Posterolateral approach to the craniocervical junction.

Rully Hanafi Dahlan, SpBS, M.Kes

Abstract

OBJECT:

The authors present the surgical results obtained using the posterolateral approach to the craniocervical junction

(CCJ) to resect a lesion with an extradural component located posterolateral to the foramen magnum and upper

cervical spine.

METHODS:

The posterolateral approach, which is a behind the mastoid process route to the CCJ, was performed in some

patients. The skin incision follows the posterior edge of the mastoid process. , the superior oblique and rectus capitis

posterior major muscles were partially exposed. This approach were followed the two muscles inferiorly until the

posterior arch of the atlas appeared. The two muscles were removed to create ample working space without violating

the posterior atlanto-occipital membrane. The vertebral artery was identified by the landmark of the posterior arch of

the atlas, and the atlanto-occipital joint and foramen magnum were exposed. In addition to suboccipital craniectomy,

transcondylar, supracondylar, and paracondylar extension by drilling were applicable through the narrow corridor

under superb visualization. The intradural neurovascular structures from the acousticofacial bundle to the dorsal root

of C2, anterolateral space of the foramen magnum, cerebellomedullary fissure, and fourth ventricle were clearly

demonstrated.

CONCLUSIONS:

The aforementioned technique allows for sufficient access to lesions located posterolateral to the CCJ. It is a

versatile avenue to approach a variety of lesions ventrolateral to the brain stem and upper cervical cord. Exposure is

quite satisfactory with minimal or no retraction of important neurovascular structures in the region. This approach

can easily be combined with a posterolateral approach and can be extended anteriorly toward the jugular foramen

and inferiorly toward the lower cervical spine. Modifications of this theme can be applied as the lesions require.

Malignancy of spine : Case Report

Sevline Esthetia O, dr.

Malignant spinal-cord compression (MSCC) is a common complication of cancer and has a substantial

negative effect on quality of life and survival. The outcome of treatment is poor, with less than half of patients

retaining or regaining the ability to walk and about two fifths requiring a permanent urinary catheter. The most

important prognostic factor for functional outcome is neurological function before treatment, with about 70% of

initially ambulant patients, 30% of paraparetic patients, and 5% of paraplegic patients retaining or regaining the

ability to walk. Despite widespread availability of good diagnostic technology, studies indicate that most patients are

diagnosed only after they become unable to walk. It is widely accepted that malignant spinal cord compression is a

medical or surgical emergency, requiring urgent diagnosis and treatment because delay can result in irreversible

paralysis or loss of sphincter function. Many authors, however, have referred to unnecessary and preventable delay

in its diagnosis and treatment. While the common occurrence of severe neurological compromise at the time of

treatment is well documented, the extent, cause, and effect of delay in referral and treatment are not and have

therefore been investigated in the present study.

We review the epidemiology, pathophysiology, and clinical features of MSCC. Clinical trials have

informed the optimum management of MSCC, and we review the role of corticosteroids, radiotherapy, and surgery

in the management of patients. We also emphasise advances in radiation delivery and the results of a randomised

trial that supported aggressive debulking in patients with MSCC.