• Chetan Bettegowda, Mehdi Shajari, Ian Suk, Oliver P Simmons, Ziya L Gokaslan, and Jean-Paul Wolinsky.
• Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA. cbetteg1@jhmi.edu
• Neurosurgery. 2011 Sep 1;69(1 Suppl Operative):ons77-82; discussion ons82.

BackgroundBasilar impression (BI) is an uncommon condition in which there is upward displacement of the elements forming the foramen magnum, causing translocation of vertebral elements into the brainstem. Most commonly a developmental anomaly, BI is often associated with congenital conditions such as Down syndrome. Symptomatic BI is often difficult to treat surgically secondary to the anatomic variants associated with many of the coinciding congenital syndromes.ObjectiveTo present a feasible approach for the treatment of BI.MethodsWe present an alternative surgical approach for the treatment of symptomatic BI in a 37-year-old woman with Klippel-Feil syndrome. Because of the altered anatomy, traditional approaches such as the transoral-transpharyngeal, transmandibular circumglossal, and transcervical endoscopic routes were not feasible.ResultsWe chose a staged sublabial, transnasal, transpalatal route for the anterior brainstem decompression followed by posterior fixation. The patient tolerated the procedures well and at last follow-up had nearly complete resolution of symptoms.ConclusionThe sublabial route is an alternative approach for anterior decompression in patients with symptomatic basilar impression and altered anatomic circumstances such as that caused by Klippel-Feil syndrome.

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