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Atul Goel, Mohinish Bhatjiwale and Ketan Desai

B asilar invagination, a primary developmental anomaly, 19, 45 has been a subject of clinical interest for some time. 4, 5, 7, 14, 20, 22, 26, 28, 29, 31, 32, 40, 45–47 Lessons learned during the management of 190 cases of basilar invagination are analyzed in this report. Clinical Material and Methods Approximately 1800 patients with craniovertebral anomalies were treated in the neurosurgery department at King Edward Memorial Hospital between 1950 and 1996. In the present study 190 cases of patients with basilar invagination who were surgically treated

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

P ediatric basilar invagination and cranial settling are progressively debilitating conditions that result in profound neurological deficits if left untreated. Primary basilar invagination is thought to be a developmental defect of the chondrocranium and is often associated with notochord malformations (Oc–C1 assimilation and Klippel-Feil abnormality), representing a failure of craniocervical segmentation 10 , 25 , 37 as well as abnormalities of the epichordal neural axis (Chiari I malformation and syringobulbia). 10 , 15 , 25 Secondary basilar

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Atul Goel

W e have discussed the subject of basilar invagination and described a classification for these anomalies based on the presence or absence of Chiari I malformation. 3, 7 Based on the possibility of pathogenetic factors, we had suggested a specific treatment protocol for each of the two groups. With our improved understanding of the subject, we reclassified basilar invagination into two groups based on parameters that determined an alternative treatment strategy. In Type A basilar invagination, there was a fixed atlantoaxial dislocation and the tip of the

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Atul Goel and Abhidha Shah

M any abnormalities of the neck and spine are associated with basilar invagination. Torticollis, reduced neck length, and a low hairline have been recognized as the hallmarks for several decades. A wide range of cervical vertebral fusion defects and soft tissue abnormalities have also been recognized. Although a number of parameters have been used to identify cases of basilar invagination, the criterion of the tip of the odontoid process being at least 2.5 mm above the Chamberlain line has been uniformly accepted. 1 We had earlier further classified

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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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Paul D. Sawin and Arnold H. Menezes

Anomalies of the craniovertebral junction occur with less frequency, but may precipitate severe structural deformity and progressive neurological dysfunction when present. Of these anomalies, secondary basilar invagination may be the most common and disabling. 2, 5, 8, 9, 11, 15, 17, 18, 22, 30, 34, 37, 38 Since Ekman's initial description of this condition as “congenital osteomalacia” in 1788, several taxonomic schemes have been proposed to categorize OI, including one by Weil. 48 Looser 23 divided OI into congenita and tarda forms, based on age at presentation

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

resection of the ligamentous structures. Results Three patients with irreducible basilar invagination were operated upon using this approach ( Table 1 ). The patients’ ages ranged from 42 to 74 years. All were symptomatic, with neck pain and myelopathy. The degree of basilar invagination (as measured by millimeters above the McGregor line) ranged from 8 to 14 mm. Preoperative and postoperative sagittally reconstructed images are presented for each case ( Figs. 3–5 ). In all three cases, complete decompression was achieved through the endoscopic transcervical

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Ricardo V. Botelho, Eliseu B. Neto, Gustavo C. Patriota, Jefferson W. Daniel, Paulo A. S. Dumont and José M. Rotta

deformity. References 1 Friede RL , Roessmann U : Chronic tonsillar herniation: an attempt at classifying chronic herniations at the foramen magnum . Acta Neuropathol 34 : 219 – 235 , 1976 2 Goel A : Treatment of basilar invagination by atlantoaxial joint distraction and direct lateral mass fixation . J Neurosurg Spine 1 : 281 – 286 , 2004 3 Goel A , Bhatjiwale M , Desai K : Basilar invagination: a study based on 190 surgically treated patients . J Neurosurg 88 : 962 – 968 , 1998 4 Joseph V , Rajshekhar V : Resolution of

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Mitchell A. Hansen, Melville J. da Cruz and Brian K. Owler

correlation . Pediatr Radiol 24 : 427 – 430 , 1994 7 Wolinsky JP , Sciubba DM , Suk I , Gokaslan ZL : Endoscopic image-guided odontoidectomy for decompression of basilar invagination via a standard anterior cervical approach. Technical note . J Neurosurg Spine 6 : 184 – 191 , 2007

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Jörg Klekamp

T he management of Chiari I malformations and basilar invaginations has been quite controversial in recent years. Issues such as whether the dura mater should be opened, if duraplasties are required, or whether the arachnoid should be opened have been discussed for patients with Chiari I malformations, and the necessity for transoral decompressions in basilar invagination has been questioned, emphasizing that realignment and C1–2 fusion is sufficient. Although most patients with basilar invagination will also demonstrate a Chiari I malformation, almost all