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Vigneul E, Del Gaudio N, de Nijs L, Raftopoulos C. Neurological outcome following delayed traction and fixation in severe tetraparesis consecutive to posterior decompression for Chiari malformation: a case report. Childs Nerv Syst 2024; 40:1943-1947. [PMID: 38374472 DOI: 10.1007/s00381-024-06327-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Chiari malformation type 1 (CM1) is a congenital hindbrain malformation characterized by herniation of the cerebellar tonsils below the foramen magnum. The term Chiari type 1.5 is used when herniation of the brainstem under the McRae line and anomalies of the craniovertebral junction are also present. These conditions are associated with several symptoms and signs, including headache, neck pain, and spinal cord syndrome. For symptomatic patients, surgical decompression is recommended. When radiographic indicators of craniovertebral junction (CVJ) instability or symptoms related to ventral brainstem compression are present, CVJ fixation should also be considered. CASE DESCRIPTION We report the case of a 13-year-old girl who presented with severe tetraparesis after posterior decompression for Chiari malformation type 1.5, followed 5 days later by partial C2 laminectomy. Several months after the initial surgery, she underwent two fixations, first without and then with intraoperative cervical traction, leading to significant neurological improvement. DISCUSSION AND CONCLUSION This case report underscores the importance of meticulous radiological analysis before CM surgery. For CM 1.5 patients with basilar invagination, CVJ fixation is recommended, and C2 laminectomy should be avoided. In the event of significant clinical deterioration due to nonadherence to these guidelines, our findings highlight the importance of traction with increased extension before fixation, even years after initial destabilizing surgery.
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Affiliation(s)
- Eric Vigneul
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
- Laboratory of Neural Differentiation (NEDI), Animal Molecular and Cellular Biology Group, Louvain Institute of Biomolecular Science and Technology, Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Nicole Del Gaudio
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Loïc de Nijs
- Department of Neurosurgery, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Marulanda J, Retrouvey JM, Lee B, Sutton VR, Rauch F, Briner M. Cranio-cervical abnormalities in moderate-to-severe osteogenesis imperfecta - Genotypic and phenotypic determinants. Orthod Craniofac Res 2024; 27:237-243. [PMID: 37642979 PMCID: PMC11198608 DOI: 10.1111/ocr.12707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Cranio-cervical anomalies are significant complications of osteogenesis imperfecta (OI), a rare bone fragility disorder that is usually caused by mutations in collagen type I encoding genes. OBJECTIVE To assess cranio-cervical anomalies and associated clinical findings in patients with moderate-to-severe OI using 3D cone beam computed tomography (CBCT) scans. METHODS Cross-sectional analysis of CBCT scans in 52 individuals with OI (age 10-37 years; 32 females) and 40 healthy controls (age 10-32 years; 26 females). Individuals with a diagnosis of OI type III (severe, n = 11), type IV (moderate, n = 33) and non-collagen OI (n = 8) were recruited through the Brittle Bone Disorders Consortium. Controls were recruited through the orthodontic clinic of the University of Missouri-Kansas City (UMKC). RESULTS OI and control groups were similar in mean age (OI: 18.4 [SD: 7.2] years, controls: 18.1 [SD: 6.3] years). The cranial base angle was increased in the OI group (OI: mean 148.6° [SD: 19.3], controls: mean 130.4° [SD: 5.7], P = .001), indicating a flatter cranial base. Protrusion of the odontoid process into the foramen magnum (n = 7, 14%) and abnormally located odontoid process (n = 19, 37%) were observed in the OI group but not in controls. Low stature, expressed as height z-score (P = .01), presence of DI (P = .04) and being male (P = .04) were strong predictors of platybasia, whereas height z-score (P = .049) alone was found as positive predictor for basilar impression as per the Chamberlain measurement. CONCLUSION The severity of the phenotype in OI, as expressed by the height z-score, correlates with the severity of cranial base anomalies such as platybasia and basilar impression in moderate-to-severe OI. Screening for cranial base anomalies is advisable in individuals with moderate-to-severe OI, with special regards to the individuals with a shorter stature and DI.
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Affiliation(s)
- Juliana Marulanda
- Shriners Hospital for Children, Montreal, Quebec, Canada
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | | | - Brendan Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - V Reid Sutton
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas, USA
| | - Frank Rauch
- Shriners Hospital for Children, Montreal, Quebec, Canada
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Michelle Briner
- University of Missouri-Kansas City, Kansas City, Missouri, USA
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Henderson FC, Schubart JR, Narayanan MV, Tuchman K, Mills SE, Poppe DJ, Koby MB, Rowe PC, Francomano CA. Craniocervical instability in patients with Ehlers-Danlos syndromes: outcomes analysis following occipito-cervical fusion. Neurosurg Rev 2024; 47:27. [PMID: 38163828 PMCID: PMC10758368 DOI: 10.1007/s10143-023-02249-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/30/2023] [Accepted: 12/09/2023] [Indexed: 01/03/2024]
Abstract
Craniocervical instability (CCI) is increasingly recognized in hereditary disorders of connective tissue and in some patients following suboccipital decompression for Chiari malformation (CMI) or low-lying cerebellar tonsils (LLCT). CCI is characterized by severe headache and neck pain, cervical medullary syndrome, lower cranial nerve deficits, myelopathy, and radiological metrics, for which occipital cervical fusion (OCF) has been advocated. We conducted a retrospective analysis of patients with CCI and Ehlers-Danlos syndrome (EDS) to determine whether the surgical outcomes supported the criteria by which patients were selected for OCF. Fifty-three consecutive subjects diagnosed with EDS, who presented with severe head and neck pain, lower cranial nerve deficits, cervical medullary syndrome, myelopathy, and radiologic findings of CCI, underwent open reduction, stabilization, and OCF. Thirty-two of these patients underwent suboccipital decompression for obstruction of cerebral spinal fluid flow. Questionnaire data and clinical findings were abstracted by a research nurse. Follow-up questionnaires were administered at 5-28 months (mean 15.1). The study group demonstrated significant improvement in headache and neck pain (p < 0.001), decreased use of pain medication (p < 0.0001), and improved Karnofsky Performance Status score (p < 0.001). Statistically significant improvement was also demonstrated for nausea, syncope (p < 0.001), speech difficulties, concentration, vertigo, dizziness, numbness, arm weakness, and fatigue (p = 0.001). The mental fatigue score and orthostatic grading score were improved (p < 0.01). There was no difference in pain improvement between patients with CMI/LLCT and those without. This outcomes analysis of patients with disabling CCI in the setting of EDS demonstrated significant benefits of OCF. The results support the reasonableness of the selection criteria for OCF. We advocate for a multi-center, prospective clinical trial of OCF in this population.
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Affiliation(s)
- Fraser C Henderson
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA.
| | - Jane R Schubart
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Malini V Narayanan
- Division of Neurosurgery, University of Maryland Capital Region Medical Center, Largo, Maryland, USA
| | - Kelly Tuchman
- The Metropolitan Neurosurgery Group LLC, Silver Spring, MD, USA
| | - Susan E Mills
- Department of Surgery, Penn State College of Medicine, Hershey, PA, USA
| | - Dorothy J Poppe
- Bobby Jones Chiari & Syringomyelia Foundation, Staten Island, New York, USA
| | - Myles B Koby
- Luminis Health, Doctors Community Medical Center, Lanham, Maryland, USA
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Han RK, Chae JK, Garton ALA, Cruz A, Navarro-Ramirez R, Hussain I, Härtl R, Greenfield JP. Intraoperative occipital to C2 angle and external acoustic meatus-to-axis angular measurements for optimizing alignment during posterior fossa decompression and occipitocervical fusion for complex Chiari malformation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2023; 14:365-372. [PMID: 38268687 PMCID: PMC10805164 DOI: 10.4103/jcvjs.jcvjs_59_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/21/2023] [Indexed: 01/26/2024] Open
Abstract
Background Excess flexion or extension during occipitocervical fusion (OCF) can lead to postoperative complications, such as dysphagia, respiratory problems, line of sight issues, and neck pain, but posterior fossa decompression (PFD) and OCF require different positions that require intraoperative manipulation. Objective The objective of this study was to describe quantitative fluoroscopic morphometrics in Chiari malformation (CM) patients with symptoms of craniocervical instability (CCI) and demonstrate the intraoperative application of these measurements to achieve neutral craniocervical alignment while leveraging a single axis of motion with the Mayfield head clamp locking mechanism. Methods A retrospective cohort study of patients with CM 1 and 1.5 and features of CCI who underwent PFD and OCF at a single-center institution from March 2015 to October 2020 was performed. Patient demographics, preoperative presentation, radiographic morphometrics, operative details, complications, and clinical outcomes were analyzed. Results A total of 39 patients met the inclusion criteria, of which 37 patients (94.9%) did not require additional revision surgery after PFD and OCF. In this nonrevision cohort, preoperative to postoperative occipital to C2 angle (O-C2a) (13.5° ± 10.4° vs. 17.5° ± 10.1°, P = 0.047) and narrowest oropharyngeal airway space (nPAS) (10.9 ± 3.4 mm vs. 13.1 ± 4.8 mm, P = 0.007) increased significantly. These measurements were decreased in the two patients who required revision surgery due to postoperative dysphagia (mean difference - 16.6°° in O C2a and 12.8°° in occipital and external acoustic meatus to axis angle). Based on these results, these fluoroscopic morphometrics are intraoperatively assessed, utilizing a locking Mayfield head clamp repositioning maneuver to optimize craniocervical alignment prior to rod placement from the occipital plate to cervical screws. Conclusion Establishing a preoperative baseline of reliable fluoroscopic morphometrics can guide surgeons intraoperatively in appropriate patient realignment during combined PFD and OCF, and may prevent postoperative complications.
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Affiliation(s)
- Rachael K. Han
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - John K. Chae
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Andrew L. A. Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Amanda Cruz
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Rodrigo Navarro-Ramirez
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian-Och Spine, New York, NY, USA
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, USA
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Ismail MA, Boehm H, El Ghait HA, Akar A. Surgical treatment of craniocervical instability: comparison of two constructs regarding clinical and radiological outcomes of 100 patients. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3511-3521. [PMID: 37294357 DOI: 10.1007/s00586-023-07795-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/11/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE There is an increased demand for surgical solutions to treat craniocervical instability. This retrospective study demonstrates the clinical and radiological outcomes of unstable craniocervical junction treated with occipitocervical fusion. MATERIAL AND METHODS The mean age of 52 females and 48 males was 56.89 years. The clinical and radiological outcomes were assessed, including NDI, VAS, ASIA score, imaging, complications and bony fusion in two used constructs: a modern occipital plate-rod-screw system (n = 59) and previous bilateral contoured titanium reconstruction plates-screws (n = 41). RESULTS Clinically and on imaging, patients presented with neck pain, myelopathy, radiculopathy, vascular symptoms and craniocervical instability. The mean follow-up was 6.47 years. A solid bony fusion was achieved in 93.81% of the patients. The NDI and the VAS improved significantly from 28.3 and 7.67 at the presentation to 16.2 and 3.47 at the final follow-up. The anterior and posterior atlantodental interval (AADI and PADI), the clivus canal angle (CCA), the occipitoaxial angle (OC2A) and the posterior occipitocervical angle (POCA) improved significantly. Six patients required early revision. CONCLUSION Occipitocervical fusion can yield excellent results regarding clinical improvement and long-term stability with a high fusion rate. Simple reconstruction plates, though more demanding surgically, achieve similar results. Preserving a neutral patient's position for fixation avoids postoperative dysphagia and may help prevent adjacent segment disease development.
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Affiliation(s)
- Mohammed Ahmed Ismail
- Orthopaedic Department, El Hussien University Hospital, Al Azhar University, Gawhar El Kaeed Street, El Darassa, Cairo, 11651, Egypt.
| | - Heinrich Boehm
- Spine Surgery Department, Zentralklinik Bad Berka, Bad Berka, Germany
| | - Hussein Abou El Ghait
- Orthopaedic Department, El Hussien University Hospital, Al Azhar University, Gawhar El Kaeed Street, El Darassa, Cairo, 11651, Egypt
| | - Ahmed Akar
- Orthopaedic Department, El Hussien University Hospital, Al Azhar University, Gawhar El Kaeed Street, El Darassa, Cairo, 11651, Egypt
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Akyuz ME, Karadag MK, Sahin MH. Effect of modified clivoaxial angle on surgical decision making and treatment outcomes in patients with Chiari malformation type 1. Front Surg 2023; 10:1143086. [PMID: 37215352 PMCID: PMC10196391 DOI: 10.3389/fsurg.2023.1143086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/17/2023] [Indexed: 05/24/2023] Open
Abstract
Introduction Chiari malformation type 1 (CM1), a complex pathological developmental disorder of the craniovertebral junction, is typically characterized by herniation of the cerebellar tonsils from the foramen magnum. Treatment using posterior fossa decompression alone without taking the ventral cervico-medullary compression into consideration may lead to unsatisfactory treatment outcomes. The current study evaluated the utility of the modified clivoaxial angle (MCAA) in assessing ventral compression and also examined its effect on treatment outcomes. Method This retrospective study included 215 adult patients who underwent surgical treatment for CM1 at one medical center over a 10-year period. The following surgical techniques were used to decompress the posterior fossa: (a) PFD: bone removal only; (b) PFDwD: bone removal with duraplasty; and (c) CTR: cerebellar tonsil resection. The morphometric measurements of the craniovertebral junction (including MCAA) were recorded using preoperative images, and the postoperative clinical status was evaluated using the Chicago Chiari outcome scale (CCOS). Results MCAA was positively correlated with the CCOS score and also independently predicted treatment outcome. To enable Receiver operating characteristic (ROC) curve analysis of CCOS scores, the patients were divided into three groups based on the MCAA cut-off values, as follows: (a) severe (n = 43): MCAA ≤ 126; (b) moderate (n = 86): 126 < MCAA ≤ 138; and (c) mild (n = 86): MCAA > 138. Group a exhibited severe ventral cervico-medullary compression (VCMC), and their CCOS scores for the PFD, PFDwD, and CTR groups were 11.01 ± 1.2, 11.24 ± 1.3, and 13.01 ± 1.2, respectively (p < 0.05). The CCOS scores increased with widening of the MCAA angle in all surgical groups (p < 0.05). Furthermore, patients with mild MCAA (>138°) exhibited 78% regression of syringomyelia, and this was significantly greater than that observed in the other groups. Discussion MCAA can be used in the selection of appropriate surgical techniques and prediction of treatment outcomes, highlighting the importance of preoperative evaluation of ventral clivoaxial compression in patients with CM1.
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Ottenhausen M, Greco E, Bertolini G, Gerosa A, Ippolito S, Middlebrooks EH, Serrao G, Bruzzone MG, Costa F, Ferroli P, La Corte E. Craniovertebral Junction Instability after Oncological Resection: A Narrative Review. Diagnostics (Basel) 2023; 13:1502. [PMID: 37189602 PMCID: PMC10137736 DOI: 10.3390/diagnostics13081502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
The craniovertebral junction (CVJ) is a complex transition area between the skull and cervical spine. Pathologies such as chordoma, chondrosarcoma and aneurysmal bone cysts may be encountered in this anatomical area and may predispose individuals to joint instability. An adequate clinical and radiological assessment is mandatory to predict any postoperative instability and the need for fixation. There is no common consensus on the need for, timing and setting of craniovertebral fixation techniques after a craniovertebral oncological surgery. The aim of the present review is to summarize the anatomy, biomechanics and pathology of the craniovertebral junction and to describe the available surgical approaches to and considerations of joint instability after craniovertebral tumor resections. Although a one-size-fits-all approach cannot encompass the extremely challenging pathologies encountered in the CVJ area, including the possible mechanical instability that is a consequence of oncological resections, the optimal surgical strategy (anterior vs posterior vs posterolateral) tailored to the patient's needs can be assessed preoperatively in many instances. Preserving the intrinsic and extrinsic ligaments, principally the transverse ligament, and the bony structures, namely the C1 anterior arch and occipital condyle, ensures spinal stability in most of the cases. Conversely, in situations that require the removal of those structures, or in cases where they are disrupted by the tumor, a thorough clinical and radiological assessment is needed to timely detect any instability and to plan a surgical stabilization procedure. We hope that this review will help shed light on the current evidence and pave the way for future studies on this topic.
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Affiliation(s)
- Malte Ottenhausen
- Department of Neurological Surgery, University Medical Center Mainz, 55131 Mainz, Germany
| | - Elena Greco
- Department of Radiology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Giacomo Bertolini
- Head and Neck Department, Neurosurgery Division, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy
| | - Andrea Gerosa
- Head and Neck Department, Neurosurgery Division, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy
| | - Salvatore Ippolito
- Head and Neck Department, Neurosurgery Division, Azienda Ospedaliero-Universitaria di Parma, 43126 Parma, Italy
| | - Erik H. Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, FL 32224, USA
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Graziano Serrao
- Department of Health Sciences, San Paolo Medical School, Università Degli Studi di Milano, 20142 Milan, Italy
| | - Maria Grazia Bruzzone
- Department of Neuroradiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Francesco Costa
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Paolo Ferroli
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
| | - Emanuele La Corte
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milan, Italy
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Dastagirzada YM, Kurland DB, Hankinson TC, Anderson RCE. Craniovertebral Junction Instability in the Setting of Chiari Malformation. Neurosurg Clin N Am 2023; 34:131-142. [DOI: 10.1016/j.nec.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Arnautovic A, Pojskić M, Arnautović KI. Adult Chiari Malformation Type I. Neurosurg Clin N Am 2023; 34:91-104. [DOI: 10.1016/j.nec.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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10
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Hou Z, Fan T, Fan W, Jian Q, Wang Y. Basilar invagination without atlantoaxial dislocation: treatment by correction of clivus canal angle with interfacet distraction and fixation. BMC Musculoskelet Disord 2022; 23:1138. [PMID: 36581884 PMCID: PMC9798678 DOI: 10.1186/s12891-022-06102-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/19/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND This study reports on the surgical technique used and clinical outcomes obtained during the treatment of basilar invagination (BI) without atlantoaxial dislocation (AAD) through the correction of the clivus canal angle (CCA) using interfacet distraction and fixation. METHODS Nineteen cases with BI without AAD treated by the correction of the clivus canal angle were retrospectively analyzed. Pre- and postoperative computed tomography scans and three-dimensional reconstruction views were obtained to measure the size of the CCA, pB-C2 distance, and degree of BI. Chiari malformation and syringomyelia were evaluated by magnetic resonance imaging (MRI). The clinical outcomes for all patients were measured using the Japanese Orthopedic Association (JOA) scale. The CCA was corrected by using interfacet distraction and fixation techniques. The Wilcoxon test was used to compare pre- and postoperative measurements. RESULTS All the patients were followed up for 24.95 ± 5.22 months (range 12-36 months); no patient suffered intraoperative nerve or vascular injury. Clinical symptoms improved in 17 patients (89.5%). The mean JOA score increased from 12.32 ± 1.89 to 14.37 ± 1.30 (Z = -3.655, P < 0.001). The mean CCA improved from 129.34 ± 8.52° preoperatively to 139.75 ± 8.86° postoperatively (Z = -3.824, P < 0.001). The mean pB-C2 decreased from 7.47 ± 2.21 to 5.68 ± 3.13 (Z = -3.060, P = 0.002). Syringomyelia was significantly reduced in 10 out of 13 patients by the first follow-up year. All patients achieved bony fusion. CONCLUSION Posterior interfacet distraction and fixation to correct the CCA is a feasible and effective method for treating BI without AAD.
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Affiliation(s)
- Zhe Hou
- grid.478016.c0000 0004 7664 6350Department of Neurosurgery, Beijing Luhe Hospital, Capital Medica University, Beijing, People’s Republic of China ,grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Tao Fan
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wayne Fan
- grid.17091.3e0000 0001 2288 9830Faculty of Science, The University of British Columbia, Vancouver, BC Canada
| | - Qiang Jian
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yinqian Wang
- grid.24696.3f0000 0004 0369 153XSpine Center, Sanbo Brain Hospital, Capital Medical University, Beijing, People’s Republic of China
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Marathe N, Lohkamp LN, Fehlings MG. Spinal manifestations of Ehlers-Danlos syndrome: a scoping review. J Neurosurg Spine 2022; 37:783-793. [PMID: 35986728 DOI: 10.3171/2022.6.spine211011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Since its initial description, the definition of Ehlers-Danlos syndrome (EDS) has notably changed. At present, it broadly refers to disorders of the connective tissue that are heritable and have similar features including joint hypermobility, dermal dysplasia, and vascular as well as internal organ fragility. There has been no comprehensive review of spinal manifestations of EDS in the recent literature. That has led to controversies in management protocols of this so-called orphan disease. METHODS The authors used the latest version of the EDS classification from 2017, in which 13 subtypes were recognized. EDS has 19 different causal genes, mainly associated with collagen synthesis. Of these, 5 subtypes have associated spinal manifestations. RESULTS Some of the spinal pathologies associated with EDS include Chiari malformation, craniocervical instability, kyphoscoliosis, segmental instability and kyphosis, spontaneous CSF leaks, Tarlov cyst syndrome, tethered cord, and problems associated with wound healing. Here, the authors briefly discuss the demographics, etiology, pathophysiology, clinical features, management strategies, and directions for further research for each of these manifestations. CONCLUSIONS EDS belongs to the group of orphan diseases, with the total patient population being below 200,000. Further research on spinal manifestations of EDS is the need of the hour to establish clinical practice guidelines and close the significant knowledge gaps that currently exist.
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Affiliation(s)
- Nandan Marathe
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Laura-Nanna Lohkamp
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Ontario; and.,2Division of Neurosurgery, Krembil Neuroscience Centre, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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Mao G, Kopparapu S, Jin Y, Davidar AD, Hersh AM, Weber-Levine C, Theodore N. Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management. Spine J 2022; 22:1944-1952. [PMID: 36028216 DOI: 10.1016/j.spinee.2022.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Yike Jin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
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13
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Lohkamp LN, Marathe N, Fehlings MG. Craniocervical Instability in Ehlers-Danlos Syndrome-A Systematic Review of Diagnostic and Surgical Treatment Criteria. Global Spine J 2022; 12:1862-1871. [PMID: 35195459 PMCID: PMC9609512 DOI: 10.1177/21925682211068520] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE Ehlers-Danlos Syndrome (EDS) comprises a spectrum of connective tissue disorders, which may be associated with cranio-cervical instability (CCI). There is a lack of consensus on diagnostic imaging parameters, indications, and outcomes of surgical treatment. METHODS This systematic review analyses the literature on diagnostic methods and/or criteria for CCI, screening the databases Ovid Medline, Embase, Cochrane Library, and PubMed. Articles were included based on the PRISMA guidelines and assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS) and according to their evidence level. RESULTS Sixteen articles, including 78 surgical patients, met the inclusion criteria. The main diagnostic measures for CCI were dynamic x-rays and CT imaging. Ten different radiographic parameters were reported, of which 4 were the most frequently applied for surgical decision-making: the clivo-axial angle (CXA), the Harris measurement, the Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2. The evidence level ranged between III and V and the article quality between 4 and 8 out of 9 stars on the NOS Scale. CONCLUSIONS There is a lack of high quality, prospective evidence regarding the evaluation of suspected CCI in patients with EDS. Based on our systematic review, we recommend that the CXA, Harris measurement, Grabb-Mapstone-Oakes measurement, and the angular displacement of C1 to C2 be used to evaluate suspected CCI in EDS patients. Surgical fixation of suspected CCI should only be performed in cases with clear radiographic presence of instability and concordant symptoms/signs. Consensus-based guidelines and care pathways are required.
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Affiliation(s)
- Laura-Nanna Lohkamp
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada
| | - Nandan Marathe
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery,
Department of Surgery, University of Toronto, Toronto, ON, Canada,Division of Neurosurgery, Spinal
Program, Krembil Nuroscience Centre, Toronto Western Hospital, University Health
Network, Toronto, ON, Canada,Michael G. Fehlings MD PhD, Division of
Neurosurgery and Spinal Program, Department of Surgery, University of Toronto,
Krembil Neuroscience Centre Toronto Western Hospital, 399 Bathurst Street, Suite
4W-449 Toronto, ON M5T 2S8, Canada.
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14
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Serindere G, Gunduz K, Avsever H. Morphological Measurement and Anatomical Variations of the Clivus Using Computed Tomography. Skull Base Surg 2022; 83:e75-e82. [DOI: 10.1055/s-0040-1722712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/15/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Objectives The aim of this study was to evaluate the clivus morphology, including fossa navicularis magna (FNM), canalis basilaris medianus (CBM), and craniopharyngeal canal (CC), on computed tomography (CT) images.
Design This is a retrospective study.
Setting Faculty of Dentistry, Department of Dentomaxillofacial Radiology.
Participants The CT images of 500 patients (253 males; 247 females) were evaluated.
Main Outcome Measures The prevalence of FNM, CBM, and CPC; the length, width, and depth of FNM; and CBM types were recorded. Also, a morphological analysis of the clivus (length of the clivus, angle between the clivus and the posterior margin of the foramen magnum, angle between the clivus and the dens axis, and anteroposterior diameter of the foramen magnum) was performed.
Results FNM was identified in 5.4%, CBM in 4%, and CC in 0.8% of the study group. Type 5 CBM was not found. Type 6 was the most common CBM type. There was no significant correlation between the age and gender of patients with FNM. There were significant differences between the clivus length, the angle between the clivus and the dens axis, the anteroposterior diameter of the foramen magnum, and gender. Also, there was a significant difference between the angle between the clivus and the foramen magnum and age.
Conclusions The anatomical variations of the clivus are rare and important for the oral and maxillofacial radiologist to make the differential diagnosis. These anatomical variations should not be confused with pathologic formations. The morphological measurements and anatomical variations of the clivus can be evaluated in detail on CT images.
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Affiliation(s)
- Gozde Serindere
- Department of Dentomaxillofacial Radiology, Hatay Mustafa Kemal University, Faculty of Dentistry, Hatay, Turkey
| | - Kaan Gunduz
- Department of Dentomaxillofacial Radiology, Ondokuz Mayıs University, Faculty of Dentistry, Samsun, Turkey
| | - Hakan Avsever
- Department of Dentomaxillofacial Radiology, Health Sciences University, Gulhane Faculty of Dentistry, Ankara, Turkey
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Li T, Du YQ, Yin YH, Xing SL, Qiao GY. Treatment of Reducible Atlantoaxial Dislocation and Basilar Invagination Using the Head Frame Reduction Technique and Atlantoaxial Arthrodesis. Global Spine J 2022; 12:909-915. [PMID: 33138641 PMCID: PMC9344496 DOI: 10.1177/2192568220970164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECT To evaluate the outcomes of a head frame reduction and atlantoaxial arthrodesis technique for the treatment of reducible basilar invagination (BI) and atlantoaxial dislocation (AAD). METHODS Seventy-two reducible BI and AAD cases who were treated with the head frame reduction and atlantoaxial arthrodesis technique from June 2015 to December 2018 were retrospectively analyzed. Radiological measurements including the atlantodental interval (ADI), the height of odontoid process above Chamberlain line, Wackenheim line, clivus-canal angle (CCA) and JOA score were evaluated. RESULTS There was no death in this series. The follow-up period ranged from 6 to 32 months (mean: 21.2 months). Radiological, complete or 90% reduction was attained and complete decompression was demonstrated in all patients. The CCA increased from 123.22 ± 8.36 preoperatively to 143.05 ± 8.79 postoperatively (P < 0.01). There was no patient found postoperative dysphagia. Neurological improvement was observed in all patients, with the JOA scores increasing from 12.53 ± 1.93 preoperatively to 16.13 ± 1.23 postoperatively (P < 0.01). Solid bony fusion was demonstrated in 69 patients at follow-up (95.8%). CONCLUSION Head frame reduction technique is a simple and effective treatment which could relief neurologic compression and adjust the CCA in patients with reducible AAD and BI with lower potential risks. Atlantoaxial fixation with short segmental fixation, strong purchase and low shearing force could maintain superior stabilization. The safety and long-term efficacy of such fixation and reduction technique were favorable, which illustrated that it could be a promising treatment algorithm for such kind of disease.
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Affiliation(s)
- Teng Li
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yue-Qi Du
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Yi-Heng Yin
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China,Guang-Yu Qiao and Yi-Heng Yin, Department of
Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing
Road, Haidian District, Beijing 100853, China.
;
| | - Shao-Ling Xing
- Department of Anesthesia and
Operative Services, The First Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Guang-Yu Qiao
- Department of Neurosurgery, The
First Medical Centre, Chinese PLA General Hospital, Beijing, China,Guang-Yu Qiao and Yi-Heng Yin, Department of
Neurosurgery, The First Medical Center, Chinese PLA General Hospital, 28 Fuxing
Road, Haidian District, Beijing 100853, China.
;
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16
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Evaluation Of Cervical Sagittal Parameters On Supine Magnetic Resonance Imaging In Patients With Chiari I Malformation Without Syringomyelia. Neurochirurgie 2022; 68:504-509. [PMID: 35525315 DOI: 10.1016/j.neuchi.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/27/2022] [Accepted: 04/21/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE . The current study aimed to assess the effects of tonsillar herniation on cervical alignment in Chiari I patients without syringomyelia using new cervical sagittal alignment parameters, such as C0-2 Cobb angle, C2-7 cobb angle, T1 slope, and C2-7 sagittal vertical axis (SVA). METHODS Two spinal surgeons independently evaluated midline T2-weighted sagittal magnetic resonance imaging findings of 28 Chiari I patients without syringomyelia and 40 patients without tonsillar herniation but with similar complaints. Thereafter, the measured C0-2 Cobb angle, C2-7 Cobb angle T1 slope, and C2-7 SVA were compared using the t-test. RESULTS Differences in the mean values for C2-7 Cobb angle, T1 slope, and C2-7 SVA were found between Chiari I patients and those without tonsillar herniation Conclusion: The current study showed that Chiari I patients were less lordotic (kyphotic) compared to subjects without tonsillar herniation.
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Sangwanloy P, Vaniyapong T, Norasetthada T, Jetjumnong C. Influence of clivo-axial angle on outcome after foramen magnum decompression in adult symptomatic Chiari type 1 malformation. Clin Neurol Neurosurg 2022; 216:107214. [PMID: 35339104 DOI: 10.1016/j.clineuro.2022.107214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/05/2022] [Accepted: 03/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE A significant number of patients with Chiari type 1 malformation (CM1) have abnormal clivo-axial angle (CXA) without other radiographic indicators of basilar invagination or craniovertebral junction (CVJ) instability. This study aimed to investigate whether abnormal CXA alone influences postoperative outcomes among patients who underwent foramen magnum decompression (FMD). METHODS A total of 44 adult patients with symptomatic CM1 undergoing FMD without CVJ fixation were enrolled. Preoperative clinical characteristics and radiographic measurement include the CXA as well as the radiographic indicators of basilar invagination and instability were recorded. The univariate and multivariate binary logistic regression tests were used to identify the potential prognostic factors for favorable outcomes. RESULTS Eighteen patients (41%) and 26 patients (59%) were divided into unfavorable and favorable outcome groups, respectively. Baseline demographic and imaging characteristics were similar between the two patient groups. The mean CXA was 132.3 ± 15.8 and 145 ± 13.6 degrees in the unfavorable and favorable groups, respectively (P = 0.091). In the favorable outcome group, the proportion of patients with CXA > 135 degrees was significantly higher than that of the unfavorable outcome group (77% vs. 44%; P = 0.05). The CXA > 135 degrees was found to be the only independent predictor associated with favorable outcomes (adjusted risk ratio 2.16; 95% CI 1.01-4.76; P = 0.047). CONCLUSION The preoperative CXA of greater than 135 degrees was identified as a prognostic factor associated with a favorable outcome at one-year follow-up after FMD among adult patients with symptomatic CM1 without basilar invagination or CVJ instability. This factor should be incorporated into preoperative considerations.
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Affiliation(s)
- Prawit Sangwanloy
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Tanat Vaniyapong
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Thunya Norasetthada
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Chumpon Jetjumnong
- Clinical Surgical Research Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand.
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18
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Klekamp J. Relevance of C1/2 facet configurations and clivus-canal-angles for adult patients with Chiari I malformation with and without basilar invagination. World Neurosurg 2022; 162:e156-e167. [PMID: 35247617 DOI: 10.1016/j.wneu.2022.02.110] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE C1/2 facet configurations and clivus-canal angles (CXA) have been proposed as criteria for posterior fusion in Chiari I malformation (CMI). METHODS 340 adults with CMI without basilar invagination (BI), 111 with CMI with BI and 100 age and sex matched controls were studied using sagittal T2-weighted MRI scans analyzing pre- and postoperative values with their impact on progression-free survival rates. RESULTS For CMI without BI, C1/2 facet configurations and CXA were similar to controls (142+11° and 144+10°, respectively) with low rates for posterior C1 displacements (7.1% and 10%, respectively). In CMI with BI, C1 facet displacements were common (54.9%) with lower CXA (120+15°). After foramen magnum decompression (FMD) in CMI without BI (n = 169), 1.8% developed posterior C1 facet displacements without CXA changes and a 97% progression-free survival rate for 10 years. In CMI with BI, patients without ventral compression or instability underwent FMD without fusion (n = 19). 5.3% developed a posterior C1 facet displacement without CXA changes and a 94% progression-free survival rate for 10 years. The remainder of CMI with BI underwent FMD with C1/2 fusion (n = 48). Among these, CXA values increased with 10 year progression-free survival rates of 74% and 93% with and without ventral compression, respectively. CONCLUSION For adult CMI without BI, C1/2 facet configurations and CXA are irrelevant. FMD alone provides excellent long-term outcomes. In CMI with BI, anterior C1 facet displacements indicate C1/2 instability. Posterior fusions can be reserved for patients with ventral compression or C1/2 instability.
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Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Quakenbrück Christian Hospital, Quakenbrück, Germany.
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19
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Tam SKP, Chia J, Brodbelt A, Foroughi M. Assessment of patients with a Chiari malformation type I. BRAIN AND SPINE 2022; 2:100850. [PMID: 36248113 PMCID: PMC9560699 DOI: 10.1016/j.bas.2021.100850] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 11/30/2022]
Abstract
Introduction The prevalence of Chiari malformation type I (CM-I) has been estimated as up to 1% of the general population. The majority of patients are asymptomatic and usually do not need treatment. Symptomatic patients, and some asymptomatic patients with associated conditions, may benefit from further assessment and treatment. Research question The aim of this review was to describe the clinical and radiological assessment of patients presenting with a CM-I. Material and methods A literature search was performed using the PubMed and Embase databases focused on clinical assessment and imaging techniques used to diagnose CM-I. Results Following a complete clinical evaluation in patients with symptomatic CM-I and/or radiologically significant CM-I (tonsillar impaction, resulting tonsillar asymmetry and loss of CSF spaces), MRI of the brain and whole spine enables an assessment of the CM-I and potential associated or causative conditions. These include hydrocephalus, syringomyelia, spinal dysraphism, and tethered cord. Flow and Cine MRI can provide information on CSF dynamics at the craniocervical junction, and help in surgical decision-making. Hypermobility or instability at the upper cervical and craniocervical junction is less common and can be measured with CT imaging and flexion/extension or upright MRI. Discussion and conclusion The majority of CM-I detected are incidental findings on MRI imaging of brain or spine, and do not require intervention. Once a radiological diagnosis and concern has been raised, clinical assessment by an appropriate specialist is required. A MRI brain and cervical spine is indicated in all radiologically labelled CM-I. In symptomatic patients or cases of radiologically significant CM-I, MRI of the brain and entire spine is indicated. Further investigations should be tailored to individuals’ needs. A CM-I assessment should include a history and examination and a referral to a specialist. MRI of the brain and spine enables an assessment of the CM-I and potential associated conditions. Flow and Cine MRI can help in surgical decision-making.
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Affiliation(s)
- Sharon Ka Po Tam
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
- Corresponding author.
| | - Jonathan Chia
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
| | | | - Mansoor Foroughi
- Royal Sussex County Hospital, Brighton and Sussex University Hospitals NHS Trust, UK
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20
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Mantha S, Coulthard LG, Campbell R. CSF-space volumetric change following posterior fossa decompression in paediatric Chiari type-I malformation: a correlation with outcome. Childs Nerv Syst 2021; 37:3861-3869. [PMID: 34390378 DOI: 10.1007/s00381-021-05307-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We have previously reported inferior post-operative clinical outcomes in younger children with Chiari type-I malformation (CIM). We sought to quantify the CSF volumetric changes pre- and post-decompression, in a paediatric cohort, to determine whether cisternal volume change is associated with clinical outcomes. METHODS In this retrospective clinical study, the CSF spaces of the posterior fossa (supracerebellar/quadrigeminal, prepontine, fourth ventricle, cisterna magna) were measured on magnetic resonance images pre- and post-operatively using a semi-automated method. Additionally, we describe a novel CSF space of the upper cervical canal incorporating the subarachnoid space from the foramen magnum to the inferior cortex of the C2 body, FM-C2 cistern. Morphometric measurements included the pB-C2 distance, clivoaxial angle, clival length, clival angle and Boogard's angle. Volumetric and morphometric data were correlated with clinical outcomes at 4-12 months post-operatively as measured by the Chicago Chiari Outcome Scale (CCOS). RESULTS Of 59 adequate clinical cases, 57 and 36 patients had acceptable imaging for morphometric and volumetric analysis respectively. All CSF spaces measured had a significant increase in volume post-operatively (p < 0.05). There was no correlation between the change in volume or post-operative CSF volumes and CCOS. The pre-operative volume of the FM-C2 was positively correlated with total CCOS (Wald [Formula: see text], [Formula: see text]) and was significantly smaller in the 0-6-year age group (2.38 ± 1.27 ml vs. 3.67 ± 1.56 ml, p = 0.014). No morphometric measurement changed significantly after surgery or demonstrated a relationship with CCOS. CONCLUSIONS Volumetric changes in the CSF cisterns of the posterior cranial fossa and upper cervical canal do not correlate with the age-related differences in clinical outcomes in paediatric CIM. The pre-operative volume of the FM-C2 cistern may have a role in predicting the likelihood of a beneficial post-operative outcome in paediatric CIM.
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Affiliation(s)
- Sidharth Mantha
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia. .,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia.
| | - Liam G Coulthard
- Kenneth G Jamieson Department of Neurosurgery, Royal Brisbane and Women's Hospital, Herston, QLD, 4029, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Robert Campbell
- School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia.,Department of Neurosurgery, Queensland Children's Hospital, South Brisbane, QLD, 4101, Australia.,Brisbane Clinical Neuroscience Centre, Mater Hospital, South Brisbane, QLD, 4101, Australia
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Chae JK, Marianayagam NJ, Hussain I, Cruz A, Baaj AA, Härtl R, Greenfield JP. Predicting clinical outcomes using morphometric changes in adults with complex Chiari malformation undergoing occipitocervical fusion with or without ventral decompression: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 2:CASE21364. [PMID: 36059719 PMCID: PMC9435543 DOI: 10.3171/case21364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The authors assessed the connection between clinical outcomes and morphometrics in patients with complex Chiari malformation (CM) who have undergone posterior fossa decompression (PFD) and subsequent occipitocervical fusion (OCF) with or without ventral decompression (VD). OBSERVATIONS The authors retrospectively reviewed 33 patients with CM aged over 21 years who underwent PFD and OCF with or without endoscopic endonasal odontoidectomy at the authors’ institution (21 OCF only and 12 OCF + VD). Clivoaxial angle (CXA), pB-C2 (perpendicular line to the line between the basion and C2), atlantodental interval (ADI), basion-dens interval (BDI), basion-axial interval (BAI), and C1 canal diameter were measured on preoperative and approximately 3-month postoperative computed tomography or magnetic resonance imaging scans. Common symptoms included headache, paresthesia, and bulbar symptoms. Clinical improvement after surgery was observed in 78.8% of patients. CXA, ADI, and BDI all significantly increased after surgery, whereas pB-C2 and BAI significantly decreased. OCF + VD had a significantly more acute CXA and longer pB-C2 preoperatively than OCF only. Patients who clinically improved postoperatively showed the same significant morphometric changes, but those who did not improve showed no significant morphometric changes. LESSONS Patients showing improvement had greater corrections in skull base morphometrics than those who did not. Although there are various mutually nonexclusive reasons why certain patients do not improve after surgery, smaller degrees of morphometric correction could play a role.
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Affiliation(s)
- John K. Chae
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Neelan J. Marianayagam
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Amanda Cruz
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Ali A. Baaj
- Department of Neurosurgery, University of Arizona College of Medicine, Phoenix, Arizona
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
| | - Jeffrey P. Greenfield
- Department of Neurological Surgery, Weill Cornell Medicine/NewYork-Presbyterian Hospital, New York, New York; and
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22
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Chu EC, Zoubi FA, Yang J. Cervicogenic Dizziness Associated With Craniocervical Instability: A Case Report. J Med Cases 2021; 12:451-454. [PMID: 34804305 PMCID: PMC8577610 DOI: 10.14740/jmc3792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/13/2021] [Indexed: 12/03/2022] Open
Abstract
Cervicogenic dizziness (CGD) is a clinical syndrome characterized by an illusory sensation of motion and disequilibrium secondary to neck pathologies. Reported here is the case of a 40-year-old male presented with neck pain, dizziness, and aural symptoms in the past 12 months. The patient was previously diagnosed with Meniere’s disease and treated with a low-sodium diet, betahistine and vestibular rehabilitation for 4 months, but the symptoms had not been relieved. Subsequently he sought out chiropractic evaluation. Radiographic clues illustrated a subtle anterolisthesis of the occiput on the cervical spine, manifested by a dissociation of the clivo-axial angle (CXA). After exclusion of other neurological, vascular and vestibular causes, craniocervical instability was considered as the cause of the CGD. He was treated with multi-component intervention consisting of spinal manipulation, intermittent motorized traction and ultrasound therapy to release cervical complaints. The patient reported salutary consequences to the 3-month treatment course with no neurologic sequelae. The current study serves as a vivid example of identifying CGD based on a subtle radiographic clue and by utilizing CXA as an assessment tool for craniocervical instability.
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Affiliation(s)
- Eric ChunPu Chu
- New York Chiropractic and Physiotherapy Centre, 41/F Langham Place Office Tower, 8 Argyle Street, Hong Kong, China
| | - Fadi Al Zoubi
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong, China
| | - Jian Yang
- LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021; 88:332-341. [PMID: 33313928 DOI: 10.1093/neuros/nyaa460] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology. OBJECTIVE To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD. METHODS The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD. RESULTS All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups. CONCLUSION Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Gabrielle W Johnson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Raheel Ahmed
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Phillipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - Lissa Baird
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - David F Bauer
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karin S Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Robert C Dauser
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Susan R Durham
- Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Timothy M George
- Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Patrick C Graupman
- Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Naina L Gross
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gabe Haller
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Gregory G Heuer
- Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Jea
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James M Johnston
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nickalus Khan
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Mark D Krieger
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Jeffrey R Leonard
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Timothy B Mapstone
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - J Gordon McComb
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael Muhlbauer
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - W Jerry Oakes
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Greg Olavarria
- Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Ragheb
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis Shannon
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Joshua S Shimony
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jodi Smith
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mandeep S Tamber
- Department of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - James C Torner
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Scott D Wait
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Spiessberger A, Dietz N, Gruter B, Virojanapa J. Ehlers-Danlos syndrome-associated craniocervical instability with cervicomedullary syndrome: Comparing outcome of craniocervical fusion with occipital bone versus occipital condyle fixation. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 11:287-292. [PMID: 33824558 PMCID: PMC8019109 DOI: 10.4103/jcvjs.jcvjs_166_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 10/11/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction: Ehlers–Danlos syndrome (EDS) predisposes to craniocervical instability (CCI) with resulting cranial settling and cervicomedullary syndrome due to ligamentous laxity. This study investigates possible differences in radiographic outcomes and operative complication rate between two surgical techniques in patients with EDS and CCI undergoing craniocervical fusion (CCF): occipital bone (OB) versus occipital condyle (OC) fixation. Methods: A retrospective search of the institutional operative database between January 07, 2017, and December 31, 2019, was conducted to identify EDS patients who underwent CCF with either OB (Group OB) or OC (Group OC) fixation. For each patient, pre- and post-operative radiographic measurements and operative complications were extracted and compared between groups (OB vs. OC): pB-C2, clivoaxial angle (CXA), tonsillar descent, C2C7 sagittal Cobb angle, C2 long axis, and operative complications. Results: Of a total of 26 patients, 13 underwent OV and 13 underwent OC fixation. Eighty-five percent of the patients underwent OC underwent fusion from occiput to C2, while the remaining 15% fusion from occiput to C3. Radiographic outcome in the OC versus OB group was preoperative measurements were similar between OC and OB group: pB-C2 8.8 mm (1.5, 6–11) versus 8.3 mm (1.7, 4–9.6), P = 0.43; CXA 128.2° (5.4, 122–136) versus 131.9° (6.8,122–141), P = 0.41; tonsillar descent 6.2 mm (4.8, 0–15) versus 2.9 mm (3.4, 0–8), P = 0.05; C2 long axis 75.2° (6.7, 58–85) versus 67.2° (21.4, 1–80), P = 0.21; postoperative change of CXA + 14.4° (8.8, 0–30) versus 16.2° (12.4, −4–38), P = 0.43; change of pB-C2 − 2.6 mm (1.8, −-5.3 to 0) versus − 1.2 mm (4, −4.6–8), P = 0.26; and postoperative C2C7 sagittal Cobb angle − 2.6° (19.5, −43–39) versus − 2.6° (11.4, −21–12). Operative complications were seen in 1 out of 13 patients (8%) versus 2 out of 13 patients (16%), P = 1. Conclusions: In EDS, patients with CCI undergoing CCF radiographic and clinical outcome were similar between those with OC versus OB fixation. Both techniques resulted in sufficient correction of pB-C2 and CXA measurements with a low complication rate.
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Affiliation(s)
- Alexander Spiessberger
- Department of Neurosurgery, Hofstra School of Medicine, North Shore University Hospital, Manhasset, NY, USA
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Basil Gruter
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Justin Virojanapa
- Department of Neurosurgery, Hofstra School of Medicine, North Shore University Hospital, Manhasset, NY, USA
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25
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Sayah A, Farley AD, Munoz EC, Sandhu FA, Berkowitz F. Normal range of clivoaxial angle in adults using flexion and extension cervical magnetic resonance imaging scans. Neuroradiol J 2021; 34:348-354. [PMID: 33678065 DOI: 10.1177/1971400921998982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE An abnormally decreased clivoaxial angle (CXA) is used during the clinical evaluation for corrective skull base surgery. Published normal ranges of CXA using x-ray, computed tomography, or magnetic resonance imaging (MRI) vary dramatically, especially with neck flexion or extension. The aim of this study was to use high-resolution MRI to determine the normal range of CXA in various neck positions using a reproducible measurement technique. METHODS The CXA was measured in 10 healthy volunteers on sagittal T2 SPACE c-spine MRI in supine and prone positions and with the neck both neck and extended. CXA is strictly defined as the angle between a line along the inferior third of the dorsal clival cortex and a line from the superior/posterior cortex of the dens to the posterior/inferior corner of the C2 body. Statistical analysis was performed in all positions and included mean CXA, range, standard deviation (SD), inter-reader agreement, and group comparisons. RESULTS The mean CXA overall was 156.92° (SD=4.23°; range 134-179°). The mean value for extension CXA was 169.20° (SD=5.81°), and the mean value for flexion CXA was 144.73° (SD=5.71°), the difference being statistically significant (p<0.0001) regardless of supine or prone position. Concordant correlations of reader measurements showed substantial agreement in the supine position at 0.96, with lower agreement in the prone position at 0.87. CONCLUSIONS We report normal ranges for CXA in various neck positions based on 3D T2-weighted MRI, using a reproducible measurement method. There was a significant difference in the CXA values between neck extended and neck flexed positions but not between supine and prone positions.
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Affiliation(s)
- Anousheh Sayah
- Division of Neuroradiology, Department of Radiology, Medstar Georgetown University Hospital, USA
| | - April D Farley
- Division of Neuroradiology, Department of Radiology, Medstar Washington Hospital Center, USA
| | | | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, USA
| | - Frank Berkowitz
- Division of Neuroradiology, Department of Radiology, Medstar Georgetown University Hospital, USA
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26
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Talamonti G, Ferrari E, D’Aliberti G. Chiari malformation type 1: are we doing less with more? Illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20145. [PMID: 36045936 PMCID: PMC9394174 DOI: 10.3171/case20145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/28/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Classic treatment of Chiari malformation type 1 consists of foramen magnum decompression. Selected patients may require occipitocervical fixation, transoral odontoidectomy, tonsillectomy, and so forth. Treatment standardization does not yet exist, and some patients risk being overtreated. OBSERVATIONS A 20-year-old man with headache and Chiari malformation type 1 underwent extradural bone decompression. One year later, he was managed with the extradural section of his filum terminale. Eighteen months later, the patient underwent monitoring of intracranial pressure, occipitocervical stabilization, transoral odontoidectomy, minimally invasive subpial tonsillectomy, and occipital cranioplasty. His headache never changed, and he progressively developed hemiparesis and swallowing and respiratory disturbances. Two years later, a new magnetic resonance imaging scan showed extended syringomyelia with scarce peritonsillar subarachnoid space. The umpteenth operation consisted of the removal of a constricting epidural scar, arachnoid dissection, total tonsillectomy, creation of a wide subarachnoid space, and dural sac augmentation. The patient’s initial postoperative course was smooth, and his headache improved. However, 8 days after surgery, the patient acutely presented with vegetative disturbances and died because of malignant brainstem edema of unknown origin. LESSONS The story of this patient is not so uncommon. He underwent all the possible surgical treatments rather than a timely adequate osteodural decompression. Probably, he received less with more.
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Affiliation(s)
- Giuseppe Talamonti
- Department of Neurosurgery, Territorial Health and Social Services Authority Niguarda, Milan, Italy
| | - Erika Ferrari
- Department of Neurosurgery, Territorial Health and Social Services Authority Niguarda, Milan, Italy
| | - Giuseppe D’Aliberti
- Department of Neurosurgery, Territorial Health and Social Services Authority Niguarda, Milan, Italy
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Henderson FC, Rowe PC, Narayanan M, Rosenbaum R, Koby M, Tuchmann K, Francomano CA. Refractory Syncope and Presyncope Associated with Atlantoaxial Instability: Preliminary Evidence of Improvement Following Surgical Stabilization. World Neurosurg 2021; 149:e854-e865. [PMID: 33540088 DOI: 10.1016/j.wneu.2021.01.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND The proclivity to atlantoaxial instability (AAI) has been widely reported for conditions such as rheumatoid arthritis and Down syndrome. Similarly, we have found a higher than expected incidence of AAI in hereditary connective tissue disorders. We demonstrate a strong association of AAI with manifestations of dysautonomia, in particular syncope and lightheadedness, and make preliminary observations as to the salutary effect of surgical stabilization of the atlantoaxial motion segment. METHODS In an institutional review board-approved retrospective study, 20 subjects (16 women, 4 men) with hereditary connective tissue disorders had AAI diagnosed by computed tomography. Subjects underwent realignment (reduction), stabilization, and fusion of the C1-C2 motion segment. All subjects completed preoperative and postoperative questionnaires in which they were asked about performance, function, and autonomic symptoms, including lightheadedness, presyncope, and syncope. RESULTS All patients with AAI reported lightheadedness, and 15 had refractory syncope or presyncope despite maximal medical management and physical therapy. Postoperatively, subjects reported a statistically significant improvement in lightheadedness (P = 0.003), presyncope (P = 0.006), and syncope (P = 0.03), and in the frequency (P < 0.05) of other symptoms related to autonomic function, such as nausea, exercise intolerance, palpitations, tremors, heat intolerance, gastroesophageal reflux, and sleep apnea. CONCLUSIONS This study draws attention to the potential for AAI to present with syncope or presyncope that is refractory to medical management, and for surgical stabilization of AAI to lead to improvement of these and other autonomic symptoms.
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Affiliation(s)
- Fraser C Henderson
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA.
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Malini Narayanan
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA
| | - Robert Rosenbaum
- Department Neurosurgery, University of Maryland Capital Region Health Center, Cheverly, Maryland, USA; Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA; Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA; Department of Neurosurgery, Walter Reed-Bethesda National Military Medical Center, Bethesda, Maryland, USA
| | - Myles Koby
- Departments of Neurosurgery and Radiology, Doctors Community Hospital, Lanham, Maryland, USA
| | - Kelly Tuchmann
- Metropolitan Neurosurgery Group LLC, Silver Spring, Maryland, USA
| | - Clair A Francomano
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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28
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Silva ATPDB, Silva LTPDB, Vieira AENR, de Melo CIE, do Nascimento JJC, de Mello Júnior CF, Vasconcelos SC, de Araújo-Neto SA. Craniometric parameters for the evaluation of platybasia and basilar invagination on magnetic resonance imaging: a reproducibility study. Radiol Bras 2020; 53:314-319. [PMID: 33071375 PMCID: PMC7545739 DOI: 10.1590/0100-3984.2019.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective The present study aims to perform a reproducibility study of the clivus-canal angle (CCA), Welcker’s basal angle (WBA), and the distance from the odontoid process to Chamberlain’s line (DOCL) on magnetic resonance imaging (MRI). Materials and Methods Two medical students and two radiologists respectively evaluated 100 and 50 consecutive MRI scans of adult skulls, selected randomly. Each examiner, working independently and blinded to the previous results, performed readings for each patient on two different occasions. Measurements were performed in T1-weighted sequences acquired in the midsagittal plane. The levels of intraobserver reproducibility and interobserver agreement were evaluated by calculating the intraclass correlation coefficients (ICCs) and the corresponding 95% confidence intervals. Results The mean values obtained by the examiners were 150º for the CCA, 130º for the WBA, and 2.5 mm for the DOCL. The ICC for interobserver agreement was 0.980, 0.935, and 0.967, for the CCA, WBA, and DOCL, respectively, for the students, compared with 0.977, 0.941, and 0.982, respectively, for the radiologists, and 0.980, 0.992, and 0.990, respectively, for all of the examiners together. In the analysis of intraobserver agreement, the ICC ranged from 0.929 to 0.959 for the CCA, from 0.918 to 0.964 for the WBA, and from 0.918 to 0.981 for the DOCL. Conclusion The measurement of the CCA, WBA, and DOCL appears to show excellent intraobserver reproducibility and interobserver agreement on MRI.
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29
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Bragée B, Michos A, Drum B, Fahlgren M, Szulkin R, Bertilson BC. Signs of Intracranial Hypertension, Hypermobility, and Craniocervical Obstructions in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Neurol 2020; 11:828. [PMID: 32982905 PMCID: PMC7485557 DOI: 10.3389/fneur.2020.00828] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/02/2020] [Indexed: 12/24/2022] Open
Abstract
The pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is unknown. In this study, we test the hypothesis that hypermobility, signs of intracranial hypertension (IH), and craniocervical obstructions may be overrepresented in patients with ME/CFS and thereby explain many of the symptoms. Our study is a retrospective, cross-sectional study, performed at a specialist clinic for referred patients with severe ME/CFS as defined by the Canada Consensus Criteria. The first 272 patients with ME/CFS were invited to participate, and 229 who provided prompt informed consent were included. Hypermobility was assessed using the Beighton Score. IH was assessed indirectly by the quotient of the optic nerve sheet diameter (ONSD)/eyeball transverse diameter on both sides as measured on magnetic resonance imaging (MRI) of the brain. We also included assessment of cerebellar tonsil position in relation to the McRae line, indicating foramen magnum. Craniocervical obstructions were assessed on MRI of the cervical spine. Allodynia was assessed by quantitative sensory testing (QST) for pain in the 18 areas indicative of fibromyalgia syndrome (FMS). A total of 190 women, mean age 45 years, and 39 males, mean age 44 years, were included. Hypermobility was identified in 115 (50%) participants. MRI of the brain was performed on 205 participants of whom 112 (55%) had an increased ONSD and 171 (83%) had signs of possible IH, including 65 (32%) who had values indicating more severe states of IH. Cerebellar tonsils protruding under the McRae line into the foramen magnum were identified in 115 (56%) of the participants. MRI of the cervical spine was performed on 125 participants of whom 100 (80%) had craniocervical obstructions. Pain at harmless pressure, allodynia, was found in 96% of the participants, and FMS was present in 173 participants or 76%. Compared to a general population, we found a large overrepresentation of hypermobility, signs of IH, and craniocervical obstructions. Our hypothesis was strengthened for future studies on the possible relation between ME/CFS symptoms and hypermobility, IH, and craniocervical obstructions in a portion of patients with ME/CFS. If our findings are confirmed, new diagnostic and therapeutic approaches to this widespread neurological syndrome should be considered.
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Affiliation(s)
- Björn Bragée
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden
| | | | - Brandon Drum
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden
| | - Mikael Fahlgren
- ME-center, Bragée Clinics, Stockholm, Sweden.,Academic Primary Health Care Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Robert Szulkin
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden
| | - Bo C Bertilson
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Solna, Sweden.,ME-center, Bragée Clinics, Stockholm, Sweden.,Academic Primary Health Care Center, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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30
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Tanrisever S, Orhan M, Bahşi İ, Yalçin ED. Anatomical evaluation of the craniovertebral junction on cone-beam computed tomography images. Surg Radiol Anat 2020; 42:797-815. [PMID: 32221664 DOI: 10.1007/s00276-020-02457-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 03/10/2020] [Indexed: 01/16/2023]
Abstract
INTRODUCTION There are many craniometric measurements that are used in evaluating craniovertebral junction (CVJ) pathologies such as basilar invagination, atlantoaxial dislocation and platybasia. Therefore, it is important to determine the normal reference range of the craniometric measurements. This study aims to determine the morphometric reference values of the bony structures in the CVJ from cone-beam computed tomography (CBCT) images of a group of South Eastern Anatolian population. MATERIALS AND METHODS The CBCT images of 300 individuals were retrospectively evaluated. 14 parameters on midsagittal and 2 parameters on the coronal plane were studied. The data were statistically evaluated. RESULTS Measurement results were found as follows; the distances between odontoid process (OP) and McGregor line as 0.31 ± 3.22 mm, OP and Chamberlain line 1.06 ± 3.22 mm, OP and McRae line 5.30 ± 1.59 mm, OP and Fischgold digastric line 8.70 ± 4.12 mm, OP and Fischgold bimastoid line - 5.15 ± 4.86 mm, length of McRae line 35.58 ± 2.52 mm, atlantodental interval 1.28 ± 0.48 mm, posterior atlantodental interval 19.54 ± 2.24 mm, basion axial interval 4.01 ± 1.83 mm, basion dental interval 4.92 ± 1.77 mm, length of Modified Ranawat line 28.66 ± 2.38 mm, length of Redlund-Johnell line 35.11 ± 4.09 mm, clivus canal angle 157.62° ± 11.85°, Welcher basal angle 130.83° ± 6.29°, craniocervical tilt 126.98° ± 12.24° and Powers ratio as 0.72 ± 0.06. CONCLUSION In this study, the morphometric values were evaluated according to age and gender in individuals who did not have any radiologic anomalies. The normal reference ranges may be useful for researchers who are researching pathology in this region. It is recommended to conduct further studies with different populations to determine the normal reference range.
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Affiliation(s)
- Sefkan Tanrisever
- Department of Anatomy, Faculty of Medicine, Gaziantep University, 27310, Gaziantep, Turkey
| | - Mustafa Orhan
- Department of Anatomy, Faculty of Medicine, Gaziantep University, 27310, Gaziantep, Turkey
| | - İlhan Bahşi
- Department of Anatomy, Faculty of Medicine, Gaziantep University, 27310, Gaziantep, Turkey.
| | - Eda Didem Yalçin
- Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Gaziantep University, Gaziantep, Turkey
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Henderson F, Rosenbaum R, Narayanan M, Mackall J, Koby M. Optimizing Alignment Parameters During Craniocervical Stabilization and Fusion: A Technical Note. Cureus 2020; 12:e7160. [PMID: 32257703 PMCID: PMC7112711 DOI: 10.7759/cureus.7160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Proper craniocervical alignment during craniocervical reduction, stabilization, and fusion optimizes cerebrospinal fluid (CSF) flow through the foramen magnum, establishes the appropriate “gaze angle”, avoids dysphagia and dyspnea, and, most importantly, normalizes the clival-axial angle (CXA) to reduce ventral brainstem compression. To illustrate the metrics of reduction that include CXA, posterior occipital cervical angle, orbital-axial or “gaze angle”, and mandible-axial angle, we present a video illustration of a patient presenting with signs and symptoms of the cervical medullary syndrome along with concordant radiographic findings of craniocervical instability as identified on dynamic imaging and through assessment of the CXA, Harris, and Grabb-Oakes measurements.
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Affiliation(s)
- Fraser Henderson
- Neurological Surgery, University of Maryland Prince George's Hospital Center, Largo, USA.,Neurological Surgery, Doctors Community Hospital, Lanham, USA
| | - Robert Rosenbaum
- Neurological Surgery, The Metropolitan Neurosurgery Group, Silver Spring, USA
| | - Malini Narayanan
- Neurological Surgery, University of Maryland Prince George's Hospital Center, Cheverley, USA
| | - John Mackall
- Neurological Surgery, D&K Medical, LLC., Lanham, USA
| | - Myles Koby
- Radiology, Doctors Community Hospital, Lanham, USA
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Huang CWC, Chang YM, Brook A, Bezuidenhout AF, Bhadelia RA. Clinical utility of 2-D anatomic measurements in predicting cough-associated headache in Chiari I malformation. Neuroradiology 2020; 62:593-599. [PMID: 31996967 DOI: 10.1007/s00234-019-02356-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 12/27/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Cough-associated headache (CAH) is the most distinctive symptom of patients with Chiari I malformation (CMI) and indicates clinically significant disease. We determined the clinical utility of simple 2D anatomic measurements performed on a PACS workstation by assessing their diagnostic accuracy in predicting CAH in CMI patients. METHODS Seventy-two consecutive CMI patients (cerebellar tonsillar herniation > 5 mm) with headache seen by neurosurgeons over 6 years were included. Sagittal T1 images were used by two readers to measure: extent of tonsillar herniation, lengths of the clivus and supra-occiput, McRae and pB-C2 lines, as well as clivus-canal, odontoid retroversion, and skull base angles. Neurosurgery notes were reviewed to determine presence of CAH. Mann-Whitney test was used to compare measurements between patients with and without CAH. Predictive accuracy was assessed by receiver operating characteristic (ROC) curve. RESULTS 47/72 (65.3%) CMI patients reported CAH. Tonsillar herniation with CAH (10.2 mm, 7-14 mm; median, interquartile range) was significantly greater than those without CAH (7.9 mm, 6.3-10.9 mm; p = 0.02). Tonsillar herniation ≥ 10 mm showed sensitivity and specificity of 51% and 68%, and tonsillar herniation > 14 mm showed sensitivity and specificity of 30% and 100%, respectively, for predicting CAH. Other 2D measurements showed no statistically significant differences. CONCLUSIONS Among the 2D measurements used, only the extent of tonsillar herniation is different between CMI patients with and without CAH. Although CMI is diagnosed with tonsillar herniation of only 5 mm, we found that a much higher extent of herniation is needed to be predictive of CAH.
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Affiliation(s)
- Chi Wen C Huang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,Department of Radiology, Wan Fang Hospital, Taipei Medical University, No. 250, Wuxing Street, Xinyi District, Taipei City, Taiwan, 110
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A Fourie Bezuidenhout
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. .,Department of Radiology, Beth Israel Deaconess Medical Center, WCB90, 330 Brookline Ave, Boston, MA, 02215, USA.
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Hussain I, Winston GM, Goldberg J, Curri C, Williams N, Chazen JL, Greenfield JP, Baaj AA. Impact of imaging modality, age, and gender on craniocervical junction angles in adults without structural pathology. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2020; 10:240-246. [PMID: 32089618 PMCID: PMC7008666 DOI: 10.4103/jcvjs.jcvjs_125_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/11/2020] [Indexed: 11/12/2022] Open
Abstract
Context: Multiple angles of the craniocervical junction (CCJ) are associated with pathological conditions and surgical outcomes, including the clivo-axial angle (CXA), clival slope (CS), and sagittal axis (XS). However, there are varying normative ranges reported and a paucity of data analyzing the effects of imaging modality, age, and gender on these angles. Setting and Design: A retrospective review of computed tomographic (CT) and magnetic resonance imaging (MRI) scans in fifty adults without CCJ pathology from 2014 to 2019. Methods: Age, gender, indication, and hours between scans were recorded. Two-blinded observers measured all angles. Analysis between angles from the same patient was performed using the Wilcoxon signed-rank test. Multivariable linear regression was used to test for associations between average angles and age or gender. Results: Average age and time between scans were 41.3 and 14.3 h, respectively, with 94% performed due to trauma. On CT, average CXA, CS, and XS were 162.1°, 118.4°, and 81.3°, respectively. On MRI, they were 159.8°, 117.2°, 85.3°, respectively. There were statistically significant differences between CXA and XS (P < 0.01) based on imaging modality. On CT, there was a significant increase in XS by 1.93°° and decrease in CS by 1.88°° and on MRI, there was a significant increase in CXA by 1.93°° and decrease in CS by 2.75°° corresponding with a 10-year advancement of age. Gender did not have an effect. Conclusion: There are significant differences in angular measurements of the CCJ between CT and MRI from the same patient, as well as changes in normative values based on age.
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Affiliation(s)
- Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Graham M Winston
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jacob Goldberg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Cloe Curri
- Department of Paediatric Surgery and Transplant, Orthopaedic Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Nicholas Williams
- Department of Healthcare Policy and Research, Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - J Levi Chazen
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
| | - Ali A Baaj
- Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York Presbyterian Hospital, New York, NY, USA
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Henderson FC, Francomano CA, Koby M, Tuchman K, Adcock J, Patel S. Cervical medullary syndrome secondary to craniocervical instability and ventral brainstem compression in hereditary hypermobility connective tissue disorders: 5-year follow-up after craniocervical reduction, fusion, and stabilization. Neurosurg Rev 2019; 42:915-936. [PMID: 30627832 PMCID: PMC6821667 DOI: 10.1007/s10143-018-01070-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 02/07/2023]
Abstract
A great deal of literature has drawn attention to the "complex Chiari," wherein the presence of instability or ventral brainstem compression prompts consideration for addressing both concerns at the time of surgery. This report addresses the clinical and radiological features and surgical outcomes in a consecutive series of subjects with hereditary connective tissue disorders (HCTD) and Chiari malformation. In 2011 and 2012, 22 consecutive patients with cervical medullary syndrome and geneticist-confirmed hereditary connective tissue disorder (HCTD), with Chiari malformation (type 1 or 0) and kyphotic clivo-axial angle (CXA) enrolled in the IRB-approved study (IRB# 10-036-06: GBMC). Two subjects were excluded on the basis of previous cranio-spinal fusion or unrelated medical issues. Symptoms, patient satisfaction, and work status were assessed by a third-party questionnaire, pain by visual analog scale (0-10/10), neurologic exams by neurosurgeon, function by Karnofsky performance scale (KPS). Pre- and post-operative radiological measurements of clivo-axial angle (CXA), the Grabb-Mapstone-Oakes measurement, and Harris measurements were made independently by neuroradiologist, with pre- and post-operative imaging (MRI and CT), 10/20 with weight-bearing, flexion, and extension MRI. All subjects underwent open reduction, stabilization occiput to C2, and fusion with rib autograft. There was 100% follow-up (20/20) at 2 and 5 years. Patients were satisfied with the surgery and would do it again given the same circumstances (100%). Statistically significant improvement was seen with headache (8.2/10 pre-op to 4.5/10 post-op, p < 0.001, vertigo (92%), imbalance (82%), dysarthria (80%), dizziness (70%), memory problems (69%), walking problems (69%), function (KPS) (p < 0.001). Neurological deficits improved in all subjects. The CXA average improved from 127° to 148° (p < 0.001). The Grabb-Oakes and Harris measurements returned to normal. Fusion occurred in 100%. There were no significant differences between the 2- and 5-year period. Two patients returned to surgery for a superficial wound infections, and two required transfusion. All patients who had rib harvests had pain related that procedure (3/10), which abated by 5 years. The results support the literature, that open reduction of the kyphotic CXA to lessen ventral brainstem deformity, and fusion/stabilization to restore stability in patients with HCTD is feasible, associated with a low surgical morbidity, and results in enduring improvement in pain and function. Rib harvest resulted in pain for several years in almost all subjects.
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Affiliation(s)
- Fraser C Henderson
- Doctor's Community Hospital, Lanham, MD, USA.
- The Metropolitan Neurosurgery Group, LLC, Silver Spring, MD, USA.
| | | | - M Koby
- Doctor's Community Hospital, Lanham, MD, USA
| | - K Tuchman
- The Metropolitan Neurosurgery Group, LLC, Silver Spring, MD, USA
| | - J Adcock
- Harvey Institute of Human Genetics, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - S Patel
- Medical University of South Carolina, Charleston, SC, USA
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Determination of Normal Values of the Basal Angle in the Era of Magnetic Resonance Imaging. World Neurosurg 2019; 132:363-367. [DOI: 10.1016/j.wneu.2019.09.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 09/09/2019] [Accepted: 09/10/2019] [Indexed: 11/17/2022]
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Abstract
STUDY DESIGN A mechanism-based reasoning and retrospective cohort study. OBJECTIVE To establish a quantitative relationship between the change of clivo-axial angle (CXA) and the change of subaxial cervical lordosis (CL) in correction surgery of atlantoaxial dislocation (AAD). SUMMARY OF BACKGROUND DATA The evolving understanding of mechanism has dramatically improved the treatment modality of AAD. Cervical sagittal alignment is another important aspect of the surgery, in addition to reduction of odontoid process. However, a quantitative reference for correction surgery has not been established. METHODS Frankfort-axial angle (FXA) was introduced. Based on two assumptions, (1) sagittal alignment of the spine aims at keeping horizontal gaze and (2) deformities at craniovertebral junction make little impact on slope of T1 vertebra, we deduced that the change of CXA equaled change of CL (ΔCXA = -ΔCL). We retrospectively reviewed our case cohort to validate this finding with linear regression analysis. RESULTS Sixteen cases (eight male and eight female, mean age 40.4±12.5 yr old) were included. Liner fitting equation for ΔFXA and ΔCXA is y=1.005x (coefficient of determination, R=0.966; significance of the estimated coefficients P<0.001, t-statistics) and that for ΔCL and ΔCXA is y=-1.023x (R=0.976, P<0.001). These results support our deduction that ΔCXA = -ΔCL, which can be used as a guidance of quantitative correction of sagittal deformity in AAD. CONCLUSION Correction of CXA will influence the subaxial cervical lordosis (ΔCXA = -ΔCL) of AAD patients. This equation can serve as a quantitative reference for preoperative planning and intraoperative refining of the correction of cervical sagittal deformity in AAD. LEVEL OF EVIDENCE 4.
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He Y, Zheng T, Wu B, Wang J. Significance of Modified Clivoaxial Angles in the Treatment of Adult Chiari Malformation Type I. World Neurosurg 2019; 130:e1004-e1014. [PMID: 31306845 DOI: 10.1016/j.wneu.2019.07.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/05/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the influence of modified clivoaxial angle (MCAA) on the surgical planning and outcome in adult patients with Chiari malformation type I. METHODS Clinical data of 268 adult patients undergoing posterior fossa decompression without (PFD) or with duraplasty (PFDD) or with resection of tonsils (RT) for Chiari malformation type I over 10 years were reviewed retrospectively, with outcome evaluated by Chicago Chiari Outcome Scale (CCOS) score. By means of receiver operating characteristic curve, the threshold of MCAA was calculated to stratify the patients. RESULTS MCAA was positively correlated with CCOS score. In the MCAA ≤ 127° group (n = 57) with severe ventral cervicomedullary compression (VCMC), CCOS score of PFD, PFDD, and RT was 11.00, 11.06, and 12.42 (P < 0.05), respectively. In the 127° < MCAA ≤ 138° group (n = 87) with moderate VCMC, CCOS score of PFD, PFDD, and RT was 11.71, 12.72, and 13.00 (P < 0.01), respectively. In the MCAA > 138° group (n = 124) with mild or no VCMC, CCOS score of PFD, PFDD, and RT was 13.19, 13.90, and 13.67 (P < 0.05), respectively. The mean MCAA increased by 4.4° postoperatively (P < 0.05), which was positively associated with syringomyelia shrinkage. CONCLUSIONS MCAA may play a role in guiding the surgical treatment and predicting the prognosis in adult CMI patients. The larger the MCAA, the less invasive surgery is preferred with higher CCOS. PFDD should be the first choice in patients with mild or no VCMC (MCAA >138°) and RT in patients with moderate VCMC (127° < MCAA ≤ 138°). For patients with severe VCMC (MCAA ≤ 127°), RT could be considered as the primary surgery with awareness of the possible insufficiency of posterior decompression alone.
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Affiliation(s)
- Yunsen He
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Tao Zheng
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China
| | - Bo Wu
- Department of Neurosurgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, People's Republic of China.
| | - Jiyang Wang
- Department of Neurosurgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, People's Republic of China
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Ma L, Guo L, Li X, Qin J, He W, Xiao X, Lu L, Xu Y, Wu Y. Clivopalate angle: a new diagnostic method for basilar invagination at magnetic resonance imaging. Eur Radiol 2019; 29:3450-3457. [PMID: 30820721 PMCID: PMC6554245 DOI: 10.1007/s00330-018-5972-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/15/2018] [Accepted: 12/14/2018] [Indexed: 11/25/2022]
Abstract
Objectives To investigate the diagnostic value of clivopalate angle (CPA) for basilar invagination (BI) at magnetic resonance imaging (MRI). Methods In this retrospective case-control study, CPA, clivodens angle (CDA), and clivoaxial angle (CXA) were measured on midsagittal MR images from 112 patients with BI (22 men; mean age, 43.9 years ± 13.1 years; range, 21–79 years) and 200 control subjects (57 men; mean age, 47.1 years ± 13.3 years; range, 20–80 years). Intraclass correlation coefficient (ICC), linear regression, Mann-Whitney U test, binary logistic regression, and receiver operating characteristic (ROC) curve were used for statistical analysis. Results Clivopalate angle showed better inter-observer agreement (ICC = 0.951) than CXA (0.867) or CDA (0.853). CPA significantly correlated with CXA (R = 0.811, p < 0.001) and CDA (R = 0.716, p < 0.001). Patients with BI had a significantly smaller CPA (45.9° ± 9.9°) than control subjects (61.9° ± 6.2°) (p < 0.001). With the optimal cutoff value of 53.5°, CPA had a sensitivity of 0.839 (94/112) and a specificity of 0.915 (183/200). The area under the ROC curve (AUC) was 0.937 (95% CI, 0.911–0.963) for CPA, which was similar to that of CXA (AUC, 0.957; 95% CI, 0.936–0.978) or CDA (AUC, 0.925; 95% CI, 0.892–0.957). The combination of CPA and CDA or CXA showed a higher diagnostic value than CDA or CXA alone. Conclusions The diagnostic performance of CPA was similar to that of CXA or CDA, but CPA might be more reliable in evaluation of BI. CPA provided complementary information to CXA and CDA. Key Points • Clivopalate angle has a high diagnostic value for basilar invagination. • Clivopalate angle demonstrates high inter-reader agreement than does clivoaxial angle or clivodens angle. • Clivopalate angle provides complementary information to clivoaxial angle and clivodens angle. Electronic supplementary material The online version of this article (10.1007/s00330-018-5972-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lichao Ma
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Liuji Guo
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Xiaodan Li
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Jie Qin
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Wenle He
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Xiang Xiao
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Lijun Lu
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Yikai Xu
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China
| | - Yuankui Wu
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, No. 1838 Guangzhou Avenue North, Guangzhou, Guangdong, 510515, People's Republic of China.
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Diagnostic accuracy of classical radiological measurements for basilar invagination of type B at MRI. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:345-352. [DOI: 10.1007/s00586-018-5841-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022]
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Botelho RV, Ferreira JA, Zandonadi Ferreira ED. Basilar Invagination: A Craniocervical Kyphosis. World Neurosurg 2018; 117:e180-e186. [DOI: 10.1016/j.wneu.2018.05.233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
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