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

clinicians who appreciate the craniocervical junction as part of their discipline. Materials and Methods Fifty dried adult human C-1 vertebrae were used in this study. Twenty-nine specimens were obtained in male cadavers and 21 in female cadavers. All specimens were obtained in elderly caucasian individuals. Three male specimens were from C-1 vertebrae that had assimilated into the occiput. All dimensions were measured using calipers, and No. 2.5 surgical loupes were used for magnification. Measurements were made on both the left and right tubercles of each vertebra

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

the craniocervical junction does not correlate with the presence of syringomyelia in the Chiari I malformation and that this compression was seemingly due to a posteriorly oriented odontoid, not true basilar invagination. Our present results show that higher grades of odontoid angulation do indeed correlate with syringomyelia: a syrinx was apparent in 74% of patients with a Grade II or Grade III odontoid angulation. Of holocord syringes, 70% were demonstrated in patients with a Grade III odontoid angulation. Curiously, no single grade of odontoid angulation

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Travis R. Ladner, Michael C. Dewan, Matthew A. Day, Chevis N. Shannon, Luke Tomycz, Noel Tulipan and John C. Wellons III

P osterior fossa decompression with duraplasty (PFDD) is a common surgical correction for Chiari I malformation (CM-I) in children. A recent metaanalysis found that 78.6% of pediatric patients have clinical improvement and 87% have a reduction in syrinx size postoperatively with PFDD. 3 A preoperative evaluation to predict success of PFDD in clinical outcomes could assist with identifying patients who are likely to respond well to PFDD and allow the surgeon to counsel families regarding treatment. Radiological measurements of the craniocervical junction

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Travis R. Ladner, Michael C. Dewan, Matthew A. Day, Chevis N. Shannon, Luke Tomycz, Noel Tulipan and John C. Wellons III

O sseous anomalies of the craniocervical junction (CCJ) are hypothesized to precipitate the hindbrain herniation observed in Chiari I malformation (CM-I). One previous single-center study by Tubbs et al. showed that posterior angulation of the odontoid process is more prevalent in children with CM-I than in healthy controls. 20 The present study is an external validation of that report. The goals of our study are 3-fold: 1) to externally validate the results of Tubbs et al. in a different patient population; 2) to compare how morphometric parameters vary

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

. 7 Fig. 1. Drawing showing the posterior view of the craniocervical junction. The PAO membrane is seen (arrow) . The PAO membrane has been historically referenced as the cephalad extension of the ligamentum flavum; hence, in earlier studies it was thought to play a role in craniocervical stability. 15, 17 The authors of more recent studies, however, have shown that the PAO membrane plays an insignificant role in atlantooccipital stability. 4, 8, 9, 14, 16 The tensile strength of this membrane, however, has been found to be fourfold that of the

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R. Shane Tubbs, Kevin Ammar, Peter Liechty, John C. Wellons III, Jeffrey P. Blount, E. George Salter and W. Jerry Oakes

the cavernous sinus. Additional knowledge of this sinus may be useful to the neurosurgeon who operates in this region. References 1 Browder J , Kaplan HA : Cerebral Dural Sinuses and Their Tributaries Springfield, IL , Thomas , 1976 2 Caruso RD , Rosenbaum AE , Chang JK , Joy SE : Craniocervical junction venous anatomy on enhanced MR images: the suboccipital cavernous sinus . AJNR Am J Neuroradiol 20 : 1127 – 1131 , 1999 3 de Oliveira E , Rhoton AL Jr , Peace D : Microsurgical anatomy of the region of the foramen magnum

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

children who were evaluated for craniocervical stability as part of their workup for a Chiari I malformation. Ages ranged from 16 months to 18 years (mean 9.1 years); there were 32 male and 42 female patients. All 74 children enrolled in this study were thought to have both normal architecture and motion of the craniocervical junction and cervical spine. The ILD was measured between the atlas and axis in all children. This distance was defined as that between a midpoint of the anterior cortex of the atlantal posterior arch and a midpoint of the anterior cortex of the

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Robert P. Naftel, R. Shane Tubbs, Joshua Y. Menendez, John C. Wellons III, Ian F. Pollack and W. Jerry Oakes

preexisting syrinx likely represents a variant of this phenomenon, reflecting the emergence or worsening of a CSF flow limitation at the craniocervical junction. The response of syringomyelia to posterior fossa decompression is well described. In most patients, the syrinx is expected to decrease in size, and clinical symptoms should stabilize or improve. 12 , 13 , 16 Reported rates of persistent syringomyelia have ranged from 0% to 40%. 4 , 8 , 13 , 16 , 17 Causes of treatment failure have also been investigated. 5 , 10 , 13 Zhang et al. reported worsening

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Joshua J. Chern, Amber S. Gordon, Robert P. Naftel, R. Shane Tubbs, W. Jerry Oakes and John C. Wellons III

instruments are in the channel. Case 1: Spinal Cord Tumor History and Examination This 14-year-old boy developed progressive weakness in his right hand grip and numbness in the back of the neck and head. An MR imaging study was obtained and revealed a multinodular enhancing lesion in the cervical spine with an associated syrinx extending from the craniocervical junction to T-3. Operation A C2–7 laminotomy was performed with a myelotomy extending this entire distance. Intraoperative monitoring was used. Bipolar cautery and an ultrasonic aspirator were used to

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R. Shane Tubbs, Joshua Beckman, Robert P. Naftel, Joshua J. Chern, John C. Wellons III, Curtis J. Rozzelle, Jeffrey P. Blount and W. Jerry Oakes

(mean 11 years). The group included 271 boys and 229 girls. The senior author (W.J.O.) performed 293 of the operations. All patients underwent preoperative imaging of the head, craniocervical junction, and spine. Supratentorial imaging was used to verify the absence of intracranial pathology and hydrocephalus. Spine imaging was performed to exclude syringomyelia. Cerebrospinal fluid flow studies were obtained early in this series but not over the last 12 years due to our experience with multiple false negative results (in more than 10% of cases). Each patient