case_images: PMC11723764_01
case_images: (a) Mid-sagittal CT scan of the cervical spine showing spondylotic changes (b-c) T2W Mid-sagittal and axial MR imaging showing hyperintense lesion at C1 level causing significant compression of the spinal cord.
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case_images: F1
case_images: C1 level in the T2W mid-sagittal image causing significant compression and thinning of the spinal cord (Fig. 1). CT angiogram was performed and revealed a normal course of the bilateral vertebral arteries.
case_images: (a-b) Showing the positioning of the cervical spine in Mayfield skull clamp. Note the orotracheal tube for intubation and mouth retractors are not used (c) Shows the placement of oral tubular retractors. Note the attachment of dynamic reference array - DRA(*) to the Mayfield clamp. It is important not to cover the DRA using drapes to ensure accurate navigation.
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case_images: F2
case_images: The patient was then positioned supine on the operating table using a Mayfield skull clamp (Integra LifeSciences Co.; USA) (Fig. 2).
case_images: (a) Intraoperative AP fluoroscopy image-centered over the odontoid process (b) Lateral fluoroscopy image placed at the level C1 anterior tubercle.
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case_images: F3
case_images: In the AP view, trochar was placed initially and after sequential dilator (METRX Dilator) placement, a 8 cm x 26 mm tubular retractor (METRX 2; Medtronic) was docked centering the odontoid process and in the lateral view, the tube was placed at the level of the C1 anterior tubercle (Fig. 3).
case_images: (a) Surgical corridor through the tubular retractors (b) Showing navigation to locate the center of the C1 anterior arch (c) Vertical incision placed over the posterior pharyngeal wall (d) Intraoperative navigation to precisely locate the extent of C1 anterior arch resection (e) Burring of the C1 anterior arch using a high-speed burr.
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case_images: F4
case_images: Adrenaline. A straight midline incision of about 3 cm was placed over the posterior pharyngeal wall at the level of the C1 anterior tubercle (Fig. 4). Using the navigation, the extent of superior-inferior and mediolateral dissection was identified (Fig. 4).
case_images: (a) Shows the burring of the C2 odontoid process (b) TAL (arrow) after removing the odontoid process (c) showing the yellowish smooth cystic lesion (*) compressing the spinal cord.
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case_images: F5
case_images: The odontoid process was visualized and the outer cortex was carefully burred (Fig. 5). Transverse Atlantal Ligament (TAL) was noted (Fig. 5) and removed piecemeal using Kerrison rongeur.
case_images: (a) Showing adequate decompression of the spinal cord after removal of the compressive lesion (b) Dural rent and CSF leak noted at the end of decompression (c) Dural rent sealed with duragen and tisseel (d) Resected cystic lesion (Histopathology report - Synovial cyst).
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case_images: F6
case_images: The cystic mass was removed en bloc, resulting in an unavoidable dural defect on the anterior aspect of the dura (Fig. 6).
case_images: (a) T2W mid-sagittal MRI after transoral MIS surgery showing adequate decompression of the spinal cord (b-c) AP and lateral intraoperative fluoroscopy images after C1-C3 posterior stabilization (Note the DRA attached to C3 spinous process).
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case_images: F7
case_images: Finally, rods were inserted and C1-C3 stabilization was performed (Fig. 7).