{"paper_id":"1fc8a7a6-2da4-405f-8e2b-0c242fb0d568","body_text":"Perioperative Management of Craniocervical Junction Tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative Management of Craniocervical Junction Tumors Xiaoxiao Zhang, Liu Yang, Ping Zhu, Ruquan Han, Haiyang Liu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6416829/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Objective: To analyze the clinical characteristics of patients with craniocervical junction space-occupying lesions and summarize the perioperative management experience in combined skull base and spinal neurosurgery. Methods: Medical records of patients who underwent combined skull base and spinal neurosurgery at Beijing Tiantan Hospital, Capital Medical University, from April 1, 2020, to April 1, 2025, were retrospectively analyzed. Clinical data, multidisciplinary treatment, anesthetic management, and outcomes were evaluated. Results: Among the 9 patients, 7 (77.8%) completed skull base tumor resection combined with cervical or atlanto occipital fusion internal fixation under one anesthesia. Two (22.2%) patients initially underwent only skull base tumor resection, but due to detected cervical instability during ICU stay, a second surgery for occipitocervical fusion was performed. Five (55.6%) patients were discharged with good recovery, one (11.1%) was discharged wearing a cervical orthosis, one (11.1%) with preoperative quadriplegia was discharged with residual deficits, one (11.1%) declined tumor resection and was discharged, and one (11.1%) died. Conclusion: Craniocervical junction lesions are rare. Preoperative multidisciplinary consultation should focus on assessing craniocervical stability. Intraoperative neuroprotection and strict postoperative vital sign monitoring are essential to prevent complications. Skull base tumors Neurosurgery Spinal neurosurgery Anesthesia Introduction The craniocervical junction is a unique anatomical region composed of the clivus, foramen magnum, and atlantoaxial complex. Due to its intricate structure and dense neurovascular distribution, space-occupying lesions in this area can lead to diverse clinical manifestations, including headache, neck pain, vertigo, blurred vision, hearing loss, and facial numbness [ 1 ]. Given that tumors in this region frequently invade the spinal canal and cause bony destruction, special attention must be paid to cervical spine stability. Cases involving safe tumor resection, skull base reconstruction, and preservation of cervical stability are exceedingly rare. Perioperative management remains challenging, and standardized treatment protocols are currently lacking, warranting further investigation. This study summarizes case data from patients who underwent combined skull base and spinal neurosurgery at Beijing Tiantan Hospital, Capital Medical University, and reviews relevant literature to explore key perioperative management strategies for these patients. Materials and Methods General Data This study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KY2024-186-01). We retrospectively analyzed the medical records of patients who underwent combined skull base and spinal neurosurgery at our institution between April 1, 2020, and April 1, 2025. Research Methods From April 1, 2020, to April 1, 2025, a total of 12,358 cases of complex skull base tumor resections were performed, among which 9 cases involved lesions extending to the high cervical spine, requiring collaboration between skull base and spinal neurosurgery teams. General anesthesia was administered in all cases, using the following agents: Induction/maintenance: Propofol (Liaoning Haisco Pharmaceutical Co., Ltd.), Etomidate (Jiangsu Nhwa Pharmaceutical Co., Ltd.). Cisatracurium Besylate (Nanjing King-Friend Biochemical Pharmaceutical Co., Ltd.), Rocuronium Bromide (Hainan Star Pharmaceutical Co., Ltd.). Sufentanil (Humanwell Healthcare Group Co., Ltd.), Remifentanil (Humanwell Healthcare Group Co., Ltd.). Sevoflurane (Maruishi Pharmaceutical Co., Ltd., Japan). Midazolam (Jiangsu Nhwa Pharmaceutical Co., Ltd.), Dexmedetomidine (Shijiazhuang No.4 Pharmaceutical Co., Ltd.). Norepinephrine (Sichuan Meidakang Jiale Pharmaceutical Co., Ltd.), Dopamine (Guangdong Saifeng Pharmaceutical Technology Co., Ltd.). Intraoperative monitoring included electrocardiography (ECG), non-invasive blood pressure (NIBP), invasive arterial pressure, pulse oximetry (SpO₂), end-tidal carbon dioxide (EtCO₂), and fluid input/output. Observation Parameters Demographic data collection included gender, age, height, weight, medical history, clinical symptoms, and neurosurgical characteristics (tumor size, tumor location, and adjacent relationships). Intraoperative data includes patient classification by the American Society of Anesthesiologists (ASA), number of surgeries, duration of surgery, anesthesia method, blood loss, intraoperative fluid management, and inflow/outflow. Postoperative data collection focused on patients' general condition immediately after surgery, postoperative complications, airway management, pathological findings, and prognosis. Statistical Analysis Statistical analysis was performed using SPSS 24.0 software. Normally distributed continuous variables were expressed as mean ± standard deviation , while non-normally distributed continuous variables were presented as median [interquartile range] [M (Q1, Q3)]. Categorical data were described using counts and percentages. Results General situation The study cohort comprised 9 patients with a mean age of 46.1 ± 16.2 years, including 4 male patients (44.4%). Two (22.2%) patients had a history of hypertension, one (11.1%) had a history of diabetes, and one (11.1%) had a history of symptomatic epilepsy. Nine patients had skull base masses that were of the intracranial extracranial communication type, invading the foramen magnum area and involving the cervical canal. The general situation is shown in Table 1. Perioperative Management Among the 9 patients, ASA physical status classification was as follows: 1 patient (11.1%) was Class I, 4 patients (44.4%) were Class II, 3 patients (33.3%) were Class III, and 1 patient (11.1%) was Class IV. Among the 9 patients, 7 (77.8%) completed skull base tumor resection combined with cervical or atlanto occipital fusion internal fixation under one anesthesia. Two patients (22.2%) initially underwent skull base tumor resection alone, but required subsequent occipitocervical fusion due to detected cervical instability during ICU care. One patient (11.1%) required a third surgical intervention for cerebrospinal fluid (CSF) leak repair following severe CSF leakage and intracranial infection. Surgical approaches included craniotomy in 6 patients (66.7%) and endoscopic endonasal surgery in 3 patients (33.3%). Airway management consisted of orotracheal intubation in 7 patients (77.8%), nasotracheal intubation in 1 patient (11.1%), and 1 patient (11.1%) with concurrent large thyroid mass causing tracheal compression underwent tracheostomy under local anesthesia prior to general anesthesia. The intraoperative bleeding volume of 7 cases with 1 surgery was 800 (400, 1800) ml, and the surgery duration was 7 (7, 9.25) hours. Gross total resection was achieved in 8 patients (88.9%), while 1 patient (11.1%) underwent only occipitocervical fusion and biopsy due to extensive tumor burden and family preference against aggressive resection. Seven (77.8%) patients retained tracheal intubation or tracheostomy intubation after surgery, while two (22.2%) patients had their tracheal intubation removed after surgery. One extubated patient required reintubation in the ICU due to fluctuating hypoxemia. Complications included pulmonary infection in 3 patients (33.3%), intracranial infection in 3 patients (33.3%), and postoperative seizures in 1 patient with pre-existing epilepsy. Pathological examination revealed chordoma in 8 patients (88.9%) and cholesteatoma in 1 patient (11.1%). 5 patients (55.6%) with good recovery, 1 patient (11.1%) discharged with cervical orthosis, 1 quadriplegic patient (11.1%) discharged with residual deficits, 1 patient (11.1%) discharged after declining tumor resection, and 1 mortality (11.1%). Detailed perioperative data are presented in Table 2. Discussion Tumors of the craniocervical junction present significant surgical challenges due to their deep-seated and anatomically complex location [ 2 ]. These lesions often invade surrounding osseous structures and may compress or encase critical neurovascular elements including the brainstem, vertebrobasilar arterial system, and multiple cranial nerves. Postoperative complications may include craniocervical instability and severe brainstem injury, potentially leading to paralysis or cardiorespiratory failure, representing substantial surgical risks [ 3 ]. Due to the difficulty of surgery in this area, both oral, nasal, and traditional craniotomy approaches face disadvantages such as poor exposure and incomplete resection [ 4 ], with additional risks of CSF leakage and infection, posing formidable perioperative management challenges [ 5 ]. Our case series has yielded several important conclusions that may inform future perioperative management strategies. First, comprehensive multidisciplinary evaluation and meticulous preoperative preparation are essential. Collaborative planning involving skull base surgeons, spinal neurosurgeons, and anesthesiologists should focus on tumor characteristics (size, location, neurovascular relationships, vascular supply) [ 6 – 8 ] and anticipate potential intraoperative crises (neurovascular injury, hemorrhagic events, or hemodynamic instability from neural manipulation). All nine patients in our series demonstrated aggressive, hypervascular tumors, prompting implementation of massive hemorrhage protocols [ 9 , 10 ] including invasive arterial monitoring for real-time hemodynamic assessment, goal-directed fluid resuscitation, and vasopressor support with blood gas analysis to guide transfusion therapy. Second, meticulous neural protection is paramount throughout the procedure. Both skull base and high cervical approaches require strategies to prevent iatrogenic motor or sensory deficits [ 11 – 13 ]. This study used intraoperative electrophysiological monitoring to monitor the patient's upper and lower limb sensation, movement, and cranial nerve function in real-time. To ensure monitoring accuracy, anesthesia is maintained using a combination of intravenous and inhalation anesthesia (with an MCA controlled below 0.5), and no muscle relaxants are added during monitoring. This approach successfully prevented new neurological deficits in all cases. Third, special Considerations for Craniocervical Stability Management [ 1 – 3 ]. In this study, 7 patients had sufficient preoperative preparation and fully considered the issue of tumor invasion of the high cervical spine. Under one anesthesia, tumor resection was completed and occipital cervical fixation surgery was performed [ 14 , 15 ]. When changing positions after skull base surgery, it is important to protect the cervical spine and move the patient axially to avoid cervical cord injury. In this study, the other two patients experienced severe complications such as severe circulatory fluctuations and respiratory dysfunction leading to hypoxemia after skull base surgery due to insufficient attention to head and neck stability, providing valuable lessons for future surgeries. The sixth patient wore a neck brace after surgery, which to some extent protected the cervical cord. Although there were circulation fluctuations, they were detected in a timely manner and a second surgery was performed for occipital cervical fusion fixation. The postoperative recovery was good and did not cause serious sequelae. On the first day after surgery, the ninth patient experienced fluctuating hypoxemia and was intubated again, but was not aware of the stability of the head and neck. Later, there was a decrease in limb muscle strength, and a cervical CT scan revealed cervical problems. Due to delayed detection, although a second posterior occipital cervical fusion fixation surgery was performed, the cervical spinal cord was already damaged, the sympathetic nervous system in the neck was damaged, and the circulation fluctuated violently during the second surgery, relying on high-dose vasoactive drugs. Moreover, due to cerebrospinal fluid leakage, the patient suffered from severe intracranial infection, prolonged tracheal intubation, and secondary pulmonary infection. The cultivation of difficult to treat Acinetobacter baumannii resulted in sepsis, further exacerbating anemia and malnutrition. Eventually, the patient died due to respiratory and circulatory failure despite rescue efforts. The patient is only 20 years old, and we deeply regret the occurrence of such serious complications. From this, we can see the importance of head and neck stability. We recommend making strict judgments during preoperative evaluation, and for patients who invade the cervical canal, we recommend completing occipital cervical fusion fixation surgery during the current surgery to ensure head and neck stability. Wear a neck brace or external head and neck fixator during the perioperative period to prevent cervical cord injury. Strictly monitor vital signs after surgery, carefully evaluate the timing of extubation, and promptly address any emergency situations. Finally, the complexity and prolonged hospitalization of these cases demand aggressive complication prevention [ 5 , 12 ]. Endonasal cases require CSF leak and infection prophylaxis [ 16 – 19 ], while craniotomies necessitate cerebral edema and seizure management. Significant blood loss or sellar involvement mandates close electrolyte/hemoglobin monitoring, and skull base reconstruction demands infection control for flap viability [ 20 – 22 ]. Additionally, early mobilization protocols should prevent venous thromboembolism. As a single-center study with limited sample size, our findings have inherent limitations. Larger multicenter studies are needed to refine perioperative protocols. Conclusion Optimal management of craniocervical junction tumors requires: (1) multidisciplinary preoperative assessment emphasizing stability evaluation, (2) intraoperative neural protection and hemorrhage control, and (3) rigorous postoperative monitoring with prudent extubation decisions. Through comprehensive preparation and collaborative expertise, improved patient outcomes can be achieved. Declarations C onflict of interest The authors declare that they have no competing interests, and the manuscript has been approved by all the authors for publication. I would like to declare on behalf of my coauthors that the work described is original research that has not been published previously and is not under consideration for publication elsewhere, in whole or in part. Author Contribution Statement Xiaoxiao Zhang: Data collection and analysis, paper writing; Liu Yang, Ping Zhu, Ruquan Han, Haiyang Liu: Research guidance, paper revision Paper revision. Ethics approval and consent to participate This study has obtained informed consent from all participants involved. Our research fully complies with the Helsinki Declaration. Human Ethics and Consent to Participate declarations This study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KY2024-186-01). Data availability Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analysed during the current study. Consent for publication Written informed consent was obtained from the patient for publication of this case report. Funding Declaration This article has no funding. Clinical trial number Not applicable. References Forst DA, Jones PS. Skull Base Tumors. Continuum (Minneap Minn). 2023 Dec 1;29(6):1752-1778. doi: 10.1212/CON.0000000000001361. PMID: 38085897. Spiessberger A, Gruter B, Prashant G, Haegler J, Eisenberg M, Cohen-Gadol AA, Dehdashti AR. A Contemporary Clinico-Anatomical Guide to Craniovertebral Junction Surgery. J Neurol Surg B Skull Base. 2022 Sep 28;84(4):413-420. doi: 10.1055/s-0042-1755600. PMID: 37405236; PMCID: PMC10317559. Morimoto LR, Kase DT, Esmanhotto PG, Maciel MA, Augusto ACL, Catricala PF, Anaya JEC, Mukherjee S, Fernandes ARC, Aihara AY. Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review. Radiographics. 2024 May;44(5):e230137. doi: 10.1148/rg.230137. PMID: 38635454. Ulici V, Hart J. Chordoma. 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PMID: 36859355; PMCID: PMC9977110. Pasternak JJ. Neuroanesthesiology Update. J Neurosurg Anesthesiol. 2021 Apr 1;33(2):107-136. doi: 10.1097/ANA.0000000000000757. PMID: 33480638. Chavali S, Dash HH. Practice Changing Articles in Neuroanesthesiology and Neurocritical Care in Recent Years: A Literature Review. Neurol India. 2021 May-Jun;69(3):573-577. doi: 10.4103/0028-3886.319203. PMID: 34169844. Ashida R, Walsh P, Brooks JCW, Cerminara NL, Apps R, Edwards RJ. Sensory and motor electrophysiological mapping of the cerebellum in humans. Sci Rep. 2022 Jan 7;12(1):177. doi: 10.1038/s41598-021-04220-9. PMID: 34997137; PMCID: PMC8742093. Tatter C, El-Hajj VG, Fletcher-Sandersjöö A, Edström E, Elmi-Terander A. Radiographic measurements for the prediction of dysphagia after occipitocervical fusion: a systematic review. Acta Neurochir (Wien). 2023 May;165(5):1161-1170. doi: 10.1007/s00701-023-05509-6. Epub 2023 Feb 14. PMID: 36781463; PMCID: PMC10140007. Faraj MK. 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Acta Neurochir (Wien). 2025 Mar 26;167(1):91. doi: 10.1007/s00701-025-06498-4. PMID: 40138048; PMCID: PMC11947040. Palmieri D, Champagne PO, Valappil B, McDowell MM, Gardner PA, Snyderman CH. Risk Factors in a Pediatric Population for Postoperative Intracranial Infection Following Endoscopic Endonasal Skull Base Surgery and the Role of Antibiotic Prophylaxis. Am J Rhinol Allergy. 2023 Jan;37(1):13-18. doi: 10.1177/19458924221123113. Epub 2022 Sep 1. PMID: 36050937. Racette S, Tekumalla S, Agarwal A, Curry J, Beahm DD. Anterior Skull Base Reconstruction. Otolaryngol Clin North Am. 2023 Aug;56(4):727-739. doi: 10.1016/j.otc.2023.04.015. Epub 2023 Jun 1. PMID: 37268516. Hanasono MM. Reconstruction after open surgery for skull-base malignancies. J Neurooncol. 2020 Dec;150(3):469-475. doi: 10.1007/s11060-019-03370-1. Epub 2020 Feb 13. PMID: 32056144. He J, Lu J, Zhang F, Chen J, Wang Y, Zhang Q. The Treatment Strategy for Skull Base Reconstruction for Anterior Cranial Fossa Intra- and Extracranial Tumors. J Craniofac Surg. 2021 Jul-Aug 01;32(5):1673-1678. doi: 10.1097/SCS.0000000000007244. PMID: 33208698. Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 Jul, 2025 Reviewers agreed at journal 02 Jul, 2025 Reviewers invited by journal 22 May, 2025 Editor assigned by journal 17 Apr, 2025 Submission checks completed at journal 17 Apr, 2025 First submitted to journal 17 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6416829\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":461302852,\"identity\":\"fb7b108c-0d35-4315-b73e-3c1c650c6a81\",\"order_by\":0,\"name\":\"Xiaoxiao Zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing Tian Tan Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xiaoxiao\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":461302853,\"identity\":\"c0d151d1-22c1-4e54-b58d-44e5e6283274\",\"order_by\":1,\"name\":\"Liu Yang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing Tian Tan Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Liu\",\"middleName\":\"\",\"lastName\":\"Yang\",\"suffix\":\"\"},{\"id\":461302854,\"identity\":\"a9223206-8dc8-4f3b-863f-42a1f360fa18\",\"order_by\":2,\"name\":\"Ping Zhu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing Tian Tan Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ping\",\"middleName\":\"\",\"lastName\":\"Zhu\",\"suffix\":\"\"},{\"id\":461302855,\"identity\":\"d5127a3f-103f-4062-8a0c-7dc26b5d4e2f\",\"order_by\":3,\"name\":\"Ruquan Han\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Beijing Tian Tan Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ruquan\",\"middleName\":\"\",\"lastName\":\"Han\",\"suffix\":\"\"},{\"id\":461302856,\"identity\":\"8671f796-0795-4557-8247-c1cffcf1f7f9\",\"order_by\":4,\"name\":\"Haiyang Liu\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsElEQVRIiWNgGAWjYBCDBH5m5sMPSNFgkCDZzpZmQJoWg/M8ChJEKeZnP3zwc+GPP3nGh3kYDBhqbKIJapHsSUuWnpFgUGx2mPfAA4ZjabkNhLQY3OAxkOZJMEjcdpgvwYCx4TAxWvg//wZp2dzMYyBBpBYeNrAtG5iJ1QL0i5k1T5px4ozDwEBOIMYvwBB7fJvHRi6xv//w4QcfamwIa0EFCaQpHwWjYBSMglGACwAA5rQ6lEubmKAAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Beijing Tian Tan Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Haiyang\",\"middleName\":\"\",\"lastName\":\"Liu\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-04-10 06:08:17\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6416829/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6416829/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":83514619,\"identity\":\"07af0848-02f2-4698-adf4-16eebbfeccf0\",\"added_by\":\"auto\",\"created_at\":\"2025-05-27 17:56:55\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":444391,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6416829/v1/12003e12-98da-47fe-928c-a34b4c164598.pdf\"},{\"id\":83514616,\"identity\":\"b02ad385-6966-4703-b432-aa3a377727ee\",\"added_by\":\"auto\",\"created_at\":\"2025-05-27 17:56:50\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":27011,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"Tables.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6416829/v1/988610a690413d27a48a10f7.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Perioperative Management of Craniocervical Junction Tumors\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe craniocervical junction is a unique anatomical region composed of the clivus, foramen magnum, and atlantoaxial complex. Due to its intricate structure and dense neurovascular distribution, space-occupying lesions in this area can lead to diverse clinical manifestations, including headache, neck pain, vertigo, blurred vision, hearing loss, and facial numbness [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eGiven that tumors in this region frequently invade the spinal canal and cause bony destruction, special attention must be paid to cervical spine stability. Cases involving safe tumor resection, skull base reconstruction, and preservation of cervical stability are exceedingly rare. Perioperative management remains challenging, and standardized treatment protocols are currently lacking, warranting further investigation.\\u003c/p\\u003e \\u003cp\\u003e This study summarizes case data from patients who underwent combined skull base and spinal neurosurgery at Beijing Tiantan Hospital, Capital Medical University, and reviews relevant literature to explore key perioperative management strategies for these patients.\\u003c/p\\u003e\"},{\"header\":\"Materials and Methods\",\"content\":\"\\u003ch4\\u003e\\u003cstrong\\u003eGeneral Data\\u003c/strong\\u003e\\u003c/h4\\u003e\\n\\u003cp\\u003eThis study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KY2024-186-01). We retrospectively analyzed the medical records of patients who underwent combined skull base and spinal neurosurgery at our institution between April 1, 2020, and April 1, 2025.\\u003c/p\\u003e\\n\\u003ch4\\u003e\\u003cstrong\\u003eResearch Methods\\u003c/strong\\u003e\\u003c/h4\\u003e\\n\\u003cp\\u003eFrom April 1, 2020, to April 1, 2025, a total of 12,358 cases of complex skull base tumor resections were performed, among which 9 cases involved lesions extending to the high cervical spine, requiring collaboration between skull base and spinal neurosurgery teams. General anesthesia was administered in all cases, using the following agents: \\u003cstrong\\u003eInduction/maintenance:\\u003c/strong\\u003e Propofol (Liaoning Haisco Pharmaceutical Co., Ltd.), Etomidate (Jiangsu Nhwa Pharmaceutical Co., Ltd.). Cisatracurium Besylate (Nanjing King-Friend Biochemical Pharmaceutical Co., Ltd.), Rocuronium Bromide (Hainan Star Pharmaceutical Co., Ltd.). Sufentanil (Humanwell Healthcare Group Co., Ltd.), Remifentanil (Humanwell Healthcare Group Co., Ltd.). Sevoflurane (Maruishi Pharmaceutical Co., Ltd., Japan). Midazolam (Jiangsu Nhwa Pharmaceutical Co., Ltd.), Dexmedetomidine (Shijiazhuang No.4 Pharmaceutical Co., Ltd.). Norepinephrine (Sichuan Meidakang Jiale Pharmaceutical Co., Ltd.), Dopamine (Guangdong Saifeng Pharmaceutical Technology Co., Ltd.). Intraoperative monitoring included electrocardiography (ECG), non-invasive blood pressure (NIBP), invasive arterial pressure, pulse oximetry (SpO₂), end-tidal carbon dioxide (EtCO₂), and fluid input/output.\\u003c/p\\u003e\\n\\u003ch3\\u003eObservation Parameters\\u003c/h3\\u003e\\n\\u003cp\\u003eDemographic data collection included gender, age, height, weight, medical history, clinical symptoms, and neurosurgical characteristics (tumor size, tumor location, and adjacent relationships). Intraoperative data includes patient classification by the American Society of Anesthesiologists (ASA), number of surgeries, duration of surgery, anesthesia method, blood loss, intraoperative fluid management, and inflow/outflow. Postoperative data collection focused on patients\\u0026apos; general condition immediately after surgery, postoperative complications, airway management, pathological findings, and prognosis.\\u003c/p\\u003e\\n\\u003ch3\\u003eStatistical Analysis\\u003c/h3\\u003e\\n\\u003cp\\u003eStatistical analysis was performed using SPSS 24.0 software. Normally distributed continuous variables were expressed as mean \\u0026plusmn; standard deviation \\u003cimg src=\\\"data:image/png;base64,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\\\" width=\\\"46\\\" height=\\\"16\\\"\\u003e, while non-normally distributed continuous variables were presented as median [interquartile range] [M (Q1, Q3)]. Categorical data were described using counts and percentages.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eGeneral situation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study cohort comprised 9 patients with a mean age of 46.1 ± 16.2 years, including 4 male patients (44.4%). Two (22.2%) patients had a history of hypertension, one (11.1%) had a history of diabetes, and one (11.1%) had a history of symptomatic epilepsy. Nine patients had skull base masses that were of the intracranial extracranial communication type, invading the foramen magnum area and involving the cervical canal. The general situation is shown in Table 1.\\u003c/p\\u003e\\n\\u003ch3\\u003ePerioperative Management\\u003c/h3\\u003e\\n\\u003cp\\u003eAmong the 9 patients, ASA physical status classification was as follows: 1 patient (11.1%) was Class I, 4 patients (44.4%) were Class II, 3 patients (33.3%) were Class III, and 1 patient (11.1%) was Class IV. Among the 9 patients, 7 (77.8%) completed skull base tumor resection combined with cervical or atlanto occipital fusion internal fixation under one anesthesia. Two patients (22.2%) initially underwent skull base tumor resection alone, but required subsequent occipitocervical fusion due to detected cervical instability during ICU care. One patient (11.1%) required a third surgical intervention for cerebrospinal fluid (CSF) leak repair following severe CSF leakage and intracranial infection.\\u003c/p\\u003e\\n\\u003cp\\u003eSurgical approaches included craniotomy in 6 patients (66.7%) and endoscopic endonasal surgery in 3 patients (33.3%). Airway management consisted of orotracheal intubation in 7 patients (77.8%), nasotracheal intubation in 1 patient (11.1%), and 1 patient (11.1%) with concurrent large thyroid mass causing tracheal compression underwent tracheostomy under local anesthesia prior to general anesthesia. The intraoperative bleeding volume of 7 cases with 1 surgery was 800 (400, 1800) ml, and the surgery duration was 7 (7, 9.25) hours. Gross total resection was achieved in 8 patients (88.9%), while 1 patient (11.1%) underwent only occipitocervical fusion and biopsy due to extensive tumor burden and family preference against aggressive resection.\\u003c/p\\u003e\\n\\u003cp\\u003eSeven (77.8%) patients retained tracheal intubation or tracheostomy intubation after surgery, while two (22.2%) patients had their tracheal intubation removed after surgery. One extubated patient required reintubation in the ICU due to fluctuating hypoxemia. Complications included pulmonary infection in 3 patients (33.3%), intracranial infection in 3 patients (33.3%), and postoperative seizures in 1 patient with pre-existing epilepsy.\\u003c/p\\u003e\\n\\u003cp\\u003ePathological examination revealed chordoma in 8 patients (88.9%) and cholesteatoma in 1 patient (11.1%). 5 patients (55.6%) with good recovery, 1 patient (11.1%) discharged with cervical orthosis, 1 quadriplegic patient (11.1%) discharged with residual deficits, 1 patient (11.1%) discharged after declining tumor resection, and 1 mortality (11.1%). Detailed perioperative data are presented in Table 2.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eTumors of the craniocervical junction present significant surgical challenges due to their deep-seated and anatomically complex location [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. These lesions often invade surrounding osseous structures and may compress or encase critical neurovascular elements including the brainstem, vertebrobasilar arterial system, and multiple cranial nerves. Postoperative complications may include craniocervical instability and severe brainstem injury, potentially leading to paralysis or cardiorespiratory failure, representing substantial surgical risks [\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Due to the difficulty of surgery in this area, both oral, nasal, and traditional craniotomy approaches face disadvantages such as poor exposure and incomplete resection [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e], with additional risks of CSF leakage and infection, posing formidable perioperative management challenges [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Our case series has yielded several important conclusions that may inform future perioperative management strategies.\\u003c/p\\u003e \\u003cp\\u003eFirst, comprehensive multidisciplinary evaluation and meticulous preoperative preparation are essential. Collaborative planning involving skull base surgeons, spinal neurosurgeons, and anesthesiologists should focus on tumor characteristics (size, location, neurovascular relationships, vascular supply) [\\u003cspan additionalcitationids=\\\"CR7\\\" citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e] and anticipate potential intraoperative crises (neurovascular injury, hemorrhagic events, or hemodynamic instability from neural manipulation). All nine patients in our series demonstrated aggressive, hypervascular tumors, prompting implementation of massive hemorrhage protocols [\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e] including invasive arterial monitoring for real-time hemodynamic assessment, goal-directed fluid resuscitation, and vasopressor support with blood gas analysis to guide transfusion therapy.\\u003c/p\\u003e \\u003cp\\u003eSecond, meticulous neural protection is paramount throughout the procedure. Both skull base and high cervical approaches require strategies to prevent iatrogenic motor or sensory deficits [\\u003cspan additionalcitationids=\\\"CR12\\\" citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. This study used intraoperative electrophysiological monitoring to monitor the patient's upper and lower limb sensation, movement, and cranial nerve function in real-time. To ensure monitoring accuracy, anesthesia is maintained using a combination of intravenous and inhalation anesthesia (with an MCA controlled below 0.5), and no muscle relaxants are added during monitoring. This approach successfully prevented new neurological deficits in all cases.\\u003c/p\\u003e \\u003cp\\u003eThird, special Considerations for Craniocervical Stability Management [\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. In this study, 7 patients had sufficient preoperative preparation and fully considered the issue of tumor invasion of the high cervical spine. Under one anesthesia, tumor resection was completed and occipital cervical fixation surgery was performed [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. When changing positions after skull base surgery, it is important to protect the cervical spine and move the patient axially to avoid cervical cord injury. In this study, the other two patients experienced severe complications such as severe circulatory fluctuations and respiratory dysfunction leading to hypoxemia after skull base surgery due to insufficient attention to head and neck stability, providing valuable lessons for future surgeries. The sixth patient wore a neck brace after surgery, which to some extent protected the cervical cord. Although there were circulation fluctuations, they were detected in a timely manner and a second surgery was performed for occipital cervical fusion fixation. The postoperative recovery was good and did not cause serious sequelae. On the first day after surgery, the ninth patient experienced fluctuating hypoxemia and was intubated again, but was not aware of the stability of the head and neck. Later, there was a decrease in limb muscle strength, and a cervical CT scan revealed cervical problems. Due to delayed detection, although a second posterior occipital cervical fusion fixation surgery was performed, the cervical spinal cord was already damaged, the sympathetic nervous system in the neck was damaged, and the circulation fluctuated violently during the second surgery, relying on high-dose vasoactive drugs. Moreover, due to cerebrospinal fluid leakage, the patient suffered from severe intracranial infection, prolonged tracheal intubation, and secondary pulmonary infection. The cultivation of difficult to treat Acinetobacter baumannii resulted in sepsis, further exacerbating anemia and malnutrition. Eventually, the patient died due to respiratory and circulatory failure despite rescue efforts. The patient is only 20 years old, and we deeply regret the occurrence of such serious complications. From this, we can see the importance of head and neck stability. We recommend making strict judgments during preoperative evaluation, and for patients who invade the cervical canal, we recommend completing occipital cervical fusion fixation surgery during the current surgery to ensure head and neck stability. Wear a neck brace or external head and neck fixator during the perioperative period to prevent cervical cord injury. Strictly monitor vital signs after surgery, carefully evaluate the timing of extubation, and promptly address any emergency situations.\\u003c/p\\u003e \\u003cp\\u003eFinally, the complexity and prolonged hospitalization of these cases demand aggressive complication prevention [\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. Endonasal cases require CSF leak and infection prophylaxis [\\u003cspan additionalcitationids=\\\"CR17 CR18\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e], while craniotomies necessitate cerebral edema and seizure management. Significant blood loss or sellar involvement mandates close electrolyte/hemoglobin monitoring, and skull base reconstruction demands infection control for flap viability [\\u003cspan additionalcitationids=\\\"CR21\\\" citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Additionally, early mobilization protocols should prevent venous thromboembolism.\\u003c/p\\u003e \\u003cp\\u003eAs a single-center study with limited sample size, our findings have inherent limitations. Larger multicenter studies are needed to refine perioperative protocols.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eOptimal management of craniocervical junction tumors requires: (1) multidisciplinary preoperative assessment emphasizing stability evaluation, (2) intraoperative neural protection and hemorrhage control, and (3) rigorous postoperative monitoring with prudent extubation decisions. Through comprehensive preparation and collaborative expertise, improved patient outcomes can be achieved.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eC\\u003c/strong\\u003e\\u003cstrong\\u003eonflict of interest\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests, and the manuscript has been approved by all the authors for publication.\\u003c/p\\u003e\\n\\u003cp\\u003eI would like to declare on behalf of my coauthors that the work described is original research that has not been published previously and is not under consideration for publication elsewhere, in whole or in part.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contribution Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eXiaoxiao Zhang: Data collection and analysis, paper writing; Liu Yang, Ping Zhu, Ruquan Han, Haiyang Liu: Research guidance, paper revision Paper revision.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study has obtained informed consent from all participants involved. Our research fully complies with the Helsinki Declaration.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eHuman Ethics and Consent to Participate declarations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was approved by the Ethics Committee of Beijing Tiantan Hospital, Capital Medical University (KY2024-186-01).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData availability\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials:\\u0026nbsp;Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWritten informed consent was obtained from the patient for publication of this case report.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding Declaration\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis article has no funding.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eClinical trial number\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eForst DA, Jones PS. Skull Base Tumors. Continuum (Minneap Minn). 2023 Dec 1;29(6):1752-1778. doi: 10.1212/CON.0000000000001361. PMID: 38085897.\\u003c/li\\u003e\\n\\u003cli\\u003eSpiessberger A, Gruter B, Prashant G, Haegler J, Eisenberg M, Cohen-Gadol AA, Dehdashti AR. A Contemporary Clinico-Anatomical Guide to Craniovertebral Junction Surgery. J Neurol Surg B Skull Base. 2022 Sep 28;84(4):413-420. doi: 10.1055/s-0042-1755600. PMID: 37405236; PMCID: PMC10317559.\\u003c/li\\u003e\\n\\u003cli\\u003eMorimoto LR, Kase DT, Esmanhotto PG, Maciel MA, Augusto ACL, Catricala PF, Anaya JEC, Mukherjee S, Fernandes ARC, Aihara AY. Imaging Assessment of Nontraumatic Pathologic Conditions at the Craniovertebral Junction: A Comprehensive Review. Radiographics. 2024 May;44(5):e230137. doi: 10.1148/rg.230137. PMID: 38635454.\\u003c/li\\u003e\\n\\u003cli\\u003eUlici V, Hart J. Chordoma. Arch Pathol Lab Med. 2022 Mar 1;146(3):386-395. doi: 10.5858/arpa.2020-0258-RA. 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PMID: 34997137; PMCID: PMC8742093.\\u003c/li\\u003e\\n\\u003cli\\u003eTatter C, El-Hajj VG, Fletcher-Sandersj\\u0026ouml;\\u0026ouml; A, Edstr\\u0026ouml;m E, Elmi-Terander A. Radiographic measurements for the prediction of dysphagia after occipitocervical fusion: a systematic review. Acta Neurochir (Wien). 2023 May;165(5):1161-1170. doi: 10.1007/s00701-023-05509-6. Epub 2023 Feb 14. PMID: 36781463; PMCID: PMC10140007.\\u003c/li\\u003e\\n\\u003cli\\u003eFaraj MK. Advancements in occipitocervical fusion: Biomechanical insights, surgical techniques, and clinical outcomes. Surg Neurol Int. 2025 Feb 14;16:46. doi: 10.25259/SNI_1096_2024. PMID: 40041047; PMCID: PMC11878740.\\u003c/li\\u003e\\n\\u003cli\\u003eAlosaimi A, Tawfiq IA, Makhdoom N. Recurrent Cholesteatoma with Skull Base Erosion: A Case Report. Cureus. 2025 Feb 22;17(2):e79460. doi: 10.7759/cureus.79460. PMID: 40130139; PMCID: PMC11932432.\\u003c/li\\u003e\\n\\u003cli\\u003eZhou Z, Zuo F, Chen X, Zhao Q, Luo M, Jiang X, Duan Y. Risk factors for postoperative cerebrospinal fluid leakage after transsphenoidal surgery for pituitary adenoma: a meta-analysis and systematic review. BMC Neurol. 2021 Oct 27;21(1):417. doi: 10.1186/s12883-021-02440-0. PMID: 34706659; PMCID: PMC8555154.\\u003c/li\\u003e\\n\\u003cli\\u003eCao D, Shen D, Shi Z, Wu J, Xie S, Luo H, Tang B. A study on the effectiveness of multiple intraoperative disinfections and bacteriological monitoring in reducing postoperative intracranial infection rates in transnasal endoscopic skull base surgery. Acta Neurochir (Wien). 2025 Mar 26;167(1):91. doi: 10.1007/s00701-025-06498-4. PMID: 40138048; PMCID: PMC11947040.\\u003c/li\\u003e\\n\\u003cli\\u003ePalmieri D, Champagne PO, Valappil B, McDowell MM, Gardner PA, Snyderman CH. Risk Factors in a Pediatric Population for Postoperative Intracranial Infection Following Endoscopic Endonasal Skull Base Surgery and the Role of Antibiotic Prophylaxis. Am J Rhinol Allergy. 2023 Jan;37(1):13-18. doi: 10.1177/19458924221123113. Epub 2022 Sep 1. PMID: 36050937.\\u003c/li\\u003e\\n\\u003cli\\u003eRacette S, Tekumalla S, Agarwal A, Curry J, Beahm DD. Anterior Skull Base Reconstruction. Otolaryngol Clin North Am. 2023 Aug;56(4):727-739. doi: 10.1016/j.otc.2023.04.015. Epub 2023 Jun 1. PMID: 37268516.\\u003c/li\\u003e\\n\\u003cli\\u003eHanasono MM. Reconstruction after open surgery for skull-base malignancies. J Neurooncol. 2020 Dec;150(3):469-475. doi: 10.1007/s11060-019-03370-1. Epub 2020 Feb 13. PMID: 32056144.\\u003c/li\\u003e\\n\\u003cli\\u003eHe J, Lu J, Zhang F, Chen J, Wang Y, Zhang Q. The Treatment Strategy for Skull Base Reconstruction for Anterior Cranial Fossa Intra- and Extracranial Tumors. J Craniofac Surg. 2021 Jul-Aug 01;32(5):1673-1678. doi: 10.1097/SCS.0000000000007244. PMID: 33208698.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables 1 and 2 are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-anesthesiology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bane\",\"sideBox\":\"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bane\",\"title\":\"BMC Anesthesiology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Skull base tumors, Neurosurgery, Spinal neurosurgery, Anesthesia\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6416829/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6416829/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective:\\u003c/strong\\u003e To analyze the clinical characteristics of patients with craniocervical junction space-occupying lesions and summarize the perioperative management experience in combined skull base and spinal neurosurgery.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods:\\u003c/strong\\u003e Medical records of patients who underwent combined skull base and spinal neurosurgery at Beijing Tiantan Hospital, Capital Medical University, from April 1, 2020, to April 1, 2025, were retrospectively analyzed. Clinical data, multidisciplinary treatment, anesthetic management, and outcomes were evaluated.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults:\\u003c/strong\\u003e Among the 9 patients, 7 (77.8%) completed skull base tumor resection combined with cervical or atlanto occipital fusion internal fixation under one anesthesia. Two (22.2%) patients initially underwent only skull base tumor resection, but due to detected cervical instability during ICU stay, a second surgery for occipitocervical fusion was performed. Five (55.6%) patients were discharged with good recovery, one (11.1%) was discharged wearing a cervical orthosis, one (11.1%) with preoperative quadriplegia was discharged with residual deficits, one (11.1%) declined tumor resection and was discharged, and one (11.1%) died.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion:\\u003c/strong\\u003e Craniocervical junction lesions are rare. Preoperative multidisciplinary consultation should focus on assessing craniocervical stability. 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