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R. Shane Tubbs, Matthew J. McGirt and W. Jerry Oakes

transoral odontoidectomy and occipital cervical fusion 8 days later. This patient recovered, although a left mild esotropia persisted. Unilateral tonsillar coagulation was performed in 22 patients (17%), eight of whom underwent repeated operation for continued syringomyelia. Nine patients have undergone repeated operations for continued symptoms or persistent large syringes; eight surgeries were performed for continued syringomyelia and one for continued headache that was not relieved following posterior fossa decompression without duraplasty. Indeed, the latter patient

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Joseph H. Piatt Jr.

consistent with conventional neurosurgical practice. Review of the details of clinical presentations in Table 1 shows that 60 patients (23% of the study group) presented with headaches alone. In 68 patients (27%) there were brainstem symptoms alone, predominantly dysphagia, vertigo, and difficulty with balance. Such complaints are potentially very disturbing to patients and families, but they are very difficult to measure for the purpose of clinical research. Only 69 patients (27%) had syringomyelia, the most concrete indication for surgical treatment of CM-I. Clearly and

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Editorial

Factors predicting the resectability of intramedullary spinal cord tumors and the progression-free survival following microsurgical treatment

Michael G. Fehlings and David Mercier

FJ : The role of motor evoked potentials during surgery for intramedullary spinal cord tumors . Neurosurgery 41 : 1327 – 1336 , 1997 24 Raco A , Esposito V , Lenzi J , Piccirilli M , Delfini R , Cantore G : Long-term follow-up of intramedullary spinal cord tumors: a series of 202 cases . Neurosurgery 56 : 972 – 981 , 2005 25 Samii M , Klekamp J : Surgical results of 100 intramedullary tumors in relation to accompanying syringomyelia . Neurosurgery 35 : 865 – 873 , 1994 26 Sandalcioglu IE , Gasser T , Asgari S

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Matthew J. McGirt, Shlomi Constantini and George I. Jallo

of IMSCTs in children Grade at Presentation No. Requiring Subsequent Fusion (%) I 0 (0) of 9 II 2 (5) of 41 III 15 (26) of 58 IV 18 (41) of 44 V 9 (75) of 12 The grading scale's correlation with postoperative deformity persisted when applied to patients with syringomyelia or those receiving radiotherapy or undergoing cervical decompression. In subset analysis of the 83 patients undergoing either pre- or postoperative radiotherapy, the incidence of deformity requiring fusion was 8 (100%) of 8 for Grade V, 13 (46%) of

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Kevin C. Yao, Matthew J. McGirt, Kaisorn L. Chaichana, Shlomi Constantini and George I. Jallo

irreversible despite IMSCT resection. 12 , 22 , 30 Our data confirmed that tumor-related deformity is not uncommon: 33% of patients who presented de novo with an IMSCT had a spinal deformity. Syringomyelia was independently associated with a spinal deformity and confirms the previously documented notion that syringomyelia plays an etiological role in spinal deformity. 2 , 24 Asymmetrically expanding syringomyelia damages the anterior horn neurons in the spinal cord, leading to an imbalance in paravertebral muscle strength. 14 , 15 This pathological effect may underlie the

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Matthew J. McGirt, Frank J. Attenello, Daniel M. Sciubba, Ziya L. Gokaslan and Jean-Paul Wolinsky

presented with symptoms or signs of myelopathy of varying degrees. Three patients were affected by head and neck pain, 2 with paresis, and 2 demonstrated swallowing dysfunction. Syringomyelia and syringobulbia were present in 2 patients. TABLE 1 Summary of characteristics in 4 pediatric patients undergoing ETO for basilar invagination * Age (yrs), Sex Presentation Syndrome Procedure Complication Blood Loss (ml) Postop Diet LOS (days) Postop FU (mos) Outcome 13, M neck pain, myelopathy basilar invagination

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Scott L. Parker, Saniya S. Godil, Scott L. Zuckerman, Stephen K. Mendenhall, Noel B. Tulipan and Matthew J. McGirt

associated syringomyelia due to obstruction of CSF at the level of the foramen magnum. 19 Surgical decompression of CM-I is often recommended in symptomatic patients with CSF obstruction, as it has been shown to improve the clinical course of these patients. 21 , 24 While multiple surgical treatment strategies have been described in the literature, the most common procedure currently performed is posterior fossa decompression, which consists of a suboccipital craniectomy and C-1 laminectomy, with duraplasty. 12 Multiple previous studies have reported a range of

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Matthew J. McGirt, Kaisorn L. Chaichana, April Atiba, Ali Bydon, Timothy F. Witham, Kevin C. Yao and George I. Jallo

offer conclusive evidence to this benefit. This procedure was first described in 1976 by Raimondi et al. 23 Since then, osteoplastic laminotomy has been used for several conditions, including cervical myelopathy, tethered spinal cord, syringomyelia, spasticity, and spinal tumors, among others. 1 , 11 , 12 , 20 , 29 Biomechanical and clinical studies have provided inconclusive data supporting the use of laminoplasty over laminectomy. 9 , 21 , 24 , 32 , 33 Nowinski et al., 21 using cadaveric specimens, found that spinal instability was increased after laminectomy

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Frank J. Attenello, Matthew J. McGirt, April Atiba, Muraya Gathinji, Ghazala Datoo, Jon Weingart, Benjamin Carson and George I. Jallo

C hiari malformation Type I, defined as caudal displacement of the cerebellar tonsils into the cervical canal, was first documented by Hans Chiari 4 in 1891. Over the last century, multiple symptoms of cerebellar, brainstem, and spinal cord pathology have been attributed to this complex disease. 11 , 13 , 14 Standard surgical management for CM-I remains posterior fossa decompression. 2 , 5 , 10 Up to 30% of all patients with CM-I and 60% of patients with Chiari malformation–associated syringomyelia will present with scoliosis. 1 , 3 , 6–9 , 12 , 13

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Matthew J. McGirt, Frank J. Attenello, Ghazala Datoo, Muraya Gathinji, April Atiba, Jon D. Weingart, Benjamin Carson and George I. Jallo

maintained, cataloging patient demographics, presenting symptoms, and degree of tonsil herniation. Additionally, the presence of syringomyelia, scoliosis, hydrocephalus, basilar invagination, fused cervical vertebrae, platybasia, atlantooccipital assimilation, or cervicomedullary kinking on MR imaging were also identified and recorded. Degree of tonsillar herniation was expressed as the relationship of the tonsils to the lower edge of the C-1 and the C-2 lamina on MR images obtained with the craniocervical spine in the neutral position, and classified as follows: 5-mm