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T. Glenn Pait and Justin T. Dowdy

The 35th president of the United States, John F. Kennedy (JFK), experienced chronic back pain beginning in his early 20s. He underwent a total of 4 back operations, including a discectomy, an instrumentation and fusion, and 2 relatively minor surgeries that failed to significantly improve his pain. The authors examined the nature and etiology of JFK’s back pain and performed a detailed investigation into the former president’s numerous medical evaluations and treatment modalities. This information may lead to a better understanding of the profound effects that JFK’s chronic back pain and its treatment had on his life and presidency, and even his death.

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Justin Dowdy and T. Glenn Pait

The treatment of craniospinal war wounds proved to be a significant driving force in the early growth of neurosurgery as a specialty. This publication explores the historical relationship between the evolution of combat methodology from antiquity through modern conflicts as it dovetails with and drives corresponding advancements in the field of neurosurgery.

Whether it's the basic management principles for intracranial projectile wounds derived from World War I experiences, the drastic improvement in the outcomes and management of spinal cord injuries observed in World War II, or the fact that both of these wars played a crucial role in the development of a training system that is the origin of modern residency programs, the influence of wartime experiences is pervasive.

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Demitre Serletis and T. Glenn Pait

In this paper the authors trace the history of early craniometry, referring to the technique of obtaining cranial measurements for the accurate correlation of external skull landmarks to specific brain regions. Largely drawing on methods from the newly emerging fields of physical anthropology and phrenology in the late 19th and early 20th centuries, basic mathematical concepts were combined with simplistic (yet at the time, innovative) mechanical tools, leading to the first known attempts at craniocerebral topography. It is important to acknowledge the pioneers of this pre-imaging epoch, who applied creativity and ingenuity to tackle the challenge of reproducibly and reliably accessing a specific target in the brain. In particular, with the emergence of Broca’s theory of cortical localization, in vivo craniometric tools, and the introduction of 3D coordinate systems, several innovative devices were conceived that subsequently paved the way for modern-day stereotactic techniques. In this context, the authors present a comprehensive and systematic review of the most popular craniometric tools developed during this time period (prior to the stereotactic era) for the purposes of craniocerebral measurement and target localization.

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Monir Tabbosha, Justin Dowdy and T. Glenn Pait

Over the past several decades, many advancements and new techniques have emerged regarding the instrumentation and stabilization of the upper cervical spine. In this article, the authors describe a novel technique in which a unilateral lag screw was placed to reduce and stabilize a progressively widening fracture and nonunion of the right C-1 lateral mass approximately 8 weeks after the initial injury, which was sustained when a large tree branch fell onto the patient's posterior head and neck.

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T. Glenn Pait, Phillip V. McAllister and Howard H. Kaufman

✓ Knowledge of the relevant anatomy is important when developing a strategy for introducing screws into the lateral masses to secure internal fixation devices. This paper defines key bony landmarks and their relationship to critical neurovascular structures and identifies a location for safe placement of cervical articular pillar (lateral mass) screws.

Measurements of anatomical landmarks in 10 spines from human cadavers aged 61 to 85 years were made by caliper and a metric ruler. Landmarks were the lateral facet line, rostrocaudal line, medial facet line, intrafacet line, and medial facet line—vertebral artery line. The average distances and ranges were recorded. Such great variance existed in measurements from spine to spine and within the same spine as to render averages clinically unreliable. Dissection revealed that division of the articular pillar into four quadrants leaves one, the superior lateral quadrant, under which there are no neurovascular structures; this may be considered the “safe quadrant” for placement of posterior screws and plates.

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Wayne S. Paullus, T. Glenn Pait and Albert L. Rhoton Jr.

✓ Occlusion of the cervical portion of the internal carotid artery (ICA) has been treated by vein graft bypass from the common carotid to the supraclinoid segment. However, this procedure has the disadvantages of requiring temporary occlusion of collateral flow, the short length of ICA available for anastomosis, and the retraction required for exposure of the supraclinoid area. In an attempt to find a more suitable bypass site for grafting, the petrous portion of 50 carotid arteries was studied in cadavers. It was found that there was a 1-cm length of the horizontal segment of the petrous carotid that could be exposed in the floor of the middle fossa lateral to the trigeminal nerve. This segment was covered by dura only or a thin layer of cartilage in approximately half of the specimens. In the remainder, there was often a thin shell of bone covering the artery, which could be drilled away. The petrous portion of the carotid artery had branches in only 38% of specimens, a Vidian branch in 30%, and a periosteal branch in 8%. The carotico-tympanic artery, previously reported to be the most common branch, was not found in a single case. These branches allow the retrograde flow needed to maintain the patency of this segment following proximal occlusions. The relationship of the carotid artery to structures that might be injured in exposing the petrous portion of the artery was reviewed; these structures include the cochlea, middle ear, Eustachian tube, tensor tympani muscle, geniculate ganglion, and facial, greater petrosal, and trigeminal nerves.

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Serdar Özgen, T. Glenn Pait and Y. Şsükrü ÇağLar

Object. The goal of this study was to demonstrate the origins, courses, anastomoses, and target tissues of the arterial branches that arise from the V2 segment of the vertebral artery.

Methods. Ten adult cadaveric necks (20 V2 segment specimens) were examined (magnification × 40) after injection of colored silicon. The branches at each cervical level were classified in a new system according to anatomical features and target tissues—anterior, posterior, medial, and lateral. Incidence with which each branch category was observed at each cervical level was calculated.

Anterior branches were observed at C-3 in all 20 V2 segment specimens. The incidence with which the posterior branch was present at C-4 was 45%, whereas the corresponding rates at segments superior and inferior were lower. The medial V2 segment branches were assessed in four subcategories. The anterior spinal artery was present at C-3 in all specimens, whereas the mean incidence at the C4–6 level was 46.7%. The posterior spinal artery was most frequently detected at C-3 (60%). The anterior radicular artery (RA) was present at C-5 in 50% of the specimens, whereas the posterior RA was detected at C-5 in only 35%. Lateral branches were most frequently detected at C-3.

Conclusions. The authors provide detailed anatomical information about the origins, courses, anastomoses, and target tissues of the vessels that arise from the V2 segment. This new classification allows for better understanding of the vasculature of the C3–6 region.

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Sait Naderi, Uğur Türe and T. Glenn Pait

The first reference to spinal cord injury is recorded in the Edwin Smith papyrus. Little was known of the function of the cord before Galen's experiments conducted in the second century AD. Galen described the protective coverings of the spinal cord: the bone, posterior longitudinal ligament, dura mater, and pia mater. He gave a detailed account of the gross anatomy of the spinal cord. During the medieval period (AD 700–1500) almost nothing of note was added to Galen's account of spinal cord structure. The first significant work on the spinal cord was that of Blasius in 1666. He was the first to differentiate the gray and white matter of the cord and demonstrated for the first time the origin of the anterior and posterior spinal nerve roots. The elucidation of the various tracts in the spinal cord actually began with demonstrations of pyramidal decussation by Mistichelli (1709) and Pourfoir du Petit (1710). Huber (1739) recorded the first detailed account of spinal roots and the denticulate ligaments. In 1809, Rolando described the substantia gelati-nosa. The microtome, invented in 1824 by Stilling, proved to be one of the fundamental tools for the study of spinal cord anatomy. Stilling's technique involved slicing frozen or alcohol-hardened spinal cord into very thin sections and examining them unstained by using the naked eye or a microscope. With improvements in histological and experimental techniques, modern studies of spinal cord anatomy and function were initiated by Brown-Séquard. In 1846, he gave the first demonstration of the decussation of the sensory tracts. The location and direction of fiber tracts were uncovered by the experimental studies of Burdach (1826), Türck (1849), Clarke (1851), Lissauer (1855), Goll (1860), Flechsig (1876), and Gowers (1880). Bastian (1890) demonstrated that in complete transverse lesions of the spinal cord, reflexes below the level of the lesion are lost and muscle tone is abolished. Flatau (1894) observed the laminar nature of spinal pathways.

The 20th century ushered in a new era in the evaluation of spinal cord function and localization; however, the total understanding of this remarkable organ remains elusive. Perhaps the next century will provide the answers to today's questions about spinal cord localization.