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John R. Vender, Steven J. Harrison, and Dennis E. McDonnell

N umerous surgical approaches to the anterior foramen magnum and ventral surface of the upper cervical spinal cord have been described. 6, 11, 12 The high anterior cervical approach provides wide, bilateral exposure, avoids the potential contamination of the oral and pharyngeal cavities, and allows access to cervical spine segments below C-4. In the past, after decompressive surgery was performed, patients were maintained in traction and returned to the operating room for a second posterior occipitocervical fusion procedure. We present our experience with

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Jean-Paul Wolinsky, Daniel M. Sciubba, Ian Suk, and Ziya L. Gokaslan

endotracheal tube. The risk of postoperative phonation difficulty that is present in a transoral approach is avoided with a transodontoid approach. The risk of injury to the recurrent laryngeal nerve is present but is the same as in an anterior cervical approach. Using a transodontoid approach, more caudal vertebral body resection (below the odontoid) is possible through the same incision because the technique exposes C-1 through C-4 ventrally, and the exposure can be easily extended to provide access caudal to C-4. There is no need for a tracheostomy or gastric or duodenal

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Alfred T. Ogden, Neil A. Feldstein, and Paul C. McCormick

recently established in cases involving the C-3 through T-2 vertebral levels, in which standard anterior cervical approaches and reconstructions can be used. Published accounts of anterior approaches to ventral cervical intradural pathology have included nerve sheath tumors, 13 , 20 meningiomas, 1 , 6 cavernous malformations, 1 , 2 , 19 dermoids, 14 arachnoid cysts, 1 and hemangioblastomas for which anterior resections have been described 10 and promoted as having better motor and sensory outcomes than those approached posteriorly. 21 A few descriptions of the

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Eli M. Baron, Christopher M. Loftus, Alexander R. Vaccaro, and Devanand A. Dominique

✓ Although it was originally developed to address degenerative problems, including disc herniations and cervical spondylotic myelopathy in the adult population, the anterior approach to the subaxial spine has proven to be useful for select indications in the pediatric population. The authors review indications for surgery, bone grafting, and instrumentation as they pertain to children.

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Jules Hardy, Toussaint A. LeClercq, and François Mercky

✓ A technique of selective anterior cordotomy with the operative microscope is described. The anterior approach is preferred on anatomical grounds since the anterior quadrant is in full view without manipulation of the cord and because the anterior spinal artery is readily identified, allowing the cut to be close to the midline and in an avascular space. The benign postoperative course of the technique in poor risk patients is emphasized.

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Jarl Rosenørn, Elisabeth Bech Hansen, and Mary-Ann Rosenørn

✓ A prospective randomized study to compare discectomy without (DE) and with fusion (DEF) included 63 patients operated on for cervical herniated disc. The clinical outcome 3 and 12 months postoperatively was significantly better after DE than after DEF (p < 0.05). Significantly more patients operated on with DE returned to work during the first 9 weeks postoperatively than patients operated on with DEF (p < 0.005 to 0.05). The prognosis is significantly better for men than for women after DEF (p < 0.005), while no difference can be shown after DE.

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Fred C. Lam and Michael W. Groff

anterior decompression, however, the approach outlined in this article should be considered. Anterior approaches to the upper thoracic spine currently include the following: splitting of the midline sternum, ventral cervicothoracic dissection with or without excision of the sternum and subsequent creation of an interaortocaval subinnominate window, low anterior cervical approach, and a modified anterior approach with medial claviculectomy and partial manubriotomy ( Table 1 ). 16 The midline sternotomy was first described by Cauchoix and Binnet 3 in 1957 and

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Masakazu Okawa, Takaaki Amamoto, Hiroshi Abe, Sohei Yoshimura, Toshio Higashi, and Tooru Inoue

routine angiography in our case. To prevent recurrence of stroke, decompression of the VA was essential in our patient. The factors causing compression were evaluated using MRI and CT angiography. Dynamic angiography is the gold standard for diagnosis of dynamic factors. Transcranial Doppler ultrasonography may be feasible in cases with positional VBI. 17 Neck immobilization with a collar is necessary during the preoperative period. The anterior cervical approach is frequently used for decompression of the VA, and was used in all 4 previously reported cases. The

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G. Edward Vates, Kevin C. Wang, David Bonovich, Christopher F. Dowd, and Michael T. Lawton

noninvasive confirmation of the diagnosis, and as in this case, can confirm the success of surgery. In addition, TCD ultrasonography may be a noninvasive method to screen for bow hunter stroke in a patient with signs and symptoms suspicious for the disorder. Cerebral blood flow scintigraphy and single-photon emission CT scanning have also been used to document blood flow abnormalities in patients with bow hunter stroke, 3, 8 but each modality requires injection of a radiolabelled tracer and is not without risk. We chose the anterior cervical approach in our case because

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John A. Boockvar, Matthew F. Philips, Albert E. Telfeian, Donald M. O'Rourke, and Paul J. Marcotte

plates 12 C (2) allograft yes yes (graft fracture) anterior revision & halo placement 13 D (3) allograft no yes (pseudarthrosis) posterior lat mass plates 14 C (4) allograft yes yes (graft fracture) anterior revision & halo placement * C = corpectomy; D = discectomy; ICBG = iliac crest autograft. Operative Procedures The CTJ was exposed via a low anterior cervical approach. Briefly, after the induction of general anesthesia, the patient is placed in the supine position with a slight