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Allan H. Friedman, James A. Nunley II, Richard D. Goldner, W. Jerry Oakes, J. Leonard Goldner and James R. Urbaniak

months to 3 years. Prior to surgical reconstruction, 13 patients had a completely flaccid arm and six patients had some retained lower brachial plexus function. One patient underwent a concomitant Steindler flexoplasty 30 to augment elbow flexion. Seven patients were referred because of chronic pain, and DREZ lesions were performed prior to the intercostal nerve transposition procedure. TABLE 1 Clinical characteristics of 20 patients with nerve transposition for brachial plexus avulsion injury * Case No. Age (yrs), Sex Cause of

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Jacob N. Young, W. Jerry Oakes and H. Pall Hatten Jr.

seizure none 29 mos 6 F, 5 days hydrocephalus chronic subdural 19 mos hematoma Imaging and Surgery The radiological evaluation consisted of brain computerized tomography (CT) scans and magnetic resonance (MR) imaging. The initial procedure was placement of a ventriculoperitoneal (VP) shunt, unless the radiological studies indicated the presence of septations in the cyst. In that event, ventricular exploration and creation of a communication of all cystic cavities were performed prior to placement of a VP shunt

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R. Shane Tubbs, Paul Grabb, Alan Spooner, Wally Wilson and W. Jerry Oakes

specimens were devoid of an apical ligament. This observation, if applied to the general population in which craniocervical instability is not found to this extent, would imply the nonfunction of the apical ligament in stability between the head and neck. Last, we found no tubercles of the basion or odontoid tip that would indicate chronic pull by the ligament. Conclusions In light of our findings, we believe that the apical ligament is best described as a vestigial structure that offers no added stability to the craniocervical junction; historically, it has been

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R. Shane Tubbs, George Salter and W. Jerry Oakes

account for the dilation of the sinus during life, whereby it overflows the bony border of the sulcus, in comparison with the SNL. In fact, the SNL is established after a prolonged pull of several craniocervical muscles, such as the MSC, and has no functional relation to the internally located TS. This is also the case when one considers the inion in which chronic tension from muscle and ligament attachments establishes its prominence. Indeed, the inion also has no functional relation to the internally located torcular herophili and, in the majority of our specimens

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the chronic pull of musculotendinous attachments and the transverse sulcus has its genesis from erosion by the TS. We assert and our findings demonstrate that the width of the transverse sulcus tends to be greater on the right side, and this is directly related to the right TS tending to be larger in caliber. 1, 2 In our study we found no specimen with a transverse sulcus that we would describe as S shaped, as these authors have. Perhaps these authors are actually referring to the continuity between the transverse sulcus and the sulcus for the sigmoid sinus with

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R. Shane Tubbs, John C. Wellons III, Jason Banks, Jeffrey P. Blount and W. Jerry Oakes

specimens (35.7%) the transverse ligament in a nonpathological state provides limited stability for the atlantoaxial juncture. Considering this area's unique embryological derivation, we would hypothesize that these tubercles merely represent lateral extensions of the transverse ligament (proatlantal unossified tissue 16 ) that do not undergo soft-tissue transformation and are not typical osseous protuberances produced by the chronic pull of tendinous/ligamentous attachments. Our findings that 17 tubercles (14.7%) did not protrude from the lateral masses into the

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R. Shane Tubbs, Matthew D. Smyth, John C. Wellons III, Jeffrey P. Blount, Paul A. Grabb and W. Jerry Oakes

, which begins during the 1st year of life, and incomplete ossification of the apical odontoid epiphysis. Flexion of the cervical spine tends to increase the ADI. 4, 5 The ADI is also of limited value when evaluating chronic atlantoaxial instability due to, for example, congenital anomalies such as os odontoideum and juvenile rheumatoid arthritis. 4 Naidich, et al., 9 have proposed that for anterior cervical dislocation that the interspinous distance in flexion at any cervical level should not be greater than 1.5-fold of that at both the level above and below the

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

* head/neck/back pain 55 scoliosis 23 apnea/bradycardia 11 irritability 16 drop attacks 3 rage attacks 2 hoarseness 7 upper-extremity pain/weakness/numbness 22 chronic hiccups 2 dysphagia 20 facial numbness 11 dyspnea 3 ataxia 12 lower-extremity hyperreflexia/weakness 7 chronic emesis 13 nasal speech 15 C-2 dysesthesia 26 migrainelike headache 28 urinary incontinence 2 * Many patients exhibited more than one

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R. Shane Tubbs, John C. Wellons III, Jeffrey P. Blount, W. Jerry Oakes and Paul A. Grabb

P atients with Chiari I malformation can present with a variety of symptoms, although headaches are a common presentation. Cardiovascular compromise, especially in the young patient, is seemingly rare in this form of hindbrain herniation. Hypertension has previously been treated by microvascular decompression of the brainstem, but results have varied. 3, 8–10, 15 We report on a child with preoperative chronic idiopathic hypertension that resolved after decompressive surgery for Chiari I malformation. Case Report History and Presentation This 16-year

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R. Shane TUBBS, Charles Law, W. Jerry Oakes and Paul A. Grabb

severe spasticity. Disconnection of the catheter at its connection to the pump, which occurred in 9% of implanted pumps, was the most common complication. Chiari I malformation was not reported in this large series or in other series or case reports found in a search of the literature spanning from 1966 to the present. We believe that the baclofen pump resulted in progressive, acquired Chiari I malformation in this patient who suffered from chronic shunt-treated hydrocephalus. Chronic leakage from around the catheter or through an unrecognized fracture may be the