Craniovertebral Junction Tumor

Definition: CVJ tumors are neoplastic lesions involving the occipital bone, atlas (C1), axis (C2), and adjacent structures. These tumors may be extradural, intradural-extramedullary, or intramedullary.

• Meningioma
• Chordoma
• Schwannoma (CN XI, XII)
• Paraganglioma
• Metastasis
• Epidermoid cyst
• Neurofibroma

• Maximal safe resection or control
• Preservation of neurological function
• Stabilization of the craniovertebral junction (if destabilized)
• Symptom relief (e.g., brainstem compression, myelopathy, cranial nerve dysfunction)

• Imaging: MRI with contrast ± CT with bone windows
• Neuro-navigation / intraoperative neuromonitoring
• Preoperative angiography ± embolization (esp. in vascular tumors like meningiomas or paragangliomas)
• Histology: Biopsy when necessary (for chordomas, metastases)

• Neurological deterioration
• Brainstem compression
• Spinal cord compression or instability
• Progressive symptoms
• Tumor growth

• Suboccipital midline (for posterior lesions)
• Laminectomy of C1/C2
• With or without occipitocervical fusion

• Far lateral (posterolateral for ventrolateral lesions)
• Extreme lateral / transcondylar (for anterior lesions)
• Anterolateral transjugular or infratemporal (complex skull base tumors)

• Transoral or endoscopic endonasal (midline anterior lesions)
• Mandibulotomy (rare/extensive anterior access)

• Necessary if bony resection compromises CVJ integrity
• Techniques:
  • Occipitocervical fusion (plate–rod, screw–rod systems)
  • Use of allograft/autograft ± cage

In a cadaveric anatomy-demonstration + surgical technique description Mario Ammirati et al. from the Dept. Neurosurgery, Mercy Health/St. Rita Medical Center, Lima, OH; [and] Catholic University, Rome published in Advances and technical standards in neurosurgery to describe a “simple posterolateral” microsurgical technique for craniovertebral junction (CVJ) tumor removal and review pros/cons of different approaches. The authors propose that a minimalist posterolateral route achieves tumour access with reduced retraction and operative time, avoiding extensive bony drilling seen in far‑lateral or extreme lateral approaches, though a formal clinical outcomes series is lacking ¹⁾.

* Strengths 1. Technical innovation – Proposes a streamlined, less invasive posterolateral route aimed at decreased operative morbidity. 2. Balanced discussion – Compares technique versus anterolateral/far‑lateral approaches, discussing trade-offs (e.g., retraction vs bone removal).

* Weaknesses 1. Lack of clinical data – No patient series or intraoperative metrics to validate safety or efficacy; limited to cadaver demonstration. 2. Selection bias – Technique suited for “favorable” lesions; unclear criteria limit generalizability. 3. Incomplete metrics – Missing quantitative comparison of corridor size, exposure extent, brainstem retraction, or operative time.

* Contextual comparison Prior anatomical cadaver studies (e.g., Ammirati & Colasanti 2018) showed added bone drills (transcondylar, supracondylar) may improve exposure for small tumors, but clinical relevance is debated :contentReference[oaicite:1]{index=1}. This new report simplifies further, yet without demonstrating equivalent exposure or outcomes.

Score: 4.5 / 10 Innovative as a concept, but premature without clinical validation. A descriptive anatomical technique alone earns only modest credit.

The technique may be considered for small, posterolaterally situated CVJ lesions in select cases—especially where minimizing bone removal and operative time is desirable. However, lacking patient outcomes or exposure metrics, its safety and effectiveness remain unproven. Far‑lateral variants with condyle drilling still remain the gold standard when anterior exposure is needed.

Describes a less invasive anatomical corridor, but without clinical validation; useful conceptually but not ready for routine adoption.

Minimalistic Approaches to Craniovertebral Junction Tumors. Ammirati M et al. Adv Tech Stand Neurosurg. 2025;55:165–179. doi:10.1007/978‑3‑031‑90762‑3_9. Published: 2025‑05‑??. Corresponding author: Mario Ammirati, maria.ammirati@mercystretita.org

• Stereotactic Radiosurgery (SRS): e.g., for chordomas, schwannomas, or residuals
• Fractionated Radiotherapy: if high risk for injury with surgery
• Chemotherapy: rarely indicated, unless lymphoma or metastasis
• Observation: for small, asymptomatic, benign tumors in high-risk locations

• Lower cranial nerve palsies
• CSF leak
• Vertebral artery injury
• Instability requiring fusion
• Dysphagia / aspiration
• Infection / wound healing issues

• Tumor location and extension (midline vs lateral)
• Histology (benign vs aggressive)
• Preoperative neurological status
• Surgeon’s experience and approach selection
• Use of neuromonitoring and neuronavigation