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Rinchen Phuntsok, Marcus D. Mazur, Benjamin J. Ellis, Vijay M. Ravindra and Douglas L. Brockmeyer

cannot be said about the pediatric counterpart. Primarily because of a lack of human pediatric cadaveric tissue, but also because of the relatively small number of treated patients, this is a significantly understudied area in spinal biomechanics. This fact is especially true of the most complex region of the pediatric spine: the craniocervical junction (CCJ). This region includes the bony elements of the occiput, atlas (C-1), and axis (C-2), as well as the supporting ligamentous and soft-tissue structures. Our current biomechanical knowledge is based mostly on

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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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Heidi Arponen, Ilkka Vuorimies, Jari Haukka, Helena Valta, Janna Waltimo-Sirén and Outi Mäkitie

compression of the brainstem and/or related neurovascular structures, resulting in a variety of subsequent neurological complications and symptoms. Chiari malformation is a possible comorbidity. 19 , 27 Severe pathology can lead to perinatal death, whereas milder forms restrict life and cause moderate reduction of life span. 29 Pathology of the craniocervical junction and cranial base can be divided into 1) basilar impression, characterized by relative lowering of the skull base with endocranial introflection of the posterior edge of the foramen magnum; 2) basilar

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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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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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Matthew J. McGirt, Frank J. Attenello, Daniel M. Sciubba, Ziya L. Gokaslan and Jean-Paul Wolinsky

compression and stabilization of the craniocervical junction are needed to prevent progression of deficits in children afflicted with this disease. 5 , 6 , 8 , 13 , 14 , 17 , 18 , 27 , 29 , 32–34 , 39 , 40 , 42 , 43 , 46 Currently, the standard direct approach to this area is through the transoral–transpharyngeal approach. 5 , 13 , 14 , 18 , 29 , 32–34 , 39 , 40 , 43 , 46 If added exposure is required, then a transmandibular route 6 , 8 , 17 , 27 , 42 or Le Fort osteotomies 2 , 7 , 26 can be used. Refinements in surgical technique have improved the morbidity and

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Marcílio Diogo de Oliveira Barbosa, Thiago de Bellis, Marcelo Sampaio Pousa, Rodrigo Sodré Calheiros da Silva, Flávio Assad Garcia and Marcus André Acioly

while in the spine, they predominantly affect the thoracic segment. 4 We report on the unique case of a bullet retained in the cerebellomedullary cistern, discussing the treatment strategy that we have adopted since this situation, to the best of our knowledge, has never been presented to date. Case Report History and Examination A 6-year-old girl was admitted to our emergency room with a GSW in the posterior craniocervical junction. On admission, she was alert (Glasgow Coma Scale Score 15) with reactive pupils. Incomplete tetraparesia (left flaccid

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Smruti K. Patel and James K. Liu

junction posterolat approach Fujita et al., 1997 16 yrs † M clivus/CPA retromastoid suboccipital craniectomy Lonjon et al., 1998 14 yrs M foramen magnum suboccipital craniectomy w/ C1–2 laminectomy Ergün et al., 2000 3 yrs M craniocervical junction posterior laminoplasty Vlaho et al., 2003 2 yrs M 3rd ventricle neuroendoscopic fenestration of 3rd ventricle cyst Goel et al., 2005 10 yrs F anterior & anterolat to brainstem retrosigmoid approach 18 yrs M anterior & anterolat to brainstem retrosigmoid

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Michael Karsy, Neal Moores, Faizi Siddiqi, Douglas L. Brockmeyer and Robert J. Bollo

cases of BSSMO for odontoidectomy have been reported in adult patients with juvenile rheumatoid arthritis, 13 Klippel-Feil syndrome, and congenital occipitocervical instability, 37 BSSMO has not been previously reported as a method to improve anterior access to the subaxial cervical spine in young children with cervical chin-on-chest deformities. Herein, we describe our surgical technique and present 5 pediatric cases with long-term follow-up, in which BSSMO was used to provide enhanced surgical access to the craniocervical junction and subaxial cervical spine

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Bassel Zebian, Florence Rosie Avila Hogg, Richard Zhiming Fu, Ramanan Sivakumaran and Simon Stapleton

pathological yawning. Presentation was acute in the first case and more chronic in the second. Imaging showed brainstem edema in combination with CM-I. Both patients underwent foramen magnum decompression, which resulted in complete cessation of the excessive yawning. Given the role of the brainstem in yawning, we believe that medullary compression at the craniocervical junction and ensuing edema were implicated in this curious symptomatology. Case Reports Case 1 History and Examination A 12-year-old girl whose twin sister had undergone foramen magnum