Decision Making for Management of Craniovertebral Junction Pathology

In 1977, I proposed a physiological surgical approach to treatment of abnormalities at the craniocervical junction. This strategy has been reinforced by improved neurodiagnostic imaging and surgical techniques. The evaluation of more than 5000 patients symptomatic with abnormalities at the craniocervical junction was the basis for this approach. The factors that influence specific treatment for craniovertebral abnormalities are as follows: (1) the reducibility of the bony lesion; (2) the direction of encroachment and the mechanics of compression; (3) the cause of the pathological process as well as the presence of neural, vascular and cerebrospinal fluid abnormalities; and (4) the presence of abnormal ossification centers and epiphyseal growth plates. The primary aim of treatment is to relieve compression at the cervicomedullary junction. Stabilization is paramount for reducible lesions to maintain the neural decompression. Irreducible lesions require decompression at the site of compression. For ventral compressive abnormalities, decompression is performed through a palatopharyngeal route, a transmaxillary procedure, or lateral extrapharyngeal route. For lateral or dorsal compression, posterolateral decompression or a dorsal approach is required. If instability is present after decompression, posterior fixation is mandated for stability. A decision tree illustrates the management strategy.