Extreme lateral transodontoid approach to the ventral craniocervical junction: cadaveric dissection and case illustrations

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OBJECTIVE

Surgical treatment of pathological processes involving the ventral craniocervical junction (CCJ) traditionally involves anterior and posterolateral skull base approaches. In cases of bilateral extension, when lesions extend beyond the midline to the contralateral side, a unilateral corridor may result in suboptimal resection. In these cases, the lateral extent of the tumor will prevent extirpation of the lesion via anterior surgical approaches. The authors describe a unilateral operative corridor developed along an extreme lateral trajectory to the anterior aspect of the clival and upper cervical dura, allowing exposure and resection of tumor on the contralateral side. This approach is used when the disease involves the bone structures inherent to stability at the anterior CCJ.

METHODS

To achieve exposure of the ventral CCJ, an extreme lateral transcondylar transodontoid (ELTO) approach was performed with transposition of the ipsilateral vertebral artery, followed by drilling of the C1 anterior arch. Resection of the odontoid process allowed access to the contralateral component of lesions across the midline to the region of the extracranial contralateral vertebral artery, maximizing resection.

RESULTS

Exposure and details of the surgical procedure were derived from anatomical cadavers. At the completion of cadaveric dissection, morphometric measurements of the relevant anatomical landmarks were obtained. Illustrative case examples for approaching ventral CCJ chordomas via the ELTO approach are presented.

CONCLUSIONS

The ELTO approach provides a safe and direct surgical corridor to treat complex lesions at the ventral CCJ with bilateral extension through a single operative corridor. This approach can be combined with other lateral approaches or posterior infratemporal approaches to remove more extensive lesions involving the rostral clivus, jugular foramen, and temporal bone.

ABBREVIATIONS CCJ = craniocervical junction; ELTC = extreme lateral transcondylar; ELTO = extreme lateral transodontoid; PICA = posterior inferior cerebellar artery; VA = vertebral artery.

Article Information

Correspondence William T. Couldwell: University of Utah, Salt Lake City, UT. neuropub@hsc.utah.edu.

INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.4.JNS172935.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A and B: Cadaveric dissection illustrating a left-sided hockey stick incision for the ELTO approach (A) and the V3 segment of the left VA in the J-groove and the C2 nerve root below the C1 posterior arch after the elevation of a single musculocutaneous flap laterally (B). C: The posterior arch of C1 is removed as far laterally as the lateral mass, the foramen transversarium is drilled posteriorly, and the VA is decompressed. D: The C2 nerve root is transected, and the VA is transposed to expose the occipital condyle (O)–C1 lateral mass articulation. E: The condylar–C1 joint is opened, and the lateral mass of C1 is drilled away, anteriorly toward the anterior arch of C1. F: The occipital condyle is drilled, the hypoglossal canal is opened, and the lower clivus is exposed. G: The ipsilateral C1 anterior arch is drilled, the odontoid process is removed down to its base, and all the surrounding ligaments are dissected away to expose the longus colli muscle. Then the anterior arch of C1 is followed toward the contralateral side until it curves backward behind the ventral CCJ dura. H: The dura is opened in a curvilinear fashion posterior to the ipsilateral VA, and the contralateral intradural VA is exposed. Copyright Department of Neurosurgery, University of Utah. Published with permission. Figure is available in color online only.

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    Case 1. A: Preoperative sagittal postcontrast T1-weighted MR image demonstrating an infiltrative destructive lesion at the skull base extending from the tip of the clivus to the axis with both intra- and extradural components. B–D: Preoperative sagittal (B), axial (C), and coronal (D) noncontrast CT scans showing the bony destructive lesion involving the skull base and evidence of prior surgery.

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    Illustrations of the ELTO approach demonstrating bony removal (A) and the ventrolateral trajectory (arrow, B) to the anterior craniovertebral junction. Copyright Department of Neurosurgery, University of Utah. Published with permission. Figure is available in color online only.

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    Case 1. A: Postoperative sagittal postcontrast T1-weighted MR image demonstrating radical removal of the lesion. B–D: Postoperative sagittal (B), axial (C), and coronal (D) bone window CT scans demonstrating radical resection of the occipital condyle, C1 lateral mass, and odontoid process via the ELTO approach.

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    Case 2. A: Preoperative sagittal postcontrast T1-weighted MR image demonstrating an infiltrative destructive lesion at the skull base with significant ventral brainstem compression, heterogeneous enhancement, and bilateral extension. B–D: Preoperative sagittal (B), axial (C), and coronal (D) noncontrast CT scans demonstrating the destructive lesion centered around the clivus and extending to the upper cervical spine. E–H: Postoperative sagittal postcontrast T1-weighted MR image (E) demonstrating gross-total removal of the lesion. Postoperative sagittal (F), axial (G), and coronal (H) bone window CT scans demonstrating radical resection of the occipital condyle, C1 lateral mass, and odontoid process (ELTO approach).

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    Case 3. A–D: Preoperative sagittal T1-weighted MR image with gadolinium (A), axial T2-weighted MR image (B), and sagittal (C) and axial (D) CT scans of the CCJ demonstrating an enhancing and lytic lesion located at the ventral CCJ. E–H: Postoperative sagittal (E) and axial (F) T1-weighted MR images with gadolinium, and sagittal (G) and axial (H) CT slices of the CCJ demonstrating gross-total resection of the tumor with bony removal accomplished through a left ELTO approach. I: Three-dimensional reconstruction of the CCJ after gross-total resection.

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