the basiocciput, occipital condyles, and atlas. Basilar invagination is also associated with neural axis abnormalities, including Chiari malformation, syringomyelia, syringobulbia, and hydrocephalus. Patients frequently present with neurologic symptoms and deficits and warrant surgical treatment to prevent progression.

OBJECTIVE

To review the management of basilar invagination.

METHODS

The literature was reviewed in reference to the evaluation and management of basilar invagination, with particular emphasis on the surgical treatment.

RESULTS

Reducible basilar invagination may be treated with posterior decompression and stabilization. Ventral decompression may be necessary for basilar invagination with neural compression that is not reducible with axial cervical traction. Posterior cervical stabilization is necessary after ventral decompression. Modern rod and screw systems combined with autogenous bone graft enable correction of deformity, immediate stabilization, and high fusion rates.

CONCLUSION

Basilar invagination is a developmental anomaly and commonly presents with neurologic findings. Treatment is typically surgical and involves anterior decompression followed by posterior stabilization for irreducible invagination and posterior decompression and stabilization for reducible invagination.

Surgical approaches: postoperative care and complications "transoral-transpalatopharyngeal approach to the craniocervical junction"

INTRODUCTION

The ventral approach to the craniocervical border has been described for decompression of irreducible extradural pathology. The procedures utilized encompass the transoropharyngeal and median mandibulotomy with glossotomy and the transpalatal procedures. This study was aimed to review the utility of the transoral-transpalatopharyngeal approach.

CLINICAL MATERIALS AND METHODS

Seven hundred thirty-three patients underwent transpalatopharyngeal approach for decompression of the brain stem and cervicomedullary junction. Of these, 280 were children below the age of 16 years. The main indication was irreducible ventral pathology compressing the brain stem and cervicomedullary junction. Two hundred two children had irreducible basilar invagination, 28 had proatlas segmentation abnormalities, os odontoideum with a dystopic os odontoideum in 30, and spinal tumors in seven (chordoma, fibrous dysplasia, osteoblastoma). Seven patients with Down's syndrome and irreducible bony compression of the ventral cervicomedullary junction were seen. There were six other miscellaneous diagnoses. All children required craniocervical stabilization which was carried out under the same anesthetic as the transoral procedure.

OPERATIVE PROCEDURE

The procedure entailed fiber-optic intubation. The patient was placed in cervical traction prior to the anterior procedure. The soft palate was split only in individuals with a short clivus with a high riding clivus-odontoid articulation. Craniocervical stabilization was performed in the prone position under the same anesthetic.

RESULTS

There was one retropharyngeal infection postoperatively. No cesium fluoride leaks were encountered. Velopalatine incompetence was seen in five children who already had preoperative brain stem dysfunction. Neurological recovery was the rule. Patients who had preoperative syringohydromyelia had resolution of the syrinx on postoperative magnetic resonance imaging.

DISCUSSION

The author's technique is described. Since 1977, the procedure has been performed in 732 patients (280 children) and has evolved into a safe and direct approach to the ventral cervicomedullary junction with minimal morbidity and mortality.

Median labiomandibular glossotomy approach to the craniocervical region

INTRODUCTION

In children as well as adults, adequate access to the craniocervical junction and upper cervical vertebra can usually be achieved with a transoral-transpalatopharyngeal route. However, when access is necessary to achieve the C5 level and the upper cervical spine in children, this is very difficult. This is particularly so when the incisor opening is less than 2.5 cm. The median labiomandibular glossotomy provides such an approach.

MATERIALS AND METHODS

Our experience with five children is presented in a representative case: a 4-year-old male with a family history of spondyloepiphyseal dysplasia presented with mild quadriparesis, 2 years earlier. This had rapid progression with severe upper cervical kyphosis. A standard transoral-transpalatopharyngeal approach or a lateral extrapharyngeal approach would not achieve exposure of the pathology. Hence, a median labiomandibular glossotomy was utilized for ventral decompression with an anterior interbody fusion between C2 and C4. Crown halo cervical traction was placed intraoperatively before a tracheostomy and tonsillectomy. A median labiomandibular glossotomy was then made with resection of the displaced odontoid process and the vertebral bodies of C3 and C4. This was followed by an anterior interbody fusion between the C2 and C4 vertebrae with costal rib grafts.

RESULT AND CONCLUSION

He was successfully decannulated during the second postoperative week upon resolution of lingual edema. A planned staged dorsal occipitocervical fusion was performed 6 months later, at which time the ventral fusion was quite solid. He had full neurological recovery.

Chiari malformation and odontoid panus causing craniovertebral stenosis in a child with Crouzon's syndrome

Crouzon's disease is a well-known disorder affecting multiple organ systems, specifically a craniofacial disorder with highly variable penetrance and severity of deformity. Crouzon's patients typically have anomalies of the skull base leading to gross distortion of the cranium and in some cases the cervicocranium. We present a 5-year-old girl with Crouzon's disease who suffered from an acquired Chiari I malformation after insertion of a ventriculoperitoneal shunt and a coexistent ventral odontoid panus. Both these lesions were causing cervicomedullary compression. The literature is controversial on the surgical management of anterior and posterior compression at the craniocervical junction. We review the literature on surgical options for decompression at the craniocervical junction and offer our surgical case as a treatment option for patients in this rare clinical situation.

Circumferential cervical spine surgery in an 18-month-old female with traumatic disruption of the odontoid and C3 vertebrae. Case report and review of techniques. Case report and review of techniques

STUDY DESIGN

A case study of an 18-month-old female with craniovertebral instability and spinal cord compression requiring circumferential stabilization. A review of surgical techniques in upper cervical spine and craniovertebral stabilization for young children is provided.

OBJECTIVES

To describe an interesting surgical approach in a young pediatric patient requiring circumferential stability at the craniovertebral junction.

BACKGROUND DATA

Craniovertebral instability is problematic in the young pediatric population due to the inability to secure hardware for stabilization. We present an interesting case of spinal cord compression with craniovertebral instability in an 18-month-old female requiring circumferential cervical spine and craniovertebral stabilization.

METHODS

The patient presented with acute onset quadriparesis after a fall. Radiographs demonstrated C2-C3 disruption with canal compromise. Magnetic resonance imaging revealed signal changes of the spinal cord at C2-C3. Neurological examination revealed normal muscle volume with strength 1/5 in the upper extremities and 0/5 in the lower extremities. Respirations were normal with normal diaphragmatic function. Cranial nerves were intact.

RESULTS

Halo-traction attempted at 0.453 kg induced occipital-atlantal dislocation. The patient underwent anterior corpectomy of C3 and the base of C2 with autologous rib grafts placed from C2 to C4 and macropore as an anterior plating system. Posteriorly the patient had occiput-C3 fusion with a titanium rod and autologous rib grafts bilaterally. Postoperatively the patient regained normal neurological function with circumferential fusion after 4 months in a halo vest.

CONCLUSIONS

This case demonstrates the ability to achieve circumferential stabilization in the young pediatric patient. Injuries at the odontoid synchondrosis can be difficult to treat and are only complicated by having to achieve a posterior fusion at the craniovertebral junction. We present a successful case of circumferential fusion and offer a surgical technique to achieve spinal cord decompression and fusion of the upper cervical spine and craniovertebral junction in the young pediatric population.

Craniovertebral instability with spinal cord compression in a 17-month-old boy with Sly syndrome (mucopolysaccharidosis type VII): a surgical dilemma

STUDY DESIGN

A case study with review of surgical technique in craniovertebral stabilization for young children with mucopolysaccharidosis.

OBJECTIVES

To describe an interesting patient with a rare metabolic disorder and review surgical technique for craniovertebral instability in this rare patient population.

SUMMARY OF BACKGROUND DATA

Craniovertebral instability has been reported in patients with mucopolysaccharidosis and poses a problem for spinal surgery because of the inherent metabolic disorder and age at presentation. We present the first case of craniovertebral instability and spinal cord compression occurring in Sly syndrome (mucopolysaccharidosis type VII) who is the youngest patient afflicted with this metabolic disorder to undergo craniovertebral stabilization.

METHODS

A 17-month-old boy presented with inability to support his head, decreasing muscle strength in all extremities, distended abdomen, and shortness of breath. The patient was found to have a dilated cardiomyopathy, hepatosplenomegaly, abnormal hepatobiliary function, corneal clouding, and a questionable tracheal anomaly. Genetic testing provided a diagnosis of Sly syndrome, mucopolysaccharidosis type VII. Magnetic resonance imaging revealed focal stenosis with significant spinal cord compression at the craniovertebral junction. Neurologic examination revealed normal muscle volume with strength 3/5 in all extremities and significant weakness in the neck muscles with instability at the craniovertebral junction.

RESULTS

On a concerted preoperative medical clearance by pediatric intensive care, pediatric neuroanesthesia, pediatric cardiology, pediatric gastroenterology, and pediatric neurosurgery, the patient underwent occipital to C3 decompression and fusion with autogenous rib grafts. The patient was placed in a prefitted halo-vest after surgery and was neurologically intact.

CONCLUSIONS

This case demonstrates the heterogeneity of cervical spine deformities among the mucopolysaccharidosis syndromes and confirms the propensity for deposition of glycosaminoglycans at the craniovertebral junction. Further studies should investigate the etiology for this propensity of glycosaminoglycan deposition at the craniovertebral junction. We think that this case demonstrates that, with appropriate preoperative planning, these patients can undergo successful posterior cervical arthrodesis despite their age or metabolic defects.

Occipitocervical reconstruction with the Ohio Medical Instruments Loop: results of a multicenter evaluation in 30 cases

OBJECT

Stabilization of the craniocervical junction (CCJ) remains a significant challenge. In this multicenter study, the authors present the results of an evaluation of a precontoured titanium implant, the Ohio Medical Instruments (OMI) Loop, for craniocervical fixation.

METHODS

In this multicenter retrospective study the authors evaluated 30 patients (16 female, 14 male; mean age 53.8 years) with rheumatoid arthritis (15 cases), traumatic occipitoatlantoaxial instability (six cases), congenital vertebral anomalies (two cases), instability due to basilar invagination in the setting of Chiari malformation (two cases), or Down syndrome (one case), tumor (one case), os odontoideum (two cases), and pseudarthrosis/other (one case), who underwent OMI Loop-assisted occipitocervical reconstruction. The mean follow-up period was 25.4 months (range 6-60 months). A solid reconstruction was achieved in 29 of 30 cases; there was only one case of hardware failure requiring reoperation. Noncritical hardware failure occurred in two patients in whom partial occipital screw backout occurred but did not necessitate reoperation. There were no perioperative neurological complications. One patient (3.3%) experienced a delayed postoperative worsening of myelopathy at 1 year that resolved with further surgery. Postoperatively, in 66.6% of patients the degree of myelopathy remained stable (as measured by American Spinal Injury Association [ASIA] scores), whereas 30% improved by one or more ASIA grade. The rate of osseous fusion was 96.6% at a mean follow-up period of 25.4 months.

CONCLUSIONS

The authors found that the OMI Loop is a versatile precontoured occipitocervical fixation device that can be applied to a wide range of CCJ lesions. It provides excellent immediate rigid fixation of the CCJ, a high rate of osseous fusion, and a low rate of hardware failure.

Endoscopically assisted transoral-transpharyngeal approach to the craniovertebral junction

OBJECTIVE

We describe a series of seven consecutive patients treated with endoscopically assisted transoral surgery for decompression of high cervical and clival abnormalities.

METHODS

Seven endoscopically assisted transoral procedures were performed at the University of Florida from September 1999 to April 2000 for irreducible compression at the cervicomedullary junction. The abnormalities encountered were primary basilar invagination from congenital craniovertebral junction malformation (two cases), irreducible rheumatoid cranial settling (one case), secondary basilar invagination caused by migration of odontoid fracture fragments (one case), pseudogout granulation mass (one case), clivus chordoma (one case), and Chiari malformation with associated basilar invagination (one case).

RESULTS

Successful decompression was achieved in all seven patients. There were no adverse neurological sequelae. One patient died from a perioperative myocardial infarction. At a mean clinical follow-up of 6.16 months, neurological status was noted to be stable or improved in all remaining patients.

CONCLUSION

Endoscopically assisted transoral surgery represents an emerging alternative to standard microsurgical techniques for transoral approaches to the anterior cervicomedullary junction. Used in conjunction with intraoperative fluoroscopy, it provides a safe method for anterior decompression of the cervicomedullary junction without the need for extensive soft palate splitting, hard palate resection, or extended maxillotomy. Experience is required with greater numbers of patients and long-term follow-up to further validate this promising technique.

Cervical vertebral anomalies in patients with anomalies of the head and neck

Congenital head and neck anomalies can occur in association with vertebral anomalies, particularly of the cervical vertebrae. While the former are easily recognized, especially when part of a syndrome, the latter are often occult, thereby delaying their diagnosis. The presence of vertebral anomalies must be considered in pediatric patients with head and neck abnormalities to expedite management of select cases and to prevent neurologic injury. We present our experience with 5 pediatric patients who were referred to the Department of Otolaryngology-Head and Neck Surgery at the University of Iowa with a variety of syndromic anomalies of the head and neck. Each patient was subsequently also found to have a vertebral anomaly. The relevant embryogenesis of the anomalous structures is discussed, with highlighting of potential causes such as teratogenic agents and events and germ-line mutations. A review of syndromes having both head and neck and vertebral anomalies is presented to heighten awareness of otolaryngologists evaluating children with syndromic disorders. Finally, the findings on radiographic imaging studies, particularly computed tomography, are discussed to facilitate the prompt diagnosis of vertebral anomalies.

Magnetic resonance imaging-compatible posterior cervical implant for occipitocervical stabilization. Technical note

Posterior cervical stabilization was accomplished in 30 patients (19 females and 11 males) by using sublaminar titanium cables and a new titanium bullet-shaped implant. Seventeen patients underwent occipitocervical fixation and 13 others were treated subaxially. These patients have been followed for 18 to 52 months (mean 36 months), and no implant has failed during the follow-up period.

Oropharyngeal morbidity following transoral approaches to the upper cervical spine

The transoral approach to the upper cervical spine is now well established. Oropharyngeal complications have not previously been critically assessed. In the present study, the overall complication rate was 31.6%. This dropped to 15.4% in those patients who did not undergo splitting of the soft palate. The complication rate of 75% in the split soft palate group means that this procedure should be discontinued where it is not absolutely necessary.

Pediatric transoral surgery: indications, complications, and long-term outcome

Knowledge of the role and hazards of transoral surgery has expanded rapidly, but the application of this technique in children has been limited. To assess its usefulness, 27 pediatric patients who underwent transoral surgery between 1985 and 1994 were studied. Transoral surgery was performed for irreducible anterior neuraxial compression at the craniovertebral junction caused by basilar impression, atlantoaxial subluxation with pseudotumor, or chordoma. The patients ranged in age from 3 to 17 years. Symptomatic presentation varied widely, but 89% had significant neurological deficits before surgery. No patient with normal strength deteriorated after surgery. Of the 16 patients with a preoperative motor deficit, nine improved rapidly, three were unchanged, and four significantly worsened in the perioperative period. Those with mobile atlantoaxial subluxation were most vulnerable to surgically related neurological morbidity. Twenty-four patients were alive for long-term follow-up study (average 5.7 years, range 1-9.2 years). Of those with preoperative weakness, nine improved one Frankel grade, four remained the same, and one deteriorated from Frankel Grade D to C. Swallowing and speech worsened in five patients; this occurred only after resection of lesions above the foramen magnum (p<0.05) when rostral pharyngeal disruption resulted in velopharyngeal dysfunction. This study, unlike previous reviews of pediatric transoral operations, leads the authors to suggest that although transoral surgery can be effective, it also carries a significant risk of neurological injury in patients with symptomatic spinal cord compression and it is also associated with long-term swallowing and speech difficulties.