임상 : 대후두공과 상위경추신경 전방으로의 극외측경과접근법; 수술술기와 22예의 임상분석

문주형 ( Ju Hyung Moon ),홍창기 ( Chang Ki Hong ),김창현 ( Chang Hyun Kim ),안정용 ( Jung Yong Ahn ),장종희 ( Jong Hee Chang ),이규성 ( Kyu Sung Lee ) 대한뇌종양학회 2009 대한뇌종양학회지 Vol.8 No.2

Objective:Because diseases that are situated anterior to the foramen magnum, lower clivus, and the upper cervical spinal canal permit only limited access, they are considered some of the most difficult intracranial lesions to surgically treat. The far-lateral transcondylar approach provides such a route. The author has reviewed the technique as well as the surgical results here. Methods:During a 6-year period 22 patients underwent surgery in which far-lateral approach were performed. This approach to the craniocervical junction was utilized in patients with aneurysm, schwannoma, meningioma, and chordoma affecting the cervicomedullary junction. Medical records, including imaging studies, descriptions of microsurgical findings, photographs, and video records of operative procedures, were reviewed. Mean follow up period was 4.4 years. Results:Total tumor resection was achieved in 16 patients, and a subtotal resection of the tumor was performed in the other 4 patients. In the 2 patients with vertebral artery-posterior inferior cerebellar artery(PICA) aneurysms, 1 underwent clipping, the other underwent trapping and occipital artery-PICA bypass procedure. Postoperative complications included CSF leak in 4 and temporary low cranial nerve dysfunction in 4. There was no significant postoperative complication in the remainder of the patients, and their conditions improved after surgery. Conclusion:Successful surgical management of anterior foramen magnum lesion depends on precise understanding of their unique microsurgical anatomy, avoidance of pitfalls, and the surgeon`s experience. Sufficient exposure, minimal brain retraction, and preservation of the lower cranial nerves are necessary for a safe surgery.

대후두공과 상위경추신경 전방으로의 극외측경과접근법 : 수술술기와 36례의 임상분석

조윤성(Yun seong Cho),홍창기(Chang-Ki Hong) 대한두개저학회 2019 대한두개저학회지 Vol.14 No.1

Background: Because diseases that are situated anterior to the foramen magnum and the upper cervical spinal canal permit limited access, they are considered some of the most difficult intracranial lesions to surgically treat. The far-lateral transcondylar approach provides such a route. The author has reviewed the technique as well as the surgical results here. Materials and Methods: During a 16-year period 36 patients underwent surgery in which far-lateral approach were performed. This approach was utilized in patients with aneurysm, schwannoma, meningioma, and chordoma affecting the cervicomedullary junction. Medical records, including imaging studies, descriptions of microsurgical findings were reviewed. Results: Total tumor resection was achieved in 25 patients, and a subtotal resection was performed in the other 9 patients. In the 2 patients with vertebral artery-posterior inferior cerebellar artery (PICA) aneurysms, 1 underwent clipping, the other underwent trapping and occipital artery-PICA bypass procedure. Postoperative complications included CSF leakage in 4 and temporary lower cranial nerve dysfunction in 10 patients. There was no significant postoperative complication in the remainder of the patients. Conclusions: Successful surgical management depends on precise understanding of their unique microsurgical anatomy. Sufficient exposure, minimal brain retraction, and preservation of the lower cranial nerves are necessary for a safe surgery.

Impact of Radiation Therapy on Outcomes After Spinal Instrumentation for Craniocervical Junction Malignancies

Matthew Muir,Laurence Rhines,Franco DeMonte,Claudio Tatsui,Shaan M. Raza 대한척추신경외과학회 2022 Neurospine Vol.19 No.2

Objective: Spinal reconstruction after resection of invasive craniocervical junction malignancies is fraught with technical and management considerations as well as a paucity of data in the existing literature. In this study, we describe our experience with craniocervical junction malignancies, especially the influence of radiation on the need for revision spinal instrumentation. Methods: We performed a retrospective chart review of all patients who underwent occipitocervical fixation between 2011 and 2019 at The University of Texas MD Anderson Cancer Center. Results: Twenty-five patients had primary malignancies and 12 (30%) had metastatic tumors. Thirteen (33%) underwent a staged resection in multiple operations during their hospital stay. Tumor resection was performed in 19 patients (48%), while only stabilization was performed in 21 patients (52%). Nine patients (23%) underwent expanded endoscopic transclival approaches for tumor resection, 10 patients (25%) an extreme lateral approach, and 2 patients (5%) an anterior open approach. Eleven patients underwent early postoperative radiation therapy (within 3 months) and 8 underwent delayed radiation therapy (between 3 months and 1 year in 7 patients). The revision rate was 8%, with a median time to revision surgery of 42 months. The administration and timing of adjuvant radiation therapy relative to surgery had no significant effect on the need for instrumentation revision on log-rank and Cox regression analyses (p < 0.05). Conclusion: Revision surgery was needed infrequently in our patients. Postoperative radiation therapy was not associated with hardware failure, indicating that the timing of radiation therapy should be dictated by the diagnosis and can be initiated postoperatively without delay.

Clinical and anatomical importance of foramen magnum and craniocervical junction structures in the perspective of surgical approaches

Berin Tuğtağ Demir,Simge Eşme,Dilara Patat,Burak Bilecenoğlu 대한해부학회 2023 Anatomy & Cell Biology Vol.56 No.3

This study was conducted to investigate the clinical and anatomical importance of the relevant region from theperspective of surgical approaches by determining the morphometric analysis of the craniocervical junction and foramen magnum (FM) region and determining their distances from important anatomical points. This research was carried out with 59 skulls found at the Anatomy Laboratories of Erciyes and Ankara Medipol University. Metric measurements of FM and condyle, FM shape, condyle-fossa relationship, and pharyngeal tubercle (PT) were made in mm-based dry bone samples of unknown age and sex. The distance between the anterior notches and the FM was 87.01±4.35, the distance between the anterior notches and the PT was 77.70±4.24, the distance between the PT-sphenooccipital junction was 13.23±2.42, and the FM index was 81.86±7.47. The anteroposterior and transverse lengths of FM were determined as 33.80±2.99 and 27.72±2.30, respectively. The morphometric and morphological data available regarding the craniocervical junction showed significant differences between populations. Comprehensive knowledge of this topic will provide a better approach to treat Arnold Chiari Malformation, FM meningiomas, and other posterior cranial fossa lesions. Therefore, we believe that FM and craniocervical junction morphology will be a guide not only for anatomists, but also for radiologists, neurosurgeons, ENT surgeons, and orthopedists.

두개와 경추의 이행부에서 뇌신경계와 혈관계에 대한 형태학적 계측

이규,배학근,최순관,윤석만,도재원,이경석,윤일규,변박장,Lee, Kyu,Bae, Hack-Gun,Choi, Soon-Kwan,Yun, Seok-Mann,Doh, Jae-Won,Lee, Kyeong-Seok,Yun, Il-Gyu,Byun, Bark-Jang 대한신경외과학회 2001 Journal of Korean neurosurgical society Vol.30 No.9

Objective : During the trans-condylar or trans-jugular approach for the lesion of cranio-cervical junction(CCJ), its necessary to identify the accurate locations of vertebral artery(VA), internal jugular vein(IJV) and its related lower cranial nerves. These neurovascular structures can also be damaged during the operation for vascular tumor or traumatic aneurysm around extra-jugular foramen, because of their changed locations. To reduce the neurovascular injury at the operation for CCJ, morphometric relationship of its surrounding neurovascular structures based on the tip of the transverse process of atlas(C1 TP), were studied. Materials & Methods : Using 10 adult formalin fixed cadavers, tip of mastoid process(MT) and TPs of atlas and axis were exposed bilaterally after removal of occipital and posterior neck muscles. Using standard caliper, the distances were measured from the C1 TP to the following structures : 1) exit point of VA from C1 transverse foramen, 2) branching point of muscular artery from VA, 3) entry point of VA into posterior atlanto-occipital membrane(AOM), 4) branching point of C-1 nerve. In addition, the distances were measured from the mid-portion of the posterior arch of atlas to the entry point of the VA into AOM and to the exit point of the VA from C1 transverse foramen. After removal of the ventrolateral neck muscles, neurovascular structures were exposed in the extra-jugular foraminal region. Distances were then measured from the C1 TP to the following structures : 1) just extra-jugular foraminal IJV and lower cranial nerves, 2) MT and branching point of facial nerve in parotid gland. In addition, distance between MT and branching point of facial nerve was measured. Results : The VA was located at the mean distance of 12mm(range, 10.5-14mm) from the C1 transverse foramen and entered into the AOM at the mean distance of 24mm(range, 22.8-24.4mm) from the C1 TP. The mean distance from the mid portion of the C1 posterior arch was 20.6mm(range, 19.1-22.3mm) to the entry point of the VA into AOM and 38.4mm(range, 34-42.4mm) to the exit point of the VA from C1 transverse foramen. Muscular artery branched away from the posterior aspect of the transverse portion of VA below the occipital condyle at the mean distance of 22.3mm(range, 15.3-27.5mm) from the C1 TP. The C-1 nerve was identified in all specimens and ran downward through the ventroinferior surface of the transverse segment of VA and branched at the mean distance of 20mm(range, 17.7-20.3mm) from the C1 TP. The IJV was located at the mean distance of 6.7mm(range, 1-13.4mm) ventromedially from the lateral surface of the C1 TP. The XI cranial nerve ran downward on the lateral surface of the IJV at the mean distance of 5mm(range, 3-7.5mm) from the C1 TP. Both IX and X cranial nerves were located in the soft tissue between the medial aspect of the internal carotid artery(ICA) and the medial aspect of the IJV at the mean distance of 15.3mm(range, 13-24mm) and 13.7mm(range, 11-15.4mm) from the C1 TP, respectively. The IX cranial nerve ran downward ventroinferiorly crossing the lateral aspect of the ICA. The X cranial nerve ran downward posteroinferior to the IX cranial nerve and descended posterior to the ICA. The XII cranial nerve was located between the posteroinferior aspect of the IX cranial nerve and the posterior aspect of the ICA at the mean distance of 13.3mm(range, 9-15mm) ventromedially from the C1 TP. The distance between MT and C1 TP was 17.4mm(range, 12.5-23.9mm). The VII cranial nerve branched at the mean distance of 10.2mm(range, 6.8-15.3mm) ventromedially from the MT and at the mean distance of 17.3mm(range, 13-21mm) anterosuperiorly from the C1 TP. Conclusion : This study facilitates an understanding of the microsurgical anatomy of CCJ and may help to reduce the neurovascular injury at the surgery around CCJ.

Clinical and Radiological Clues of Traumatic Craniocervical Junction Injuries Requiring Occipitocervical Fusion to Early Diagnosis

Daimon Shiraishi,Yusuke Nishimura,Isaac Aguirre-Carreno,Masahito Hara,Satoshi Yoshikawa,Kaoru Eguchi,Yoshitaka Nagashima,Hiroshi Ito,Shoichi Haimoto,Yu Yamamoto,Howard J. Ginsberg,Masakazu Takayasu,Ry 대한척추신경외과학회 2021 Neurospine Vol.18 No.4

Objective: The purpose of this study is to find the clinical and radiographic characteristics of traumatic craniocervical junction (CCJ) injuries requiring occipitocervical fusion (OC fusion) for early diagnosis and surgical intervention. Methods: We retrospectively reviewed 12 patients with CCJ injuries presenting to St. Michaels Hospital in Toronto who underwent OC fusion and looked into the following variables; (1) initial trauma data on emergency room arrival, (2) associated injuries, (3) imaging characteristics of computed tomography (CT) scan and magnetic resonance imaging (MRI), (4) surgical procedures, surgical complications, and neurological outcome. Results: All patients were treated as acute spinal injuries and underwent OC fusion on an emergency basis. Patients consisted of 10 males and 2 females with an average age of 47 years (range, 18–82 years). All patients sustained high-energy injuries. Three patients out of 6 patients with normal BAI (basion-axial interval) and BDI (basion-dens interval) values showed visible CCJ injuries on CT scans. However, the remaining 3 patients had no clear evidence of occipitoatlantal instability on CT scans. MRI clearly described several findings indicating occipitoatlantal instability. The 8 patients with normal values of ADI (atlanto-dens interval interval) demonstrated atlantoaxial instability on CT scan, however, all MRI more clearly and reliably demonstrated C1/2 facet injury and/or cruciate ligament injury. Conclusion: We advocate measures to help recognize CCJ injury at an early stage in the present study. Occipitoatlantal instability needs to be carefully investigated on MRI in addition to CT scan with special attention to facet joint and ligament integrity.

Surgical Treatment of Craniovertebral Junction Instability : Clinical Outcomes and Effectiveness in Personal Experience

Song, Gyo-Chang,Cho, Kyoung-Suok,Yoo, Do-Sung,Huh, Pil-Woo,Lee, Sang-Bok The Korean Neurosurgical Society 2010 Journal of Korean neurosurgical society Vol.48 No.1

Objective : Craniovertebral junction (CVJ) consists of the occipital bone that surrounds the foramen magnum, the atlas and the axis vertebrae. The mortality and morbidity is high for irreducible CVJ lesion with cervico-medullary compression. In a clinical retrospective study, the authors reviewed clinical and radiographic results of occipitocervical fusion using a various methods in 32 patients with CVJ instability. Methods : Thirty-two CVJ lesions (18 male and 14 female) were treated in our department for 12 years. Instability resulted from trauma (14 cases), rheumatoid arthritis (8 cases), assimilation of atlas (4 cases), tumor (2 cases), basilar invagination (2 cases) and miscellaneous (2 cases). Thirty-two patients were internally fixed with 7 anterior and posterior decompression with occipitocervical fusion, 15 posterior decompression and occipitocervical fusion with wire-rod, 5 C1-2 transarticular screw fixation, and 5 C1 lateral mass-C2 transpedicular screw. Outcome (mean follow-up period, 38 months) was based on clinical and radiographic review. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score. Results : Nine neurologically intact patients remained same after surgery. Among 23 patients with cervical myelopathy, clinical improvement was noted in 18 cases (78.3%). One patient died 2 months after the surgery because of pneumonia and sepsis. Fusion was achieved in 27 patients (93%) at last follow-up. No patient developed evidence of new, recurrent, or progressive instability. Conclusion : The authors conclude that early occipitocervical fusion to be recommended in case of reducible CVJ lesion and the appropriate decompression and occipitocervical fusion are recommended in case of irreducible craniovertebral junction lesion.

Surgical Stabilization of a Craniocervical Junction Abnormality with Atlantoaxial Subluxation in a Dog

하정호,정창수,최성재,정주현,우흥명,강병재 한국임상수의학회 2018 한국임상수의학회지 Vol.35 No.1

A 7-month-old female Bichon Frise, displaying neck pain and ataxia, was diagnosed with craniocervicaljunction abonormality (CJA), along with atlantoaxial subluxation. Surgical fixation of the atlantoaxial subluxation wasperformed, using cortical screws and bone cement, along with an odontoidectomy. After surgery, nonsteroidal antiinflammatorymedication was prescribed for pain control, and a loose bandage was applied to the neck. Mild ambulatorytetraparesis remained 1 week after surgery. Three weeks after surgery, the range of neck motion was near normal,and clinical signs had improved. CJA should be considered as a differential diagnosis in dogs with cervical myelopathy. Surgical stabilization using cortical screws and bone cement through a ventral approach can be successful in dogswith CJA and atlantoaxial subluxation.

Arteriovenous Fistula at the Craniocervical Junction Found After Cervical Laminoplasty for Ossification of the Posterior Longitudinal Ligament

Susumu Sasada,Masafumi Hiramatsu,Akira Ksumegi,Haruto Fujimura,Shogo Oshikata,Yuichi Takahashi,Kenki Nishida,Takao Yasuhara,Isao Date 대한척추신경외과학회 2020 Neurospine Vol.17 No.4

Ossification of the posterior longitudinal ligament (OPLL) is common in East Asia. Arteriovenous fistula at the craniocervical junction (CCJ-AVF), in contrast, is rare. As OPLL occurs most often in the cervical region, these 2 conditions can coexist in the cervical spinal canal of a single patient. We report a case of CCJ-AVF found after cervical laminoplasty (CLP) for OPLL. A 68-year-old man experienced progressive myelopathy due to cervical OPLL. Magnetic resonance imaging (MRI) revealed a high-intensity area inside the spinal cord. CLP was performed and his symptoms immediately improved. Three months after CLP, however, myelopathy recurred. MRI revealed an exacerbated and enlarged high-intensity area inside the cord from the medulla oblongata to the C4/5 level with a flow void around the cord. Left vertebral artery angiography revealed CCJ-AVF with ascending and descending draining veins. Direct surgery was performed to interrupt shunt flow into the draining veins. The patient’s symptoms improved to a limited degree. In this case, increased pressure inside the spinal canal due to OPLL might have decreased the shunt flow of the CCJ-AVF. Thus, the venous congestion induced by CCJ-AVF might have been exacerbated after the pressure was removed by CLP. Magnetic resonance angiography screening could help detect concurrent CCJ-AVF and OPLL.

Idiopathic Hypertrophic Pachymeningitis in the Craniocervical Junction

Jin Hyuk Bang,조근태,김어진 대한척추신경외과학회 2015 Neurospine Vol.12 No.3

Idiopathic hypertrophic pachymeningitis (IHP) is a rare disease, and it is characterized by chronic progressive inflammatory fibrosis and thickening of the dura mater with resultant compression of the spinal cord or neural structure without any identifiable cause. It can occur in the intracranial or spinal dura mater alone or as a craniospinal form. The spinal form is rarer than the cranial form and the craniospinal form is extremely rare. We report a rare case of IHP in the craniocervical junction involving both the cranial and spinal dura mater and discuss the diagnosis and management of the disease.