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BACKGROUND: Lesions of structures around the ventral side of the brainstem are located in the deep surface of the craniocervical junction, surrounded by important structures. The far lateral approach is the basic surgical method, but sex and lateral differences should be considered in the approach. OBJECTIVE: To analyze the morphological characteristics of the foramen magnum and occipital condyle by three-dimensional reconstruction measurements, thereby providing anatomical parameters for the far lateral approach to the skull base in clinical practice. METHODS: A total of 673 adult patients (448 males and 225 females) with head and neck CT scans were selected. The age ranged from 20 to 87. The length and width of the foramen magnum were measured. The area and index of the foramen magnum were then calculated by formulas. The length and width of the occipital condyle were measured, as well as the angle between the long and sagittal axis of the occipital condyle (O-S angle), the angle between the line connecting the midpoints of anterior and posterior foramen magnum and the line connecting the midpoint of anterior foramen magnum and the intersection of posterior occipital condyle and lateral foramen magnum (F-O angle), and the angle between the line connecting the midpoints of anterior and posterior foramen magnum and the line connecting the midpoint of anterior foramen magnum and the midpoint of the posterior wall of the hypoglossal canal (F-H angle). The sex and lateral differences of each index were analyzed. RESULTS AND CONCLUSION: There were statistical differences in foramen magnum indexes except between sexes (P > 0.05). The indexes of occipital condyle were significantly higher in males than in females (P < 0.05) except that the left occipital condyle width in males was lower than that in females (P > 0.05). The O-S angle in males was smaller than that in females, and there was a significant difference in the left O-S angle between sexes (P < 0.05). There was no statistical difference between right and left F-H angles. Significant differences were observed in occipital condyle length, occipital condyle width, O-S angle, and F-O angle (P < 0.05). These findings indicate that the parameters of the foramen magnum and occipital condyle were different in sex and on both sides. For the far lateral and transcondylar approaches, the right approach was relatively safe and exposed to a larger range. The length, width, and area of the foramen magnum, the length of the occipital condyle, and O-S angle in males were larger than those in females. Therefore, the sex difference should be considered in the far lateral approach. [ABSTRACT FROM AUTHOR]

Objective To study the dangerous variations of vertebral artery (VA) at craniovertebral junction (V3 segment). Methods The imaging data of 834 patients who underwent DSA in Jining No. 1 People's Hospital from January 2019 to October 2020 were collected, the incidences of dangerous anatomical variation and dangerous functional variation of persistent first intersegmental artery, VA fenestration, posterior inferior cerebellar artery (PICA) with lower origin, dominant VA and terminating PICA were analyzed. Results The variation of V3 segment of VA was divided into dangerous anatomical variation and dangerous functional variation. Dangerous anatomic variation included persistent first intersegmental vertebral artery, VA fenestration and PICA with lower origin. The incidence of the three types of unilateral dangerous anatomical variation was 1.92% (17/834), 1.80% (16/834) and 1.68 (15/834). The incidence of bilateral dangerous anatomical variation was 0.12% (1/834), while one side of the VA was fenestrated and the other side was the persistent first intersegmental artery. Dangerous functional variation included dominant VA and terminating PICA. The incidence of these two functional variation was 13.19% (110/834) and 3.72% (31/834). The left dominant VA was more common (79.09%, 87/110), while the right was 23 cases (20.91%, 23/110). Thirty-one cases (3.72%, 31/834) of terminating PICA, while 26 cases (83.87%, 26/31) in the right and 5 cases (16.13%, 5/31) in the left. Conclusions The incidence of dangerous variation in V3 segment of VA is high. Imaging dangerous anatomical variation and dangerous functional variation should be routinely performed before craniovertebral junction surgery to evaluate the possible VA examinations variation patients, so as to reduce the risk of VA injury during surgery. [ABSTRACT FROM AUTHOR]

Objective To investigate the feasibility of full-endoscopic posterolateral odontoidectomy through morphological analysis and cadaver specimen surgery. Methods We collected the DICOM data of 20 normal cervical CT patients(10 males and 10 females)from the PACS Image Library of our hospital. The Mimics software was used for cervical CT reconstruction and anatomical measurements were made to measure the maximum sagittal diameter, coronal diameter and height of the odontoid process. The C1 lateral mass could provide the maximum working height and width of endoscopic operation with a diameter of 7 mm, as well as the angle between the anchor point of C1 lateral mass and the notch on both sides of the odontoid process. The feasibility of endoscopic surgery was analyzed based on the measured data. The fresh frozen corpse was used for the operation in prone position under the guidance of C-arm. Kirschner wire was anchored at the midpoint of the lower surface of the C1 lateral mass. Part of the C1 lateral mass was removed by the grinding drill and endoscopic tools, and then the odontoid process and adjacent ligaments were removed. Results The maximum sagittal diameter, coronal diameter and height of the odontoid process were(11. 73±0. 74)mm, (10. 97±0. 71)mm and (14. 51±0. 91)mm, respectively. The working height and width of the C1 lateral mass were(13. 53±0. 57)mm and (10. 00±1. 27)mm, respectively. The angle between the anchor point and the double-edge notch of the odontoid process was(28. 3±3. 1)°, with no statistical difference between the male and female patients(P>0. 05). All the measurements met the requirements of 7 mm endoscopic implantation and surgical operation, and the space for swing could be provided for complete or partial removal of the odontoid process to meet the requirements of ventral spinal decompression. In cadaver surgery, a fully endoscopic posterolateral approach enabled complete removal of the odontoid process by grinding part of the C1 lateral mass. Postoperative cervical CT confirmed that the odontoid process had been completely resected, and there were no signs of dural sac or vertebral artery injury. Conclusion The odontoid process can be completely resected through a posterolateral endoscopic approach via the lateral mass approach of C1, providing a new surgical method for clinical odontoidectomy to decompress the spinal cord in craniovertebral junction. [ABSTRACT FROM AUTHOR]

Objective: To investigate the method of treating tuberculosis in the craniovertebral junction and its effectiveness., Methods: The clinical data of 18 patients with tuberculosis in the craniovertebral junction between July 2010 and January 2019 was analyzed retrospectively. There were 14 males and 4 females, aged 21 months to 75 years (median, 35 years). The disease duration ranged from 2 weeks to 60 months (median, 4 months), and the affected segment was C 0 -C 3 . Preoperative visual analogue scale (VAS) score was 6.7±1.5 and the Japanese Orthopaedic Association (JOA) score was 16.1±1.8. The American Spinal Cord Injury Association (ASIA) grading system was applied to classify their neurological functions, according to which there were 6 cases of grade D and 12 cases of grade E. Among 18 patients, 4 patients underwent conservative treatment, 1 patient removed tuberculosis via transoral approach, 1 patient removed tuberculosis via posterior cervical approach, and 12 patients removed tuberculosis via transoral approach immediately after posterior cervical (atlantoaxial or occipitalcervical) fusion and internal fixation. The VAS score, ASIA grading, and JOA score were applied to evaluate effectiveness. X-ray film, CT, and MRI were taken after treatment to evaluate the tubercular recurrence, cervical stability, and bone healing., Results: All the patients were followed up 3 to 42 months (median, 12 months). At 3 months after treatment, the VAS score was 1.7±1.0, showing significant difference when compared with preoperative score ( t =15.000, P =0.000); and the JOA score was 16.7±1.0, showing no significant difference when compared with preoperative score ( t =1.317, P =0.205). According to ASIA grading, 6 patients with grade D before treatment had upgraded to grade E after treatment, while the remaining patients with grade E had no change in grading. The imaging examinations showed the good stability of the cervical spine. All patients had complete tuberculosis resection and no recurrence, and the patients who underwent internal fixation via posterior cervical approach achieved atlantoaxial or occipitalcervical bone fusion., Conclusion: On the premise of regular chemotherapy, if there is no huge abscess causing dysphagia or dyspnea, atlantoaxial instability, and neurological symptoms, patients can undergo conservative treatment. If not, however, the transoral approach can be used to completely remove the tuberculosis lesion in the craniovertebral junction. One-stage debridement via transoral approach combined with posterior cervical fusion and internal fixation can achieve satisfactory effectiveness.

Objective: To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness., Methods: The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C 0, 1 , 3 cases of C 2 , 1 case of C 1, 2 , 1 case of C 2, 3 , and 1 case of C 0-2 . Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation., Results: The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 ( t =7.638, P =0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score ( t =1.549, P =0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases., Conclusion: Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.

Objective: To study the changes of bacterial flora after a series of preoperative oral disinfection and the postoperative recovery of patients with craniovertebral junction disorders who were treated with transoral approach operations. And to provide a theoretical basis for the prevention of postoperative complications such as infection., Methods: The clinical data of 20 cases with craniovertebral junction disorders and treated with transoral approach operations between October 2009 and May 2010 were analyzed. There were 8 males and 12 females, aged 2-66 years (median, 34.5 years). According to the classification of American Spinal Injury Association (ASIA)，there were 4 cases of grade B, 8 of grade C, 6 of grade D, and 2 of grade E. The Japanese Orthopedic Association (JOA) score was 10.3±3.0. The mucosa samples of the posterior pharyngeal wall were sent for bacteria culture. These samples were collected by sterile cotton swabs at four crucial points including 3 days before operation/before gargling (T1), 3 days after continuous gargling by chlorhexidine acetate/after anesthesia intubation on the day of operation (T2), after intraoperative cleaning and washing of the mouth (T3), and after intraoperative iodophor immersion for 5-10 minutes (T4). The microflora was stained by means of smear and further counted after an investigation by microscope. The ASIA classification and the JOA scores were applied to evaluate the postoperative nerve function of the patients. A regular reexamination of cervical vertebra with X-ray film, CT, and MRI was conducted after operation to evaluate the reduction of atlantoaxial dislocation, internal fixation position, bone graft fusion, inflammatory lesion, and tumor resection in the craniovertebral junction., Results: After a series of oral disinfection, the mucosa of the posterior pharyngeal wall of all the patients was in a sterile state, which was considered as type Ⅰ incision. All these 20 patients were treated with successful operations, without any intraoperative injury in vertebral artery and spinal cord, or any postoperative complications such as plate loosening, incision infection, or intracranial infection. All the patients were followed up 3-23 months, with an average of 5.15 months. The symptoms such as neck pain, limb numbness and weakness, neural symptoms, etc. were improved to different degrees after operation. The JOA score was improved to 13.4±1.9 at 3 months after operation, showing significant difference when compared with preoperative score ( t =8.677, P =0.000); and the atlantoaxial joints had been fused. At last follow-up, the ASIA grades were improved when compared with those before operation., Conclusion: It is safe and effective to cut the posterior pharyngeal muscle layer and implant internal fixation by means of transoral approach in the treatment of craniovertebral junction disorders.