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Suboccipital cranioplasty for Chiari malformation: Expansive suboccipital cranioplasty with dural plasty
S217
Video Presentations
Thursday, 10 July 1997
V·5
14:00-16:30
Spine Surgery
IV-S-61 I The transcondylar approach to extradural
non-neoplastic lesions of the craniovertebral junction
LuisA.B. Borba,Ossama AI-Melty. FederalUniversityof Sao Paulo, Sao Paulo, Brazil, Universityof Arkansas, Little Rock, USA The cranlovertsbral junction is the place of neoplastic, vascular, congenital and degenerative diseases. The lesions can be located anteriorly, laterally or posteriorly. Very often, the optimal treatment of lesions in the cranivertebral junction is provided by surgical decompression throughthe transoral approach followed by posterior craniovertebral stabilization. In this video, the authors will present the surgical technique of the transcondylar approach to reach non-neoplastic lesions located in the craniovertebral junction, where the main compression was anteriorlylocated.The videodisplaysstep by stepthe surgical technique of the transcondylar approach based on a cadaveric perspective. Operative cases will be shown.
IV-S-62!
Surgical treatment of craniovertebral junction lesions
Minoru Akino, Hiroshi Abe. Department of Neurosurgery, Universityof Hokkaido. School of Medicine, Sapporo City. Japan Purpose: Surgical treatment of craniovertebral junction lesions, focused upon Atlantoaxial dislocation (AAD) and basilar impression (Bl) are discussed according to our surgical indicationsand surgical methods. Material and Methods: The total numbers of our surgical cases of atlantoaxial dislocation (AAD) and basilar impression (BI) 97 (posterior fusion 66, transoral approach 31, combined approach 3). The surgical approach for each case has been choosen as follows: If AAD is reducible, posteriorfusion is selected. In nonreducibleAAD or BI, if the clivoaxial angle is smaller than 120 degree, transoral approach is selected and if the angle is larger than 120 degree, posterior decompression and fusion is selected. In posteriorfusion, graft taken from iliac crest has been used for posterior fusion, and recentlytitanium wire or titanium rots and other newly developed surgical instrumentation and materialsare used. Recentlydevelopedneuroradiological imagings suchas MR and 3D-CT are 9reatly contributinq to preciseand appropriate information about patho mechanism in the craniovertebral junction lesions. Surgical Results: 66 cases of posterior fusion were satisfactory although in 3 cases the grafted bones were absorbed. 30 cases of anterior approach also showed neurologicalimprovement. In 3 cases of transoralapproaches the grafted bones were slipped out, but those cases did not show any neurological deterioration. Conclusion: The appropriate surgical approach must be selected on the basis of the compression to the neural tissue as follows: Posterior approach: reducible AAD without anterior compression. Anterior approach: nonreducible AAD with anterior compression, basilar impression.
IV-S-63I
Suboccipital cranioplasty for Chiari malformation: Expansive suboccipital cranioplasty with dural plasty
Toshihisa Suzuki, Kenji Ohata, Akira Hakuba. Departmentof Neurosurgery, Tane General Hospital, Osaka, Japan, Departmentof Neurosurgery, Osaka City UniversityMedical School, Osaka,Japan Introduction: Communicating syringomyelia, a complication of adult Chiari malformation, is known to be due to a pressure gradient between the posterior fossa and spinal canal, caused by circulatory disorder of the cerebrospinal fluid in the foramen magnum. Over the years, we have considered the relative diminishmentof posterior fossa volume, as comparedto that of the brain stem and cerebellum, to be the causeof this condition, and haveperformed operations with the purpose of expandingthe posterior fossa. Method: In the semiprone park bench position, only the dura is incised, and dural plasty using the sub-scalp fascia and pericranium is performed with expansivecranioplasty. The arachnoidmembraneis preserved, and the central canal is not obstructed. The bone fragmentof the posteriorfossa,obtainedupon
craniotomy, is cut once in the median, and a larger bone fragment is prepared utilizing the posterior arch of atlas, resected in one mass, in the intermedius. The bone is fixated using a titanium miniplate, while a MIDAS REX INSTITUTE drill, which is easierto maneuver, is used for osteotomy. An operatingtable that can turn 45 degrees is used, becausethe operation is carried out in semiprone park bench position,and position similar to the prone or lateral position can be easily attained. Furthermore, in case of bleeding, the blood flows downward and does not collect in the field of operation, enabling stable surgery under a clean operating field. Results and Conclusion: Most of patients' syrinx disappeared or diminished. This is demonstrated by video.
IV-S-64'
Expanding laminoplasty for cervical myelopathy due to multilevel spondylosis or OPLL
T. Morimoto, K. Nagata,S. Kawaguchi, T. Sakaki. Department of Neurosurgery, Nara MedicalUniversity, Kashihara, Japan A novelapproach calledexpanding laminoplasty using spinous process roofing techniquehasbeenemployedfor the surgicaltreatmentof the patientswith multilevel cervical myelopathyover the past 12 years. Long-term results regarding bone fusion rate, postoperative neck movement, and neurological improvement were analyzedin patients with 3 years followup or more. Materials and Methods: Sixty-eightcases are included in this study.There are 27 cases of OPLL and 41 cases of multilevelcervical spondylosis, 39 male and 29 female. Bone fusion was assessed on CT by the medullaryconnection between spinous process and lamina. Pre- and postoperative neck movement was evaluated on lateralradiograph using"angle of neck movement". Neurological assessment was done with the Japanese Orthopaedic Association (JOA) score. Technical Note: Modified Kurokawa's methodwas used in this procedureby roofing the cutoff spinousprocess between the open-door laminae with simple suturing technique. A lateral gutter was drilled as laterally as possible with all facets kept intact. Results: There were 7 cases with 7 levels laminoplasty (Cl-G7), 18 cases with 6 levels laminoplasty (C2-G7), 32 cases of 5 levels laminoplasty (C3-C7), and 11cases with 4 levels laminoplasty (C3-C6). By analysingalilaminoplasty levels, bone fusion rate was 97% on CT. Enlargement of AP diameter of the canal was 142% to the preoperative level. Postoperative neck movement was preserved at the level of 83% to the preoperative movement.The preoperative JOA score was 7.8 points in average, resulting 13.7 points at postoperatively 3rd year. Discussion and Conclusion: Our method apparently offers advantages such as technical simplicity, disuse of foreign material, and preservation of facet. This advantages resulted in the high postoprerative bone fusion rate, good postoperative neck movement, and an excellent long-term neurological improvement.
IV-S-6sl
Cervical spondylotic myelopathy treated via trans-unco-discal approach (TUD). Experiences of 529 cases
Akira Hakuba, Michiharu Morino, Moududul Haque, Kenji Nagai, AkimasaNishio, Kenji Ohata. Dept. Of Neurosurgery, Osaka City University, Osaka,Japan Introduction: TUD approach consists of anterior discectomy. uncectomy, removal of bilateralposteriorlateral corners of the vertebral bodies and resection of the posteriorridge. We have followed this approach for the patients with cervical myelopathy since 1974,whichis a combinedanteriorand lateralapproach to cervical discs. We present the results of the TUD approach in 529 patients with cervicalspondylotic myelopathy. Methods: There were 354 male and 175 female patients; their age ranged from 22 to 79 years (mean age 53.6 years). Four hundred eighty eight patients could be followed up. The mean follow up period was 73.6 months. The neurological status was classified according to the recovery rate (RR) of the Japan neurosurgical cervicalspine scale (JNCSS)to assess the resultsof TUD approach. We analyze the relationship of RR to age, developmental stenosis, durationand number of operated disc spaces. Result: There were 460 successful cases (excellent: RR > = 80%, good: 50% :': RR < 80%, fair: 20% ::: RR < 50%) and 28 unsuccesful cases (unchanged: -20% ::: RR < 20%, worse: RR < -20%).
Video Presentations
Thursday, 10 July 1997
V·5
14:00-16:30
Spine Surgery
IV-S-61 I The transcondylar approach to extradural
non-neoplastic lesions of the craniovertebral junction
LuisA.B. Borba,Ossama AI-Melty. FederalUniversityof Sao Paulo, Sao Paulo, Brazil, Universityof Arkansas, Little Rock, USA The cranlovertsbral junction is the place of neoplastic, vascular, congenital and degenerative diseases. The lesions can be located anteriorly, laterally or posteriorly. Very often, the optimal treatment of lesions in the cranivertebral junction is provided by surgical decompression throughthe transoral approach followed by posterior craniovertebral stabilization. In this video, the authors will present the surgical technique of the transcondylar approach to reach non-neoplastic lesions located in the craniovertebral junction, where the main compression was anteriorlylocated.The videodisplaysstep by stepthe surgical technique of the transcondylar approach based on a cadaveric perspective. Operative cases will be shown.
IV-S-62!
Surgical treatment of craniovertebral junction lesions
Minoru Akino, Hiroshi Abe. Department of Neurosurgery, Universityof Hokkaido. School of Medicine, Sapporo City. Japan Purpose: Surgical treatment of craniovertebral junction lesions, focused upon Atlantoaxial dislocation (AAD) and basilar impression (Bl) are discussed according to our surgical indicationsand surgical methods. Material and Methods: The total numbers of our surgical cases of atlantoaxial dislocation (AAD) and basilar impression (BI) 97 (posterior fusion 66, transoral approach 31, combined approach 3). The surgical approach for each case has been choosen as follows: If AAD is reducible, posteriorfusion is selected. In nonreducibleAAD or BI, if the clivoaxial angle is smaller than 120 degree, transoral approach is selected and if the angle is larger than 120 degree, posterior decompression and fusion is selected. In posteriorfusion, graft taken from iliac crest has been used for posterior fusion, and recentlytitanium wire or titanium rots and other newly developed surgical instrumentation and materialsare used. Recentlydevelopedneuroradiological imagings suchas MR and 3D-CT are 9reatly contributinq to preciseand appropriate information about patho mechanism in the craniovertebral junction lesions. Surgical Results: 66 cases of posterior fusion were satisfactory although in 3 cases the grafted bones were absorbed. 30 cases of anterior approach also showed neurologicalimprovement. In 3 cases of transoralapproaches the grafted bones were slipped out, but those cases did not show any neurological deterioration. Conclusion: The appropriate surgical approach must be selected on the basis of the compression to the neural tissue as follows: Posterior approach: reducible AAD without anterior compression. Anterior approach: nonreducible AAD with anterior compression, basilar impression.
IV-S-63I
Suboccipital cranioplasty for Chiari malformation: Expansive suboccipital cranioplasty with dural plasty
Toshihisa Suzuki, Kenji Ohata, Akira Hakuba. Departmentof Neurosurgery, Tane General Hospital, Osaka, Japan, Departmentof Neurosurgery, Osaka City UniversityMedical School, Osaka,Japan Introduction: Communicating syringomyelia, a complication of adult Chiari malformation, is known to be due to a pressure gradient between the posterior fossa and spinal canal, caused by circulatory disorder of the cerebrospinal fluid in the foramen magnum. Over the years, we have considered the relative diminishmentof posterior fossa volume, as comparedto that of the brain stem and cerebellum, to be the causeof this condition, and haveperformed operations with the purpose of expandingthe posterior fossa. Method: In the semiprone park bench position, only the dura is incised, and dural plasty using the sub-scalp fascia and pericranium is performed with expansivecranioplasty. The arachnoidmembraneis preserved, and the central canal is not obstructed. The bone fragmentof the posteriorfossa,obtainedupon
craniotomy, is cut once in the median, and a larger bone fragment is prepared utilizing the posterior arch of atlas, resected in one mass, in the intermedius. The bone is fixated using a titanium miniplate, while a MIDAS REX INSTITUTE drill, which is easierto maneuver, is used for osteotomy. An operatingtable that can turn 45 degrees is used, becausethe operation is carried out in semiprone park bench position,and position similar to the prone or lateral position can be easily attained. Furthermore, in case of bleeding, the blood flows downward and does not collect in the field of operation, enabling stable surgery under a clean operating field. Results and Conclusion: Most of patients' syrinx disappeared or diminished. This is demonstrated by video.
IV-S-64'
Expanding laminoplasty for cervical myelopathy due to multilevel spondylosis or OPLL
T. Morimoto, K. Nagata,S. Kawaguchi, T. Sakaki. Department of Neurosurgery, Nara MedicalUniversity, Kashihara, Japan A novelapproach calledexpanding laminoplasty using spinous process roofing techniquehasbeenemployedfor the surgicaltreatmentof the patientswith multilevel cervical myelopathyover the past 12 years. Long-term results regarding bone fusion rate, postoperative neck movement, and neurological improvement were analyzedin patients with 3 years followup or more. Materials and Methods: Sixty-eightcases are included in this study.There are 27 cases of OPLL and 41 cases of multilevelcervical spondylosis, 39 male and 29 female. Bone fusion was assessed on CT by the medullaryconnection between spinous process and lamina. Pre- and postoperative neck movement was evaluated on lateralradiograph using"angle of neck movement". Neurological assessment was done with the Japanese Orthopaedic Association (JOA) score. Technical Note: Modified Kurokawa's methodwas used in this procedureby roofing the cutoff spinousprocess between the open-door laminae with simple suturing technique. A lateral gutter was drilled as laterally as possible with all facets kept intact. Results: There were 7 cases with 7 levels laminoplasty (Cl-G7), 18 cases with 6 levels laminoplasty (C2-G7), 32 cases of 5 levels laminoplasty (C3-C7), and 11cases with 4 levels laminoplasty (C3-C6). By analysingalilaminoplasty levels, bone fusion rate was 97% on CT. Enlargement of AP diameter of the canal was 142% to the preoperative level. Postoperative neck movement was preserved at the level of 83% to the preoperative movement.The preoperative JOA score was 7.8 points in average, resulting 13.7 points at postoperatively 3rd year. Discussion and Conclusion: Our method apparently offers advantages such as technical simplicity, disuse of foreign material, and preservation of facet. This advantages resulted in the high postoprerative bone fusion rate, good postoperative neck movement, and an excellent long-term neurological improvement.
IV-S-6sl
Cervical spondylotic myelopathy treated via trans-unco-discal approach (TUD). Experiences of 529 cases
Akira Hakuba, Michiharu Morino, Moududul Haque, Kenji Nagai, AkimasaNishio, Kenji Ohata. Dept. Of Neurosurgery, Osaka City University, Osaka,Japan Introduction: TUD approach consists of anterior discectomy. uncectomy, removal of bilateralposteriorlateral corners of the vertebral bodies and resection of the posteriorridge. We have followed this approach for the patients with cervical myelopathy since 1974,whichis a combinedanteriorand lateralapproach to cervical discs. We present the results of the TUD approach in 529 patients with cervicalspondylotic myelopathy. Methods: There were 354 male and 175 female patients; their age ranged from 22 to 79 years (mean age 53.6 years). Four hundred eighty eight patients could be followed up. The mean follow up period was 73.6 months. The neurological status was classified according to the recovery rate (RR) of the Japan neurosurgical cervicalspine scale (JNCSS)to assess the resultsof TUD approach. We analyze the relationship of RR to age, developmental stenosis, durationand number of operated disc spaces. Result: There were 460 successful cases (excellent: RR > = 80%, good: 50% :': RR < 80%, fair: 20% ::: RR < 50%) and 28 unsuccesful cases (unchanged: -20% ::: RR < 20%, worse: RR < -20%).