Results of surgical treatment of patients with basilar invagination associated with type I Chiari malformation

Introduction. Each of the pathologies is rare and can lead to compression of the brainstem and spinal cord, with the development of a “mixed” clinical picture. The tactics of treating such patients differs from one author to another.

The objective is to present the author’s experience in treating patients with basilar invagination associated with type I Chiari malformation and to analyze the literature on the methods of surgical treatment of this pathology.

Materials and methods. From 2014 to 2019, 3 patients with a basilar invagination and type I Chiari malformation were surgically treated at the N. I. Pirogov National Medical and Surgical Center. Indications for surgical intervention were long-term progressive neurological disorders, lack of effect from conservative therapy. Patients underwent anterior transnasal and posterior decompression of nerve structures followed by stabilization.

Results. All patients were evaluated 12 months after surgery. All patients in neurological status showed positive dynamics. According to magnetic resonance imaging of the craniovertebral junction, 2 patients showed positive dynamics: regression of the myelopathy, a decrease in the diameter of the syringomyelic cyst.

Conclusion. The criteria for anterior transnasal decompression are the predominance of bulbar disorders and / or paresis in the extremities in the clinical picture; posterior decompression of nerve structures, indicated in the presence of specific symptoms of type I Chiari malformation and / or syringomyelia. Taking into account the results of the latest published studies it can be assumed that stabilization is a necessary option in the treatment of patients with this pathology.

1. Alkoç O.A., Songur A., Eser O. et al. Stereological and morphometric analysis of MRI Chiari malformation type-1. J Korean Neurosurg Soc 2015;58(5): 454–61. DOI: 10.3340/jkns.2015.58.5.454.

2. Pindrik J., Johnston J.M. Jr. Clinical presentation of Chiari I malformation and syringomyelia in children. Neurosurg Clin N Am 2015;509–14. DOI: 10.1053/j.su1t.2015.12.001.

3. Kanavel A. Bullet located between the atlas and the base of the skull: technique of removal through the mouth. Surg Clin Chir 1917;1:361–6.

4. Crockard H.A. Anterior approaches to lesions of the upper cervical spine. Clin Neurosurg 1988;34:389–416.

5. Kassam A.B., Snyderman C., Gardner P. et al. The expanded endonasal approach: a fully endoscopic transnasal approach and resection of the odontoid process: technical case report. Neurosurgery 2005;57(1 Suppl):E213. DOI: 10.1227/01.neu.0000163687.64774.e4.

6. Crockard H.A. Transoral surgery: some lessons learned. Br J Neurosurg 1995;9(3):283–93. DOI: 10.1080/02688699550041304.

7. Di Lorenzo N., Fortuna A., Guidetti B. Craniovertebral junction malformations. Clinicoradiological findings, longterm results, and surgical indications in 63 cases. J Neurosurg 1982;57(5): 603–8. DOI: 10.1007/BF01401296.

8. Messina A., Bruno M.C., Decq P. et al. Pure endoscopic endonasal odontoidectomy: anatomical study. Neurosurg Rev 2007;30(3):189–94 DOI: 10.1007/s10143-007-0084-6.

9. Wu J.C., Huang W.C., Cheng H. et al. Endoscopic transnasal transclival odontoidectomy: a new approach to decompression: technical case report. Neurosurgery 2008;63:(1 Suppl 1):onse92–4. DOI: 10.1227/01.neu.0000335020.06488.c8.

10. Fujii T., Platt A., Zada G. Endoscopic endonasal approaches to the craniovertebral junction: a systematic review of the literature. J Neurol Surg B Skull Base 2015;76(6):480–8. DOI: http://dx.doi.org/10.1055/s-0035-1554904.

11. Goldschlager T., Härtl R., Greenfield J.P. et al. The endoscopic endonasal approach to the odontoid and its impact on early extubation and feeding. J Neurosurg 2015;122(3):511–8. DOI: 10.3171/2014.9.JNS14733.

12. Hankinson T.C., Grunstein E., Gardner P. et al. Transnasal odontoid resection followed by posterior decompression and occipitocervical fusion in children with Chiari malformation Type I and ventral brainstem compression. J Neurosurg Pediatr 2010;5(6):549–53. DOI: 10.3171/2010.2.PEDS09362.

13. Grammatica A., Bonali M., Ruscitti F. et al. Transnasal endoscopic removal of malformation of the odontoid process in a patient with type I Arnold–Chiari malformation: a case report. Acta Otorhinolaryngol Ital 2011;31(4):248–52.

14. Scholtes F., Signorelli F., McLaughlin N. et al. Endoscopic endonasal resection of the odontoid process as a standalone decompressive procedure for basilar invagination in Chiari type I malformation. Minim Invasive Neurosurg 2011;54(4):179–82. DOI: 10.1055/s-0031-1283168.

15. Menezes A.H., VanGilder J.C. Transoraltranspharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients. J Neurosurg 1988;69(6):895–903. DOI: 10.3171/jns.1988.69.6.0895.

16. Menezes A.H. Surgical approaches: postoperative care and complications, “transoral-transpalatopharyngeal approach to the craniocervical junction”. Childs NervSyst 2008;24(10):1187–93. DOI: 10.1007/s00381-008-0599-3.

17. Hwang S.W., Heilman C.B., Riesenburger R.I., Kryzanski J. C1–C2 arthrodesis after transoral odontoidectomy and suboccipital craniectomy for ventral brain stem compression in Chiari I patients. Eur Spine J 2008;17(9):1211–7. DOI: 10.1007/s00586-008-0706-x.

18. Kaibara T., Hurlbert R.J., Sutherland G.R. Intraoperative magnetic resonance imaging-augmented transoral resection of axial disease. Neurosurg Focus 2001;10(2):E4. DOI: 10.3171/foc.2001.10.2.5.

19. Gladi M., Iacoangeli M., Specchia N. et al. Endoscopic transnasal odontoid resection to decompress the bulbomedullary junction: a reliable anterior minimally invasive technique without posterior fusion. Eur Spine J 2012;21 Suppl 1:S55–60. DOI: 10.1097/00002517-199212000-00001.

20. Goel A., Bhatjiwale M., Desai K. Basilar invagination: a study based on 190 surgically treated patients. J Neurosurg 1998;88(6):962–8. DOI: 10.3171/foc.1998.4.4.1.

21. Dickman C.A., Locantro J., Fessler R.G. The influence of transoral odontoid resection on stability of the craniovertebral junction. J Neurosurg 1992;77(4):525–30. DOI: 10.3171/jns.1992.77.4.0525.

22. Klekamp J. Chiari I malformation with and without basilar invagination: a comparative study. Neurosurg Focus 2015;38(4):E12. DOI: 10.3171/2015.1.FOCUS14783.

23. Goel A. Goel′s classification of atlantoaxial “facetal” dislocation. J Craniovertebr Junction Spine 2014;5(1):3–8. DOI: 10.4103/0974-8237.135206.

24. Goel A. Facetal alignment: basis of an alternative Goel′s classification of basilar invagination. J Craniovertebr Junction Spine 2014;5(2):59–64. DOI: 10.4103/0974-8237.139199.

25. Goel A. Instability and basilar invagination. J Craniovertebr Junction Spine 2012;3(1):1–2. DOI: 10.4103/0974-8237.110115.