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H. Alan Crockard and Robert Bradford

T he transoral approach to anteriorly placed lesions at the craniocervical junction has been in use for over 20 years. 4, 15 It is now becoming established as a relatively safe and effective method for dealing with a variety of extradural lesions around the clivus, 6, 16 foramen magnum, 8, 9 atlantoaxial complex, 1, 5, 11, 14 and upper cervical spine. 2, 10 The use of the transoral route to treat intradural lesions, in particular basilar aneurysms, 3, 12 has been less successful. The most serious problem with this approach is the high incidence of

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H. Alan Crockard, Alan E. Heilman and John M. Stevens

widely separated ( Fig. 1 right ) the possibility must be considered. Fielding, et al. , 18 demonstrated experimentally that the transverse ligament had to be damaged to allow an atlantodental interval of greater than 3 mm. In the Type II fracture, however, the subluxation may occur due to the ligament slipping into the fracture. Modern MR imaging allows visualization of the ligaments at the craniocervical junction. 16 Careful attention to the position of the transverse ligament will allow optimum planning of the surgical approach. In terms of the

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Juan C. Bartolomei and H. Alan Crockard

. Neurosurgery 27 : 197 – 204 , 1990 Sen CN, Sekhar, LN: An extreme lateral approach to intradural lesions of the cervical spine and foramen magnum. Neurosurgery 27: 197–204, 1990 34. Sen CN , Sekhar LN : Surgical management of anteriorly placed lesions at the craniocervical junction—an alternative approach. Acta Neurochir 108 : 70 – 77 , 1991 Sen CN, Sekhar LN: Surgical management of anteriorly placed lesions at the craniocervical junction—an alternative approach. Acta Neurochir 108: 70–77, 1991 35

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2. Crockard HA : Surgery for anteriorly placed meningiomas at the foramen magnum , Schmidek HH (ed): Meningiomas and Their Surgical Management. Philadelphia : WB Saunders , 1991 , pp 471 – 479 Crockard HA: Surgery for anteriorly placed meningiomas at the foramen magnum, Schmidek HH (ed): Meningiomas and Their Surgical Management. Philadelphia: WB Saunders, 1991, pp 471–479 3. Crockard HA , Sett P , Geddes JF , et al : Damaged ligaments at the craniocervical junction presenting as an

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Gerald F. Tuite, Robert Veres, H. Alan Crockard and Debbie Sell

. Neurosurgery 8 : 675 – 679 , 1981 Delgado TE, Garrido E, Harwick RD: Labiomandibular, transoral approach to chordomas in the clivus and upper cervical spine. Neurosurgery 8: 675–679, 1981 11. Di Lorenzo N : Craniocervical junction malformation treated by transoral approach. A survey of 25 cases with emphasis on postoperative instability and outcome. Acta Neurochir 118 : 112 – 116 , 1992 Di Lorenzo N: Craniocervical junction malformation treated by transoral approach. A survey of 25 cases with emphasis on postoperative

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Adrian T. H. Casey, H. Alan Crockard, Jennian F. Geddes and John Stevens

compressed segment, the extent of maximum compression (spinal cord diameter or spinal cord area), or the degree of angulation of the craniocervical junction (Wackenheim's angle 43 ). However, the level of maximum compression of the neuraxis was significantly lower in patients with subluxation compared with those who had vertical translocation (p = 0.009), occurring on average 10.8 mm below the level of the foramen magnum. TABLE 2 Radiographic data obtained in 186 patients with myelopathy * Vertical Translocation Factor Yes No p

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H. Alan Crockard, Turgut Koksel and Nigel Watkin

posterolateral routes, it was decided to perform transclival transdural surgery. A midline hard and soft palatal split was added to a standard Le Fort maxillotomy, “hinging” laterally on the palatine vessels and nerves in each half of the palate. 6 This allowed exposure of the whole clivus and craniocervical junction down to C-2. The middle portion of the clivus was removed using a high-speed air drill, the dura was opened, and the vertebral arteries and lower two-thirds of the basilar artery were identified. The aneurysm was located deep in the substance of the brain on the

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H. Alan Crockard, Ahmed Tammam and Nigel Mendoza

: Development of transoral approaches to lesions of the skull base and craniocervical junction. Neurosurg Q 3 : 61 – 82 , 1993 Crockard HA, Johnston FG: Development of transoral approaches to lesions of the skull base and craniocervical junction. Neurosurg Q 3: 61–82, 1993 6. Ebraheim NA , Savolaine ER , Zeiss J , et al : Titanium hip implants for improved magnetic resonance and computed tomography examinations. Clin Orthop 275 : 194 – 198 , 1992 Ebraheim NA, Savolaine ER, Zeiss J, et al: Titanium hip

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Adrian T. H. Casey, H. Alan Crockard and John Stevens

the foramen magnum ( Fig. 5 ). Fig. 3. Box-plot graph illustrating the relationship between the degree of vertical translocation and postoperative neurological class. Greater degrees of vertical translocation (represented by smaller Redlund-Johnell values) are significantly associated with a poorer postoperative neurological class (Ranawat IIIB). Fig. 4. Computerized tomography myelogram slice (axial view) extending through the craniocervical junction showing marked compression of the spinal cord by the vertically translocated odontoid

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Daniel M. May, Stephen J. Jones and H. Alan Crockard

 & Klippel—Feil syndrome  (clivus—C2)  15 min 14 29, M Ranawat IIIb, syringomyelia after syringopleural shunt lt & rt intermittent drop throughout, full recovery  cord tumor 15 22, F Ranawat IIIb; rt C-2 schwannoma, rt lat excision lt & rt lost on irrigation at craniocervical junction,  neurofibromatosis  full recovery in 10 min 16 44, M Ranawat I, degenerative spondylosis anterior decompression of C5–6 & lt drop with retractor on root, full recovery over  C7—T1 (Smith—Robinson)  35-min