Rheumatological complications have been described in up to 30% of patients being followed for inflammatory bowel disease. The majority of these complications occur as spondylitic changes in the lumbar spine. Erosive arthritic disease associated with inflammatory bowel disease occurs less frequently, but it can result in ligamentous laxity and joint instability. To highlight the potential significance of the process at the craniocervical junction, the authors describe the long-term follow-up care of a complicated case. A 56-year-old woman, with a long history of ulcerative colitis, presented with atlantoaxial instability and underwent a C1-3 fusion; however, the presence of significant occipitoatlantal instability was not recognized. This resulted in high cervicomedullary quadriplegia, requiring traction reduction and a combined anterior transoral decompressive-posterior occipitocervical fusion. The patient's neurological deficit completely resolved postoperatively.
Timothy Ryken and Arnold Menezes
Vijay M. Ravindra, Jayson A. Neil, Marcus D. Mazur, Min S. Park, William T. Couldwell and Philipp Taussky
suffered a posterior fossa stroke after archery practice. We present various symptomatic cases of vascular pathology related to motion at the craniocervical junction (CCJ). We include two illustrative cases of extradural arterial compression—one of a patient with bilateral V 3 segment occlusion occurring upon head rotation and one of a patient with bilateral posterior inferior cerebellar artery (PICA) strokes caused when the artery as a solitary feeder with an extradural origin became compressed during patient positioning for an unrelated surgical procedure—and one
Ulysses C. Batista, Andrei F. Joaquim, Yvens B. Fernandes, Roger N. Mathias, Enrico Ghizoni and Helder Tedeschi
T he majority of the articles related to spinal alignment evaluate the center of gravity of the sagittal vertical axis, pelvic incidence, cervical and lumbar lordosis, and thoracic kyphosis. 7 , 18 , 23 However, the parameters of the normal craniometric relationships of the craniocervical junction (CCJ), especially those for angular craniometry, are still poorly studied and historically based on measurements taken from plain radiographs. 17 If compared with plain radiographs, where bone structures are superimposed, the use of modern diagnostic imaging
Rinchen Phuntsok, Marcus D. Mazur, Benjamin J. Ellis, Vijay M. Ravindra and Douglas L. Brockmeyer
cannot be said about the pediatric counterpart. Primarily because of a lack of human pediatric cadaveric tissue, but also because of the relatively small number of treated patients, this is a significantly understudied area in spinal biomechanics. This fact is especially true of the most complex region of the pediatric spine: the craniocervical junction (CCJ). This region includes the bony elements of the occiput, atlas (C-1), and axis (C-2), as well as the supporting ligamentous and soft-tissue structures. Our current biomechanical knowledge is based mostly on
Douglas L. Brockmeyer, Andrew Jea, Alan R. Cohen and Arnold H. Menezes
Atlas the baleful: he knows the depths of all the seas, and he, no other, guards the tall pillars that keep the sky and earth apart. — Homer, “The Odyssey” This issue of Neurosurgical Focus is devoted to one of the most fascinating topics in neurosurgery: the craniocervical junction (CCJ). Like Atlas, the mythological Titan who held up the celestial spheres, the structures that make up the CCJ are responsible for support and protection of the critical cervicomedullary structures within. As shown by the wide variety of topics presented in this issue
Liyong Sun, Jian Ren and Hongqi Zhang
Craniocervical junction dural arteriovenous fistula (CCJDAVF) is a rare and unique type of intracranial DAVF with complex neurovascular anatomy, making it difficult to identify the arterialized vein during operation. The authors report the case of a 50-year-old male who presented with symptoms of venous hypertensive myelopathy. Angiography demonstrated a left CCJDAVF. The fistula was successfully disconnected via a suboccipital midline approach. The selective indocyanine green videoangiography (SICG-VA) technique was applied to distinguish the fistula site and arterialized vein from adjacent normal vessels. Favorable clinical and angiographic outcomes were attained. The detailed operative technique, surgical nuances, and utility of SICG-VA are illustrated in this video atlas.
The video can be found here: https://youtu.be/GJYl_jOJQqU.
Grant W. Mallory, Grigoriy Arutyunyan, Meghan E. Murphy, Kathryn M. Van Abel, Elvis Francois, Nicholas M. Wetjen, Jeremy L. Fogelson, Erin K. O'Brien, Michelle J. Clarke, Laurence J. Eckel and Jamie J. Van Gompel
T he conventional approach to pathology of the ventral craniocervical junction remains the transoral route with or without various modifications to increase exposure as required by pathology. 20 However, combining the transoral route with splitting of the soft palate, maxillotomy, glossotomy, or mandibulotomy also increases morbidity. 6 , 22 , 28 To avoid additional tissue disruption, retraction of the soft palate and other approaches have been considered with or without the adjunct of an endoscope to improve exposure. 24 Other alternatives include a
Marcus D. Mazur, Vijay M. Ravindra and Douglas L. Brockmeyer
dysplasia (SED) or Down syndrome. In other cases, patients are symptomatic from medullary or spinal cord compression and present with myelopathy and/or bulbar findings. A standard biomechanical axiom states that to achieve the torsional rigidity necessary to facilitate fusion at the craniocervical junction (CCJ), it is necessary to have bilateral fixation. This concept has been passed down over many years, and has been examined in a small number of biomechanical studies that have evaluated atlantoaxial fixation. 13 , 14 In certain circumstances, such as when bone is
Thomas J. Sorenson, Lucio De Maria, Leonardo Rangel-Castilla and Giuseppe Lanzino
Craniocervical junction dural arteriovenous fistulas (dAVFs) are rare vascular lesions with a potentially dangerous natural history due to the onset of neurological deficit secondary to intracranial hemorrhage or myelopathy due to venous congestion. Despite advances in endovascular techniques, many dAVFs located in this area continue to require surgical treatment as embolization is often not feasible or safe. In this video, the authors illustrate a patient with a symptomatic craniocervical junction dAVF who had undergone attempted Onyx embolization at another institution. Because of persistent filling of the fistula and worsening myelopathy after the previous attempt, the patient was referred to the authors’ clinic for definitive surgical treatment. The video illustrates the typical location of the early draining vein in most craniocervical junction dAVFs immediately below the emergence of the vertebral artery from the dura. The patient underwent successful definitive clip ligation of the fistula, which was exposed through a lateral suboccipital craniotomy.
The video can be found here: https://youtu.be/Bvg6VKLgwO0.
Daniel S. Yanni, Alexander Y. Halim and Daniela Alexandru
O dontoid pseudotumor is a mass occurring around the odontoid process in the cervical spine, and can cause significant neurological symptoms at the craniocervical junction due to compression of the spinal cord and cervicomedullary junction at this level. 1 , 22 , 25 This in turn can lead to severe neurological deficit in patients, which can range from mild myelopathy to complete paralysis in severe cases. 21 , 22 , 25 A retroodontoid mass can occur in patients due to a variety of conditions such as rheumatoid arthritis, 13 , 15 , 16 long-term dialysis