Principles of systematization and formation of surgical strategies for craniovertebral region lesions

Surgical treatment of craniovertebral junction (CVJ) lesions is a complex multidisciplinary problem. Despite diverse diseases and traumatic injuries of CVJ, many authors note universality of clinical manifestations. This allows for their systematization and formation of homogeneous groups based on dominant clinical syndrome.

OBJECTIVE

To apply dominant clinical syndrome for systematizing CVJ lesions and formation of surgical strategies.

MATERIAL AND METHODS

A retrospective analysis and systematization of patient groups with surgical CVJ lesions were conducted in 2 neurosurgical hospitals. The study included 181 patients with one of the five main CVJ lesions. Inclusion criteria were CVJ diseases and lesions: trauma — 76 (42%), developmental anomalies — 19 (10%), inflammatory and genetic diseases — 9 (5%), extradural tumors — 27 (15%), intradural tumors — 50 (28%). Systematization of material was based on the principle of dominant clinical syndrome. Two types of dominant clinical syndrome were distinguished: compression and instability. The specialized scales were used: the White & Panjabi criteria for trauma and anomalies, the Spinal Instability Neoplastic Score (SINS) for CVJ tumors, the Ranawat scale for rheumatoid arthritis, and the Kang scale for assessing compression of medulla oblongata and spinal cord.

RESULTS

We distinguished 2 groups depending on dominant clinical syndrome: group 1 with compression (97 (54%) patients) and group 2 with instability (84 (46%) patients). Group I included 97 patients with trauma (n= 10, 10.3%), anomalies (n=16, 16.5%), inflammatory and genetic storage diseases (n=8, 8.2%), extradural tumors (n=13, 13.4%), intradural tumors (n=50, 51.6%). In this group, decompression was performed at the first stage. After eliminating compression of medulla oblongata and upper spinal cord, bone fixation was performed in 26 (34%) patients. Group II included 84 patients with trauma (n=66, 78.5%), anomalies (n=3, 3.5%), inflammatory and genetic storage diseases (n=1, 1.2%), extradural tumors (n=14, 16.8%). All patients underwent various fusion procedures. Of these, 17 (20.2%) patients underwent concomitant fusion and resection for extradural tumors, rheumatoid arthritis, and late sequelae of trauma.

CONCLUSION

Anatomical, biomechanical, and clinical similarities allow for classification of surgical CVJ lesions based on dominant clinical syndrome. Identification of dominant clinical syndrome allows for appropriate surgical strategies, sequence of surgical stages and their timing.