Skip to main content

Advertisement

SpringerLink
Log in

Treatment of basilar invagination

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Purpose

Basilar invagination is a rare craniocervical malformation which may lead to neurological deficits related to compression of brainstem and upper cervical cord as well as instability of the craniocervical junction. This study presents results of a treatment algorithm developed over a 20-year period focussing on anatomical findings, short-term and long-term outcomes.

Methods

69 patients with basilar invagination (mean age 41 ± 18 years, history 64 ± 85 months) were encountered. The clinical courses were documented with a score system for individual neurological symptoms for short-term results after 3 and 12 months. Long-term outcomes were analyzed with Kaplan–Meier statistics.

Results

Patients with (n = 31) or without (n = 38) ventral compression were distinguished. 25 patients declined an operation, while 44 patients underwent 48 operations. Surgical management depended on the presence of ventral compression and segmentation anomalies between occiput and C3, signs of instability and presence of caudal cranial nerve dysfunctions. 16 patients without ventral compression underwent foramen magnum decompressions without fusion. 19 patients with ventral compression and abnormalities of segmentation or evidence of instability underwent a foramen magnum decompression with craniocervical (n = 18) or C1/2 (n = 1) stabilization. In nine patients with severe ventral compression and caudal cranial nerve deficits, a transoral resection of the odontoid was combined with a posterior decompression and fusion. Within the first postoperative year neurological scores improved for all symptoms in each patient group. In the long-term, postoperative deteriorations were related exclusively to instabilities either becoming manifest after a foramen magnum decompression in three or as a result of hardware failures in two patients.

Conclusions

The great majority of patients with basilar invagination report postoperative improvements with this management algorithm. Most patients without ventral compression can be managed by foramen magnum decompression alone. The majority of patients with ventral compression can be treated by posterior decompression, realignment and stabilization alone, reserving anterior decompressions for patients with profound, symptomatic brainstem compression.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Menezes AH, VanGilder JC, Graf CJ, McDonnell DE (1980) Craniocervical abnormalities. A comprehensive surgical approach. J Neurosurg 53:444–455

    Article  CAS  PubMed  Google Scholar 

  2. Goel A (2004) Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation. J Neurosurg Spine 1:281–286

    Article  PubMed  Google Scholar 

  3. Klekamp J, Samii M (1993) Introduction of a score system for the clinical evaluation of patients with spinal processes. Acta Neurochir (Wien) 123:221–223

    CAS  Google Scholar 

  4. Klekamp J (2012) Surgical treatment of Chiari I malformation–analysis of intraoperative findings, complications, and outcome for 371 foramen magnum decompressions. Neurosurgery 71:365–380. doi:10.1227/NEU.0b013e31825c3426 (discussion 380)

    Article  PubMed  Google Scholar 

  5. Klekamp J, Batzdorf U, Samii M, Bothe HW (1996) The surgical treatment of Chiari I malformation. Acta Neurochir (Wien) 138:788–801

    Article  CAS  Google Scholar 

  6. Klekamp J, Samii M (2001) Syringomyelia—diagnosis and treatment. Springer Verlag, Heidelberg

    Google Scholar 

  7. Kaplan EL, Meier P (1958) Nonparametric estimation from incomplete observations. J Am Stat Assoc 53:457–481

    Article  Google Scholar 

  8. Menezes AH (2008) Craniocervical developmental anatomy and its implications. Childs Nerv Syst 24:1109–1122

    Article  PubMed  Google Scholar 

  9. Milhorat TH, Chou MW, Trinidad EM, Kula RW, Mandell M, Wolpert C, Speer MC (1999) Chiari I malformation redefined: clinical and radiographic findings for 364 symptomatic patients. Neurosurgery 44:1005–1017

    Article  CAS  PubMed  Google Scholar 

  10. Ali MM, Russell N, Awada A, McLean D (1996) A cranio-cervical malformation presenting as acute respiratory failure. J Emerg Med 14:569–572

    Article  CAS  PubMed  Google Scholar 

  11. Goel A, Shah A (2009) Reversal of longstanding musculoskeletal changes in basilar invagination after surgical decompression and stabilization. J Neurosurg Spine 10:220–227

    Article  PubMed  Google Scholar 

  12. Dickman CA, Kalani MY (2012) Resolution of cervical syringomyelia after transoral odontoidectomy and occipitocervical fusion in a patient with basilar invagination and Type I Chiari malformation. J Clin Neurosci 19:1726–1728. doi:10.1016/j.jocn.2012.04.006

    Article  PubMed  Google Scholar 

  13. Menezes AH (2012) Craniovertebral junction abnormalities with hindbrain herniation and syringomyelia: regression of syringomyelia after removal of ventral craniovertebral junction compression. J Neurosurg 116:301–309. doi:10.3171/2011.9.jns11386

    Article  PubMed  Google Scholar 

  14. Joseph V, Rajshekhar V (2003) Resolution of syringomyelia and basilar invagination after traction. Case illustration. J Neurosurg Spine 98:298

    Article  Google Scholar 

  15. Hwang SW, Heilman CB, Riesenburger RI, Kryzanski J (2008) C1-C2 arthrodesis after transoral odontoidectomy and suboccipital craniectomy for ventral brain stem compression in Chiari I patients. Eur Spine J 17:1211–1217

    Article  PubMed Central  PubMed  Google Scholar 

  16. Jian FZ, Chen Z, Wrede KH, Samii M, Ling F (2010) Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery 66:678–687 (discussion 687)

    Article  PubMed  Google Scholar 

  17. Collignon FP, Cohen-Gadol AA, Krauss WE (2004) Circumferential decompression of the foramen magnum for the treatment of syringomyelia associated with basilar invagination. Neurosurg Rev 27:168–172

    Article  PubMed  Google Scholar 

  18. Goel A, Bhatjiwale M, Desai K (1998) Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 88:962–968

    Article  CAS  PubMed  Google Scholar 

  19. Bollo RJ, Riva-Cambrin J, Brockmeyer MM, Brockmeyer DL (2012) Complex Chiari malformations in children: an analysis of preoperative risk factors for occipitocervical fusion. J Neurosurg Pediatr 10:134–141. doi:10.3171/2012.3.peds11340

    Article  PubMed  Google Scholar 

  20. Simsek S, Yigitkanli K, Belen D, Bavbek M (2006) Halo traction in basilar invagination: technical case report. Surg Neurol 66:311–314 (discussion 314)

    Article  PubMed  Google Scholar 

  21. Dahdaleh NS, Dlouhy BJ, Menezes AH (2012) Application of neuromuscular blockade and intraoperative 3D imaging in the reduction of basilar invagination. J Neurosurg Pediatr 9:119–124. doi:10.3171/2011.11.peds11332

    Article  PubMed  Google Scholar 

  22. Peng X, Chen L, Wan Y, Zou X (2011) Treatment of primary basilar invagination by cervical traction and posterior instrumented reduction together with occipitocervical fusion. Spine (Phila Pa 1976) 36:1528–1531. doi:10.1097/BRS.0b013e3181f804ff

    Article  Google Scholar 

  23. Goel A, Shah A (2008) Atlantoaxial joint distraction as a treatment for basilar invagination: a report of an experience with 11 cases. Neurol India 56:144–150

    Article  PubMed  Google Scholar 

  24. Botelho RV, Neto EB, Patriota GC, Daniel JW, Dumont PA, Rotta JM (2007) Basilar invagination: craniocervical instability treated with cervical traction and occipitocervical fixation. Case report. J Neurosurg Spine 7:444–449

    Article  PubMed  Google Scholar 

  25. Kim LJ, Rekate HL, Klopfenstein JD, Sonntag VK (2004) Treatment of basilar invagination associated with Chiari I malformations in the pediatric population: cervical reduction and posterior occipitocervical fusion. J Neurosurg 101:189–195

    Article  PubMed  Google Scholar 

  26. Salunke P, Behari S, Kirankumar MV, Sharma MS, Jaiswal AK, Jain VK (2006) Pediatric congenital atlantoaxial dislocation: differences between the irreducible and reducible varieties. J Neurosurg 104:115–122

    PubMed  Google Scholar 

  27. Kaibara T, Hurlbert RJ, Sutherland GR (2001) Intraoperative magnetic resonance imaging-augmented transoral resection of axial disease. Neurosurg Focus 10:E4

    Article  CAS  PubMed  Google Scholar 

  28. Gladi M, Iacoangeli M, Specchia N, Re M, Dobran M, Alvaro L, Moriconi E, Scerrati M (2012) Endoscopic transnasal odontoid resection to decompress the bulbo-medullary junction: a reliable anterior minimally invasive technique without posterior fusion. Eur Spine J 21(Suppl 1):S55–S60. doi:10.1007/s00586-012-2220-4

    Article  PubMed  Google Scholar 

  29. Scholtes F, Signorelli F, McLaughlin N, Lavigne F, Bojanowski MW (2011) Endoscopic endonasal resection of the odontoid process as a standalone decompressive procedure for basilar invagination in Chiari type I malformation. Minim Invasive Neurosurg 54:179–182

    Article  CAS  PubMed  Google Scholar 

  30. Goel A (2005) Progressive basilar invagination after transoral odontoidectomy: treatment by atlantoaxial facet distraction and craniovertebral realignment. Spine 30:E551–E555

    Article  PubMed  Google Scholar 

  31. Mouchaty H, Perrini P, Conti R, Di Lorenzo N (2009) Craniovertebral junction lesions: our experience with the transoral surgical approach. Eur Spine J 18(Suppl 1):13–19

    Article  PubMed Central  PubMed  Google Scholar 

  32. Naderi S, Pamir MN (2001) Further cranial settling of the upper cervical spine following odontoidectomy. Report of two cases. J Neurosurg Spine 95:246–249

    Article  CAS  Google Scholar 

  33. Daniel RT, Muzumdar A, Ingalhalikar A, Moldavsky M, Khalil S (2012) Biomechanical stability of a posterior-alone fixation technique after craniovertebral junction realignment. World Neurosurg 77:357–361. doi:10.1016/j.wneu.2011.06.039

    Article  PubMed  Google Scholar 

  34. Menezes AH (2008) Surgical approaches: postoperative care and complications “transoral-transpalatopharyngeal approach to the craniocervical junction”. Childs Nerv Syst 24:1187–1193

    Article  PubMed  Google Scholar 

  35. Bagley CA, Witham TF, Pindrik JA, Davis RF, Bydon A, Gokaslan ZL, Wolinsky JP (2009) Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement. J Spinal Disord Tech 22:170–176. doi:10.1097/BSD.0b013e318168be6f

    Article  PubMed  Google Scholar 

  36. Miyata M, Neo M, Fujibayashi S, Ito H, Takemoto M, Nakamura T (2009) O-C2 angle as a predictor of dyspnea and/or dysphagia after occipitocervical fusion. Spine (Phila Pa 1976) 34:184–188. doi:10.1097/BRS.0b013e31818ff64e

    Article  Google Scholar 

  37. Yoshida M, Neo M, Fujibayashi S, Nakamura T (2007) Upper-airway obstruction after short posterior occipitocervical fusion in a flexed position. Spine (Phila Pa 1976) 32:E267–E270. doi:10.1097/01.brs.0000259977.69726.6f

    Article  Google Scholar 

  38. Matsunaga S, Onishi T, Sakou T (2001) Significance of occipitoaxial angle in subaxial lesion after occipitocervical fusion. Spine (Phila Pa 1976) 26:161–165

    Article  CAS  Google Scholar 

  39. Arora P, Behari S, Banerji D, Chhabra DK, Jain VK (2004) Factors influencing the outcome in symptomatic Chiari I malformation. Neurol India 52:470–474

    PubMed  Google Scholar 

  40. Aghakhani N, Parker F, David P, Morar S, Lacroix C, Benoudiba F, Tadie M (2009) Long-term follow-up of Chiari-related syringomyelia in adults: analysis of 157 surgically treated cases. Neurosurgery 64:308–315. doi:10.1227/01.neu.0000336768.95044.80 (discussion 315)

    Article  PubMed  Google Scholar 

  41. Nockels RP, Shaffrey CI, Kanter AS, Azeem S, York JE (2007) Occipitocervical fusion with rigid internal fixation: long-term follow-up data in 69 patients. J Neurosurg Spine 7:117–123

    Article  PubMed  Google Scholar 

  42. Plotz GM, Schutz U, Grob D (1998) Dorsal occipitocervical fusion—indications and results. Z Orthop Ihre Grenzgeb 136:364–374

    Article  CAS  PubMed  Google Scholar 

Download references

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Christliches Krankenhaus, Danziger Str. 2, 49610, Quakenbrück, Germany

    Jörg Klekamp

Authors
  1. Jörg Klekamp
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jörg Klekamp.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Klekamp, J. Treatment of basilar invagination. Eur Spine J 23, 1656–1665 (2014). https://doi.org/10.1007/s00586-014-3423-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-014-3423-7

Keywords

Search

Navigation