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Revision suboccipital decompression for complex Chiari malformation
Published in Gregory D. Schroeder, Ali A. Baaj, Alexander R. Vaccaro, Revision Spine Surgery, 2019
Jacob L. Goldberg, Ibrahim Hussain, Ali A. Baaj, Jeffrey P. Greenfield
There are two critical relative contraindications for repeat suboccipital decompression in patients with Chiari 1 or Chiari 1.5, despite persistent symptoms following an initial surgery. First, patients with continued neck and occipital pain, particularly when upright or with activity, may be experiencing symptoms of CCI rather than static posterior fossa compression. For these patients, further decompression may exacerbate instability, and surgeons must be vigilant for patients with concomitant connective tissue disorders such as Ehlers–Danlos syndrome (EDS). Flexion-extension x-rays may demonstrate listhesis that confirms the diagnosis; however, even with negative flexion/extension plain films, a hard-cervical collar trial for 2–6 weeks may be warranted. These trials in patients with craniocervical instability (CCI) due to EDS may result in obvious self-reported improvements in pain and symptoms, providing additional support for a diagnosis of CCI. In these patients, occipitocervical fusion may be discussed as a more appropriate solution than revision decompression surgery.
Osteotomy of the Cervical Spine in Ankylosing Spondylitis
Published in Barend J. van Royen, Ben A. C. Dijkmans, Ankylosing Spondylitis Diagnosis and Management, 2006
Hesham El Saghir, Heinrich Boehm
The cervical disorders of mechanical origin are: chronic neck pain,ankylosis and limitation of neck movements,cervicothoracic kyphosis,fractures and Anderson’s lesions,subaxial instability,atlantoaxial instability, andcraniocervical instability and/or stenosis.
Hypermobility of the spine: Ehlers Danlos and neurosurgery, the route forward in the UK?
Published in British Journal of Neurosurgery, 2023
Andrew Brodbelt, Jake Timothy, Nicholas Haden, Joshi George
Three pathophysiological mechanisms for the symptoms due to craniocervical instability in hEDS have been proposed. In the series described above, 71% of the HDCT group were said to have pannus of 3mm or more and basilar invagination, supporting a direct compressive mechanism on the brainstem.3 A second proposition is that hypermobility at the craniocervical junction increases strain on the brain stem, associated tracts, and the axons.4 Stretching of axons affects synaptic firing rates and amplitude, NMDA expression, mitochondrial function, and can eventually lead to apoptosis. Fixation is postulated as reducing the strain and microtrauma of hypermobility.4 The final hypothesis relates to the myodural bridge that attaches the craniocervical dura to the adjacent musculature. This is said to support and limit movement of the spinal cord and adjacent brain stem, and when deficient, as in EDS patients, leads to excessive pathological spinal cord motion. This has been postulated as precipitating significant symptoms without the need for the hypermobility described in the diagnostic measurements described above.5
Integrity of the tectorial membrane is a favorable prognostic factor in atlanto-occipital dislocation
Published in British Journal of Neurosurgery, 2020
Gil Kimchi, Gahl Greenberg, Vincent C. Traynelis, Christopher D. Witiw, Nachshon Knoller, Ran Harel
Our hypothesis is that the extent of damage to the ligamentous structures of the craniocervical junction is variable within patients with AOD, and it may directly affect the severity of neurological deficit at the time of presentation. According to a previous retrospective analysis of 69 patients with AOD, an association between a BDI greater than 16 mm and increased mortality was demonstrated, suggesting that the degree of craniocervical instability is an independent risk factor for poor clinical outcome 3. In a pivotal publication by Traynelis et al.,5 the authors classified this injury on the basis of the vector of displacement. Recently, a comprehensive review of the literature reapproved previous reporting that a Traynelis Type II dislocation is associated with the overall highest mortality rates.2 It is reasonable to assume that the various dislocation types entail damage to different ligamentous structures of the CCJ, and accounts for the unfavorable outcome in this dislocation type. We thus consider this correlation to further exemplify the prognostic role of the type of ligamentous injury involved.