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R. Shane Tubbs, Mohammadali M. Shoja, Leslie Acakpo-Satchivi, John C. Wellons III, Jeffrey P. Blount, W. Jerry Oakes and Bermans J. Iskandar

atlantoaxial vertebral artery to treat bow hunter’s stroke: technical case report . Neurosurgery 49 : 1474 – 1476 , 2001 18 Sen C , Eisenberg M , Casden AM , Sundaresan N , Catalano PJ : Management of the vertebral artery in excision of extradural tumors of the cervical spine . Neurosurgery 36 : 106 – 116 , 1995 19 Senter HJ , Bittar SM , Long ET : Revascularization of the extracranial vertebral artery at any level without cross-clamping . J Neurosurg 62 : 334 – 339 , 1985 20 Shucart WA , Borden JA , Lateral approaches to the

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R. Shane Tubbs, Philip C. Johnson, Mohammadali M. Shoja, Marios Loukas and W. Jerry Oakes

arcuale. Cushing and colleagues 8 found a foramen arcuale in eight of 11 patients with VA dissection and occlusion. The site of arterial injury was at the level of this anatomical variation in all cases. Because more than 50% of head rotation occurs at the atlantoaxial joint, the VA is vulnerable to compression and stretching at this level and thus additional compression/tethering by a foramen arcuale may compound its predisposition to injury. During neck flexion, the VA glides superiorly and anteriorly relative to the posterior arch, and this occurs more at the level

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R. Shane Tubbs, Joshua Dixon, Marios Loukas, Mohammadali M. Shoja and Aaron A. Cohen-Gadol

Neurosurg 92 : 2 Suppl 197 – 200 , 2000 7 Tubbs RS , Griessenauer CJ , McDaniel JG , Burns AM , Kumbla A , Cohen-Gadol AA : The transverse occipital ligament: anatomy and potential functional significance . Neurosurgery [epub ahead of print] 2010 8 Tubbs RS , Kelly DR , Humphrey ER , Chua GD , Shoja MM , Salter EG , : The tectorial membrane: anatomical, biomechanical, and histological analysis . Clin Anat 20 : 382 – 386 , 2007 9 Tubbs RS , Salter EG , Oakes WJ : The accessory atlantoaxial ligament

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R. Shane Tubbs, Justin D. Hallock, Virginia Radcliff, Robert P. Naftel, Martin Mortazavi, Mohammadali M. Shoja, Marios Loukas and Aaron A. Cohen-Gadol

T he CCJ contains the complex transition from the skull to the spine. It is composed of 2 joints—the atlantooccipital and the atlantoaxial joints—and houses the spinal cord, multiple cranial nerves, and many important blood and lymphatic vessels that supply the head and neck. 44 , 45 , 66 This CCJ must protect its contents while simultaneously allowing significant mobility. The 2 most prominent and arguably the most important ligaments of the CCJ are the transverse and alar ligaments. These ligaments have been the focus of much study, but the other

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R. Shane Tubbs, Martin M. Mortazavi, Marios Loukas, Anthony V. D'Antoni, Mohammadali M. Shoja, Joshua J. Chern and Aaron A. Cohen-Gadol

procedures used to treat occipital neuralgia include neurolysis and decompression, neurectomy, rhizotomy and ganglionotomy, C1–2 fusion, radiofrequency ablation, and peripheral nerve stimulation. 2 , 4 , 12 , 20 , 21 , 24–26 , 33 Several causes of occipital neuralgia have been implicated, including trauma, fibrositis, myositis, fracture of the atlas, and compression of the C-2 nerve root, C1–2 arthrosis syndrome, atlantoaxial lateral mass osteoarthritis, cervical cord tumor, Chiari malformation, neurosyphilis, and surgery. 1 , 7–9 , 28 , 29 , 32 Third Occipital Nerve

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R. Shane Tubbs, Jeffrey R. Lancaster, Martin M. Mortazavi, Mohammadali M. Shoja, Joshua J. Chern, Marios Loukas and Aaron A. Cohen-Gadol

determination of the clinical outcome of this state depends on the particular anatomical findings. In some cases, the foramen magnum can be constricted, with symptoms exacerbated by head movement, 26 , 29 resulting in the so-called foramen magnum syndrome. 15 Often these patients have compensatory hypermobility of the atlantoaxial joint, and may have compression of the vertebral artery with resultant ischemic symptoms. 1 , 19 , 22 , 23 , 26 , 31 , 34 Atlantooccipital fusion is also commonly associated with the presence of a posteriorly constricting band of dura mater that

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R. Shane Tubbs, Martin M. Mortazavi, Marios Loukas, Anthony V. D'Antoni, Mohammadali M. Shoja and Aaron A. Cohen-Gadol

sectioning . Cephalalgia 13 : 354 – 360 , 307 , 1993 11 Joseph B , Kumar B : Gallie's fusion for atlantoaxial arthrosis with occipital neuralgia . Spine (Phila Pa 1976) 19 : 454 – 455 , 1994 12 Marzo JM , Simmons EH , Kallen F : Intradural connections between adjacent cervical spinal roots . Spine (Phila Pa 1976) 12 : 964 – 968 , 1987 13 Pallie W : The intersegmental anastomoses of posterior spinal rootlets and their significance . J Neurosurg 16 : 188 – 196 , 1959 14 Perneczky A , Sunder-Plassmann M : Intradural variant of