The craniovertebral junction (CVJ) is anatomically complex, protecting important neural and vascular structures while providing a high degree of multidirectional motion [1]. This region is not only prone to age-related changes, but also susceptible to spinal tumors, vascular malformations, and pathologies associated with congenital anomalies. Advances in preoperative imaging evaluation, surgical techniques, and intraoperative support devices have made it possible to perform safer and more sophisticated surgery, but there is still a risk of life-threatening complications. Therefore, surgery in this region requires more high-quality treatment strategy considering the pathophysiology of the disease as well as the unique anatomy and biomechanical properties.
This special issue “CVJ Challenges” focuses on complicated neurospinal surgery in the CVJ which still remains relatively unknown and controversial in terms of appropriate management. Five articles in this special issue demonstrate an update on the current status of surgery in the CVJ, incorporating cutting-edge techniques and equipment for intractable lesions. These articles provide useful information featuring advanced approaches to intramedullary spinal cord tumors and spinal neoplasms occurring at the CVJ, updated surgical indications for Chiari malformations, and strategies for kyphotic deformities in this region, alongside a historical overview and evolution of spinal fixation techniques.
For intramedullary cavernous angiomas with laterality, it has been reported that even in high cervical lesions, the posterolateral sulcus approach is a rational and safe method that aims for complete resection [2]. However, challenges remain in the removal of ventrally located angiomas. While motor evoked potentials serve as an important prognostic tool in spinal surgery, they do not necessarily reflect actual motor function with precision in cases of intramedullary tumors [3]. This highlights the importance of balancing the results of intraoperative neurophysiological monitoring with the microscopic findings of the spinal cord parenchyma [2]. Regarding vertebral body tumors extending from the clivus to C2, transnasal surgical techniques have become increasingly established [4]. Appropriate patient selection based on anatomical landmarks is crucial, and improved endoscopic visualization and surgical proficiency have enabled favorable resection outcomes [5]. This anterior approach is considered optimal, particularly in minimizing postoperative airway and swallowing dysfunction. In the treatment of Chiari malformation type I, posterior fossa decompression remains the standard procedure. However, surgical strategies based on a novel classification that incorporates posterior fossa volume, hindbrain configuration, and stability in the CVJ represent an innovative concept. This issue also reviews the genetic factors associated with Chiari malformations, offering essential updates for clinical understanding [6]. In cases of instability or kyphotic deformity at the CVJ, recent advances in fixation techniques have been remarkable. These developments allow for stronger anchor placement and enhanced fixation methods while avoiding severe neurovascular injury. It is necessary to revisit current trends and choices in fixation techniques in light of their historical progression [7]. Although various modifications in fixation methods have been proposed for kyphotic cases, there remains a lack of consensus on the ideal correction parameters. The introduction of outcome-based indicators and focal points provides clinically valuable insights [8].
Given the complexity and critical nature of this anatomical region, continued efforts are essential to refine surgical indications and techniques, aiming to minimize adverse events and improve postoperative quality of life. Although rare and highly specialized, we hope this special issue will serve as a valuable resource for further clinical advancement.
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