Fig. 71.1
Basilar impression/invagination. (a) Sagittal T1-weighted precontrast MR image. (b) Sagittal CT image. The clivus is hypoplastic, and there is incomplete segmentation of C2 and C3. The odontoid process of C2 is high riding and the foramen magnum is narrowed. A posterior fossa arachnoid cyst is displacing the cerebellar tonsils anteriorly. (a) A cervical cord syrinx is present
71.3 Clinical and Surgical Management
The management of BI should be individualized. It is often based on the patient’s signs and symptoms, degree of anterior (brainstem) compression, presence of a Chiari malformation, presence of craniocervical instability, and the patient’s age and comorbidities [5].
In some patients, especially younger ones with primary basilar invagination, cervical traction and fixation can be used successfully to achieve decompression and stabilization [2, 6, 7].
In the presence of a Chiari I malformation and reduction of posterior fossa volume, posterior decompression (with or without fixation) is a preferred approach for many patients [8].
Classically, a transoral approach has been used in treating anterior craniocervical pathology with direct brainstem compression, often followed by posterior fixation and fusion. These approaches offer good exposure of the affected region, and many patients improve with regard to compression symptoms, but complication rates are relatively high [9, 10].
In recent years, extended endoscopic endonasal and transcervical approaches to the odontoid region and clivus have expanded the ability to treat these disorders [1, 11].
Endonasal surgery may be a more feasible option in patients with platybasia, which is associated with an increased height of the odontoid process relative to the palatine line.
References
1.
Dasenbrock HH, Clarke MJ, Bydon A, Sciubba DM, Witham TF, Gokaslan ZL, Wolinsky JP. Endoscopic image-guided transcervical odontoidectomy: outcomes of 15 patients with basilar invagination. Neurosurgery. 2012;70:351–9; discussion 359–60.CrossRefPubMed
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