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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


Occipital neuralgia can be a debilitating disease and may occur following operative procedures near the occipital and nuchal regions. One nerve of this region, the third occipital nerve (TON), has received only scant attention, and its potential contribution to occipital neuralgia has not been appreciated. Therefore, in the present study the authors aimed to detail the anatomy of this nerve and its relationships to midline surgical approaches of the occiput and posterior neck.


Fifteen adult cadavers (30 sides) underwent dissection of the upper cervical and occipital regions. Special attention was given to identifying the course of the TON and its relationship to the soft tissues and other nerves of this region. Once identified superficially, the TON was followed deeply through the nuchal musculature to its origin in the dorsal ramus of C-3. Measurements were made of the length and diameter of the TON. Additionally, the distance from the external occipital protuberance was measured in each specimen. Following dissection of the TON, self-retaining retractors were placed in the midline and opened in standard fashion while observing for excess tension on the TON.


Articular branches were noted arising from the deep surface of the nerve in 63.3% of sides. The authors found that the TON was, on average, 3 mm lateral to the external occipital protuberance, and small branches were found to cross the midline and communicate with the contralateral TON inferior to the external occipital protuberance in 66.7% of sides. The TON trunk became subcutaneous at a mean of 5 cm inferior to the external occipital protuberance. In all specimens, the cutaneous main trunk of the TON was intimately related to the nuchal ligament. Insertion of self-retaining retractors in the midline placed significant tension on the TON in all specimens, both superficially and more deeply at its adjacent facet joint.


Although damage to the TON may often be unavoidable in midline approaches to the craniocervical region, appreciation of its presence and knowledge of its position and relationships may be useful to the neurosurgeon who operates in this region and may assist in decreasing postoperative morbidity.

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Kiyoshi Onda, Yuichi Yoshida, Kounosuke Watanabe, Hiroyuki Arai, Hideo Okada and Tomoaki Terada

S pinal arteriovenous malformations are rare, and the most common type is dural arteriovenous fistula (AVF). 18 A spinal dural AVF has an arteriovenous shunt located within the dura mater close to the dorsal nerve root, which is fed by the radiculomeningeal, not the spinal, arteries and drains through a single radicular vein. 5 , 12 , 14 , 21 , 22 , 24 It occurs predominantly in the thoracolumbar area and rarely in the cervical spine where the craniocervical junction is the most commonly affected site. 2 , 16 , 18 Recently, it has become recognized that

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Takao Sagiuchi, Satoru Shimizu, Ryusui Tanaka, Shigekuni Tachibana and Kiyotaka Fujii

: Cranio-cervical junction synovial cyst associated with atlantoaxial dislocation—case report . Neurol Med Chir 39 : 539 – 543 , 1999 2 Birch BD , Khandji AG , McCormick PC : Atlantoaxial degenerative articular cysts . J Neurosurg 85 : 810 – 816 , 1996 3 Choe W , Walot I , Schlesinger C , Chambi I , Lin F : Synovial cyst of dens causing spinal cord compression. Case report . Paraplegia 31 : 803 – 807 , 1993 4 Eustacchio S , Trummer M , Unger F , Flaschka G : Intraspinal synovial cyst at the craniocervical junction

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Nader S. Dahdaleh, Brian J. Dlouhy and Arnold H. Menezes

A mong the pathological processes involving the craniocervical junction, basilar invagination remains a therapeutic challenge. As illustrated in the widely used paradigm, 4 , 5 it is essential to determine whether the invagination is reducible. Reducible lesions obviate an anterior decompression, which often involves a transoral transpalatopharyngeal approach, or one of its variations. Reports suggest that in many patients, especially in the pediatric age group, the invagination can be preoperatively reduced, rendering a dorsal-only approach sufficient. 3

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Sven O. Eicker, Klaus Christian Mende, Lasse Dührsen and Nils Ole Schmidt

, 2003 2 Bertalanffy H , Bozinov O , Sürücü O , Sure U , Benes L , Kappus C : Dorsolateral approach to the craniovertebral junction, in Cappabianca P, Iaconetta G, Califano L (eds): Cranial, Craniofacial and Skull Base Surgery. . New York , Springer Verlag , 2010 . 175 – 195 3 Crockard HA , Bradford R : Transoral transclival removal of a schwannoma anterior to the craniocervical junction. Case report . J Neurosurg 62 : 293 – 295 , 1985 4 Eicker SO , Szelényi A , Mathys C , Steiger HJ , Hänggi D : Custom

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Donato Pacione, Omar Tanweer, Phillip Berman and David H. Harter

further draping of the brainstem over the clivus. 5) Our solution was not to remove the clivus and ventral C-1 and C-2 elements but to decompress the cervical spine and translate it posteriorly while distracting at the craniocervical junction. Traction alone would not achieve an adequate decompression of the ventral brainstem. 6) There were no viable fixation options at C-2 due to the previously loosened hardware on the right and the dominant high-riding vertebral artery on the left. Additionally, no true C-3 lateral mass was available; it is conjoined to C-2. The C-4

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Eric M. Horn, Iman Feiz-Erfan, Gregory P. Lekovic, Curtis A. Dickman, Volker K. H. Sonntag and Nicholas Theodore

O ccipitoatlantal dislocation is a rare traumatic injury associated with a high rate of mortality and significant neurological morbidity. 5 , 7 , 14 , 17 , 19 , 23 , 25 , 36 , 37 , 51 , 52 As prehospital care has improved during the past 20 years, more patients who sustain OAD have survived a long enough duration to be transferred to a trauma hospital. 46 The frequent use of MR imaging to evaluate patients who have sustained trauma has heightened awareness of soft-tissue and ligamentous abnormalities of the craniocervical junction, especially in

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The far lateral/combined supra- and infratentorial approach

A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem

Hillel Z. Baldwin, Christopher G. Miller, Harry R. van Loveren, Jeffrey T. Keller, C. Phillip Daspit and Robert F. Spetzler

success in exposing the cranial base adequately at the level of the craniocervical junction. The head is secured within a Mayfield head holder and the body is placed in a modified park-bench position. For the far lateral and combined supra- and infratentorial approaches to be used together, the spine must be flexed in the anteroposterior plane, rotated 45° to the contralateral side, and flexed laterally 30° toward the opposite shoulder ( Fig. 1 ). The rotation of the head must be adjusted during the procedure to place the mastoid process uppermost for the foramen magnum

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Eduardo Salas, Laligam N. Sekhar, Ibrahim M. Ziyal, Anthony J. Caputy and Donald C. Wright

(dashed line) . B: The anterior aspect of the spinal cord is exposed without the interposition of the cervical root, accessory nerve, or dentate ligament. C 1 = lateral mass of the atlas; C 2 = lateral mass of the axis. When the lesion was anterolateral to the spinal cord, it was not necessary to drill the facets extensively, and the craniocervical junction was stable after the procedure. When the lesion involved osseous elements, bone removal depended on the extent of the lesion. Retrocondylar Approach The RCA was performed to treat intradural lesions

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Richard M. Young, Jonathan H. Sherman, Joshua J. Wind, Zachary Litvack and Joseph O'Brien

P athology of the craniocervical junction represents one of the more challenging spinal abnormalities in terms of surgical management. Numerous pathologies can lead to abnormal degeneration of the craniocervical junction, including osteoarthritis, rheumatoid arthritis (RA), 13 , 23 , 25 Down's syndrome, 25 , 39 neoplasia, 25 trauma, 1 and Chiari malformation. 13 , 31 Lesions in this location have been traditionally accessed through an anterior approach to reduce mass effect on the brainstem and high cervical spinal cord. Often a large pannus forms in