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H. Alan Crockard and Robert Bradford

T he transoral approach to anteriorly placed lesions at the craniocervical junction has been in use for over 20 years. 4, 15 It is now becoming established as a relatively safe and effective method for dealing with a variety of extradural lesions around the clivus, 6, 16 foramen magnum, 8, 9 atlantoaxial complex, 1, 5, 11, 14 and upper cervical spine. 2, 10 The use of the transoral route to treat intradural lesions, in particular basilar aneurysms, 3, 12 has been less successful. The most serious problem with this approach is the high incidence of

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H. Alan Crockard, Alan E. Heilman and John M. Stevens

horizontal atlantoaxial subluxation was shown to be greater on plain x-ray films than on CT scans and, in these examples, the smaller angle (from the plain x-ray study) was used. The spinal cord could be assessed only from CT scans. The site of maximum spinal cord compression was determined from the sagittal reformatted images and checked by axial reformatting. The selected site was imaged in the true axial plane, in a slice 3 pixels thick, and the boundaries of the cord were estimated from images at electronic window settings defined by Seibert, et al. 30 The

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Gerald F. Tuite, Robert Veres, H. Alan Crockard and Debbie Sell

17 years; 18 were less than 14 years old ( Table 1 ). Nineteen patients (70%) had an associated syndrome ( Table 1 ). The patients had neuraxial compression from atlantoaxial subluxation (AAS), basilar impression, pseudotumor, skull base infolding, or chordoma ( Table 1 ). TABLE 1 Diagnostic, radiographic, and surgical details of 27 children treated with transoral surgery * Radiographic Characteristics Transoral † Posterior Fusion Case No. Age (yrs), Sex Diagnosis Principal Abnormality

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Adrian T. H. Casey, H. Alan Crockard, J. Martin Bland, John Stevens, Ronald Moskovich and Andrew Ransford

I nvolvement of the atlantoaxial region by the rheumatoid process is a well-known clinical and radiological entity. Clinical or neurological disability is typically classified using the Ranawat system (Classes I–IIIb) and radiological findings of atlantoaxial disease, including those of horizontal, lateral, or rotary subluxation and vertical translocation. 33 However, because there is often no apparent relationship between the degree of subluxation measured radiologically using the atlantodens interval (ADI) and the clinical picture, 1, 7, 21, 28 there is a

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Daniel M. May, Stephen J. Jones and H. Alan Crockard

surgical procedures used in 191 operations on the cervical spine Approach * No. of Operations anterior  transoral decompression 13  transoral decompression & odontoid screw 1  “open door” maxillotomy 5  Smith—Robinson 27  Smith—Robinson & locking plate 26  corpectomy & locking plate 21  odontoid screw fixation 2  total 95 posterior  transarticular atlantoaxial screw & Gallie fixation 14  laminectomy 6  laminoplasty 2  fixation 21

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Gerald F. Tuite, Robert Veres, H. Alan Crockard, David Peterson and Richard D. Hayward

child with atlantoaxial rotatory subluxation positioned prone on the spinal immobilization device. The child has been anesthetized and her head immobilized in a halo ring coupled to the vertical brackets of the spinal immobilization device using four Π-shaped couplers. A combination of straps and tape have not yet been applied to immobilize the child's body. Right: Photograph showing the same child undergoing computerized tomography scanning prior to surgery. Following the procedure, she was transported in the same position directly to the operating room where a C1

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Ali Abou Madawi, Adrian T. H. Casey, Guirish A. Solanki, Gerald Tuite, Robert Veres and H. Alan Crockard

S ince the introduction of the atlantoaxial transarticular screw fixation technique by Magerl and Seemann in 1987, 12 many authors 7, 8, 10, 13, 16, 17 have reported their experiences in the literature. However, few have reported on the early and late complications of the technique. 8 Compared with other posterior C1–2 fusion techniques including those of Gallie, 4 Brooks and Jenkins, 1 and fusion using Halifax interlaminar clamps, 2 atlantoaxial transarticular screw fixation has the advantage of increased biomechanical stability and allows the least

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Adrian T. H. Casey, H. Alan Crockard and John Stevens

incapacitated, largely or wholly bed-ridden or 48 40  confined to a wheelchair w/ little or no self-care * Perioperative deaths were categorized as Ranawat Class IIIB. Development of Surgical Management The type of surgery was influenced by the reducibility of the deformity (fixed or mobile), the associated cervical subluxations present (horizontal, lateral, or rotatory atlantoaxial subluxation), and the presence of subaxial disease. 12 The latter, in particular, dictated the extent of instrumentation required, with an attempt to

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Adrian T. H. Casey, H. Alan Crockard, Jennian F. Geddes and John Stevens

provide some important insights into the pathomechanics of vertical translocation and its clinical sequelae. The main thrust of the analysis was a comparison between patients with atlantoaxial subluxation and those with vertical translocation based on their demonstrated clinical and radiological features. Clinical Material and Methods This was a prospective observational study, in the course of which 256 patients were recruited over a 10-year period (1983–1993). Of the total, 186 patients had myelopathy (Ranawat Classes II, IIIA, and IIIB) 35 and underwent spinal

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H. Alan Crockard, Ahmed Tammam and Nigel Mendoza

. Craniocervical instability is managed with dorsal implants only in cases of atlantoaxial instability with good bone quality; C1–2 transarticular screw fixation is our first choice. 16 Occipitocervical fixation is used for end-stage rheumatoid disease, 4 carcinomatosis, and ligamentous laxity associated with rare congenital diseases such as Hurler's or Hunter's syndrome. 17 In the United Kingdom, the preformed Hartshill Ransford loop (Surgicraft, Redditch, Worcestershire, UK) is the most popular. Methods of Fixation From the nine iterations, the rectangle that most