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Basilar decompression via a far lateral transcondylar approach: technical note

  • Technical Note - Neurosurgery Training
  • Published:
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Abstract

Background

Treatments for symptomatic or unstable basilar invagination (BI) include posterior decompression, distraction/fusion, trans-nasal or trans-oral anterior decompression, and combined techniques, with the need for occipitocervical fusion based on the degree of craniocervical instability. Variations of the far lateral transcondylar approach are described in limited case series for BI, but have not been widely applied.

Methods

A single-institution, retrospective review of consecutive patients undergoing a far lateral transcondylar approach for odontoidectomy (± resection of the inferior clivus) followed by occipitocervical fusion over a 6-year period (1/1/2016 to 12/31/2021) is performed. Detailed technical notes are combined with images from cadaveric dissections and patient surgeries to illustrate our technique using a lateral retroauricular incision.

Results

Nine patients were identified (3 males, 6 females; mean age 40.2 ± 19.6 years). All patients had congenital or acquired BI causing neurologic deficits. There were no major neurologic or wound-healing complications. 9/9 patients (100%) experienced improvement in preoperative symptoms.

Conclusions

The far lateral transcondylar approach provides a direct corridor for ventral brainstem decompression in patients with symptomatic BI. A comprehensive knowledge of craniovertebral junction anatomy is critical to the safe performance of this surgery, especially when using a lateral retroauricular incision.

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Authors and Affiliations

  1. Department of Neurological Surgery, University of California San Diego, San Diego, CA, USA

    Robert C. Rennert

  2. Department of Neurological Surgery, University of Arkansas, Little Rock, AR, USA

    Marcus L. Stephens, Angela W. Palmer, Analiz Rodriguez, Noojan Kazemi, Thomas W. Morris III, T. Glen Pait & J. D. Day

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  1. Robert C. Rennert
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  2. Marcus L. Stephens
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  3. Angela W. Palmer
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  4. Analiz Rodriguez
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  5. Noojan Kazemi
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  6. Thomas W. Morris III
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  7. T. Glen Pait
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  8. J. D. Day
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Corresponding author

Correspondence to J. D. Day.

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Conflict of interest

The authors declare no competing interests.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Consent for surgical procedures, data collection, and review was obtained in accordance with institutional guidelines.

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Comments

The authors describe their technique of far lateral approach with odontoidectomy for use in cases with basilar invagination. The procedural details are described in detail with operative videos. Overall, the quality of the description and presentation is very good. The key step in achieving requisite exposure of this region and performance of odontoidectomy is transposition of the vertebral artery. While this is described for C1, it can also include additional levels below to enable tailored removal of tumors in this region when more inferior extension as necessary. The advantage of this approach over an anterior approach (trans-nasal or trans-oral) is that the corridor avoids traversing the nasopharynx (endoscopic endonasal) or oropharynx (trans-oral) with the higher risk of infectious complications. If we use the Extreme Lateral Trans-odontoid exposure (ELTO), we usually use a large hockey-stick incision to enable access to midline posteriorly (1), which enables a single stage odontoid removal, tumor removal if necessary, and occipital-cervical fusion to be performed at the same sitting or in a delayed fashion depending upon the particular case length of surgery and associated blood loss, etc. These lateral trans-odontoid removals allow removal of the odontoid and tumor in midline, ipsilateral and contralateral regions as indicated, unencumbered by carotid artery location. The authors should be congratulated on their nice description of their technique, and discussion of alternatives.

1. Alzhrani G, Gozal YM, Eli I, Sivakumar W, Raheja A, Brockmeyer DL, Couldwell WT (2018) Extreme lateral transodontoid approach to the ventral craniocervical junction: cadaveric dissection and case illustrations. J Neurosurg:1–11. https://doi.org/10.3171/2018.4.JNS172935.

William T. Couldwell.

Salt Lake City, UT, USA.

This article is part of the Topical Collection on Neurosurgery Training

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Rennert, R.C., Stephens, M.L., Palmer, A.W. et al. Basilar decompression via a far lateral transcondylar approach: technical note. Acta Neurochir 164, 2563–2572 (2022). https://doi.org/10.1007/s00701-022-05312-9

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