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R. Shane Tubbs, Justin D. Hallock, Virginia Radcliff, Robert P. Naftel, Martin Mortazavi, Mohammadali M. Shoja, Marios Loukas, and Aaron A. Cohen-Gadol

aspects of each. Search engines such as PubMed and various germane textbooks were used, searching for salient chapters and terms such as the following: ligaments, neck, occipital, atlas, axis, connective tissues, anatomy, biomechanics, pathology, C-1, C-2, membrane, craniocervical junction, and craniovertebral junction. Biomechanics of CCJ The CCJ is composed of 2 major joints: the atlantooccipital and the atlantoaxial joints. These joints are responsible for the majority of the movement of the cervical spine and operate on different biomechanical principles. The

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Emiliano Passacantilli, Antonio Santoro, Angelo Pichierri, Roberto Delfini, and Giampaolo Cantore

extended to the lower cervical spine. This operative route does not yield additional morbidity. Acknowledgments We thank Sharon Hobby for her assistance in the preparation of the manuscript and Alexandra Valenti for the drawing of Fig. 1 . Abbreviations used in this paper CCJ = craniocervical junction ; ICA = internal carotid artery ; MR = magnetic resonance ; VA = vertebral artery . References 1. Baldwin HZ , Miller CG , van Loveren HR , Keller JT , Daspit CP

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Jayapalli Rajiv Bapuraj, Amy K. Bruzek, Jamaal K. Tarpeh, Lindsey Pelissier, Hugh J. L. Garton, Richard C. E. Anderson, Bin Nan, Tianwen Ma, and Cormac O. Maher

O ur understanding of craniocervical junction development in children remains incomplete. Surgeons are frequently asked to evaluate children for craniocervical junction abnormalities. In many cases, treatment decisions may be influenced by an understanding of expected normal growth for each age group. 1 , 2 , 9 , 16 Grabb et al. 7 demonstrated that pB–C2 (the Grabb-Oakes line) correlated with ventral brainstem compression in patients with Chiari malformation and that halo traction and/or surgical decompression and fusion may be necessary to relieve ventral

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Flavio Leitao Filho, Marcos Tatagiba, Gustavo A. Carvalho, Wiebke Weichhold, Jörg Klekamp, and Madjid Samii

✓ Neurenteric cysts of the craniocervical junction (CCJ) are very rare lesions. Their origin is the subject of long-standing controversy, but a failure during the embryogenic phase may be responsible for their formation. Accurate histopathological diagnosis may be difficult due to the similarity they share with other cystic lesions such as colloidal cysts, Rathke cysts, and cystic teratomas. Surgical removal is the treatment of choice for intracranial neurenteric cysts, but in some cases, infiltration of the surrounding structures may hinder complete resection. Three cases of neurenteric cysts located at the CCJ are reported.

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Marcelo D. Vilela, Richard J. Bransford, Carlo Bellabarba, and Richard G. Ellenbogen

the dens fracture. Horizontal fractures of the atlas not associated with dens fractures have been regarded as stable injuries that cause no neurological deficits, and they have been treated successfully with the placement of a cervical collar only. 5 , 9 , 11 , 13 , 15 To our knowledge, horizontal fractures of the C-1 anterior arch in association with unstable ligamentous injuries of the craniocervical junction have yet to be reported. In the present study we report on 5 cases of C-1 horizontal fractures associated with severe distraction injuries of the

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Timothy Ryken and Arnold Menezes

Rheumatological complications have been described in up to 30% of patients being followed for inflammatory bowel disease. The majority of these complications occur as spondylitic changes in the lumbar spine. Erosive arthritic disease associated with inflammatory bowel disease occurs less frequently, but it can result in ligamentous laxity and joint instability. To highlight the potential significance of the process at the craniocervical junction, the authors describe the long-term follow-up care of a complicated case. A 56-year-old woman, with a long history of ulcerative colitis, presented with atlantoaxial instability and underwent a C1-3 fusion; however, the presence of significant occipitoatlantal instability was not recognized. This resulted in high cervicomedullary quadriplegia, requiring traction reduction and a combined anterior transoral decompressive-posterior occipitocervical fusion. The patient's neurological deficit completely resolved postoperatively.

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John Y. K. Lee, Bert W. O'Malley Jr., Jason G. Newman, Gregory S. Weinstein, Bradley Lega, Jason Diaz, and M. Sean Grady

3 Hadley MN , Spetzler RF , Sonntag VK : The transoral approach to the superior cervical spine. A review of 53 cases of extradural cervicomedullary compression . J Neurosurg 71 : 16 – 23 , 1989 4 Hockstein NG , O'Malley BW Jr , Weinstein GS : Assessment of intraoperative safety in transoral robotic surgery . Laryngoscope 116 : 165 – 168 , 2006 5 Menezes AH , VanGilder JC : Transoral-transpharyngeal approach to the anterior craniocervical junction. Ten-year experience with 72 patients . J Neurosurg 69 : 895 – 903 , 1988 6

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Vijay M. Ravindra, Jayson A. Neil, Marcus D. Mazur, Min S. Park, William T. Couldwell, and Philipp Taussky

suffered a posterior fossa stroke after archery practice. We present various symptomatic cases of vascular pathology related to motion at the craniocervical junction (CCJ). We include two illustrative cases of extradural arterial compression—one of a patient with bilateral V 3 segment occlusion occurring upon head rotation and one of a patient with bilateral posterior inferior cerebellar artery (PICA) strokes caused when the artery as a solitary feeder with an extradural origin became compressed during patient positioning for an unrelated surgical procedure—and one

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Stefan A. König, Axel Goldammer, and Hans-Ekkehart Vitzthum

levels, the frequency of degeneration is not comparable with the C5–7 levels. Causes of spinal degeneration beside mechanical exposure therefore have to be investigated further by focusing on genetic factors. Abbreviation used in this paper CCJ = craniocervical junction . References 1. Brade H , Koebke J : [Morphological Investigations in the lateral atlantoaxial joints of human beings.] Verh Anat Ges 73 : 141 – 143 , 1979 (Ger) Brade H, Koebke J: [Morphological Investigations in the lateral

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Ulysses C. Batista, Andrei F. Joaquim, Yvens B. Fernandes, Roger N. Mathias, Enrico Ghizoni, and Helder Tedeschi

T he majority of the articles related to spinal alignment evaluate the center of gravity of the sagittal vertical axis, pelvic incidence, cervical and lumbar lordosis, and thoracic kyphosis. 7 , 18 , 23 However, the parameters of the normal craniometric relationships of the craniocervical junction (CCJ), especially those for angular craniometry, are still poorly studied and historically based on measurements taken from plain radiographs. 17 If compared with plain radiographs, where bone structures are superimposed, the use of modern diagnostic imaging