In vivo and in vitro CT analysis of the occiput.
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Arguments concerning the best procedure for occipito-cervical fusion have rarely been based upon occipital bone thickness or only based on in vitro studies. To close this gap and to offer an outlook on preoperative evaluation of the patient, 28 patients were analysed in vivo by means of spiral CT. Ten macerated human skulls were measured by means of CT and directly. Measurements were taken according to a matrix of 66 points following a grid with 1 cm spacing based upon McRae's line. Maximum thickness in the patient group was met 4 cm above the reference plane in the median slice (11.87 mm; SD 3.41 mm) and 5 cm above it in the skull group (15.85 mm; SD 1.81 mm). Correlation between CT and direct measurements was good (91.79%). Intra-individual discrepancies from one side to the respective point on the other side are common (difference > 1 mm in 60%). Judging areas suitable for operative fixation using the 10% percentile value (6.68 mm for the maximum value of 11.87 mm) led to the conclusion that screws should only be inserted along the occipital crest in an area extending from 1.5 cm above the posterior margin of the foramen magnum to the external occipital protuberance (EOP). At the level of the EOP screws may also be inserted up to 1 cm lateral of the midline. A reduction of screw length to 7 mm (9 mm for the EOP) is proposed. Preoperative evaluation of the patient should be carried out by spiral CT with 1 mm slicing and sagittal reconstructions. (+info)
Suboccipital approach to the distal vertebral artery.
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A technique to expose directly the pars atlantica or the vertebral artery through a posterior approach was studied. It is useful when dealing with occlusive, aneurysmal, or dissecting lesions that extend to the transverse process of C1 or beyond. This technique permits exposure of the entire pars atlantica or the vertebral artery, from its exit from the foramen transversarium of C1 to its penetration of the dura mater at the foramen magnum. The experience with this technique in three patients is described. (+info)
Dandy-Walker syndrome associated with occipital meningocele and spinal lipoma--case report.
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A neonate presented with Dandy-Walker syndrome associated with occipital meningocele and spinal lipoma, manifesting as soft masses on the skull and lumbosacral regions. Magnetic resonance imaging demonstrated a large posterior fossa cyst between the fourth ventricle and occipital meningocele, but the aqueduct was patent and there was no sign of hydrocephalus. A cyst-peritoneal shunt was emplaced at the age of 8 days followed by partial removal of the spinal lipoma and untethering of the cord at the 3 months. Follow-up examination of age 3 years found almost normal development, although the cyst still persisted. (+info)
Stage-related surgery for cervical spine instability in rheumatoid arthritis.
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Thirty-six consecutive patients with cervical spine instability due to rheumatoid arthritis (RA) were treated surgically according to a stage-related therapeutic concept. The aim of this study was to investigate the clinical results of these procedures. The initial change in RA of the cervical spine is atlanto-axial instability (AAI) due to incompetence of the cranio-cervical junction ligaments, followed by development of a peridontoid mass of granulation tissue. This results in inflammatory involvement of, and excessive dynamic forces on, the lateral masses of C1 and C2, leading to irreducible atlanto-axial kyphosis (AAK). Finally, cranial settling (CS) accompanied by subaxial subluxation (SAS) occurs. According to these three separate pathological and radiological lesions, the patients were divided into three therapeutic groups. Group I comprised 14 patients with isolated anterior AAI, who were treated by posterior wire fusion. Group II comprised 15 patients with irreducible AAK, who were treated by transoral odontoid resection. The fixation was done using anterior plating according to Harms in combination with posterior wire fusion according to Brooks. Group III comprised seven patients with CS and additional SAS, who were treated with occipito-cervical fusion. Pre- and postoperatively, evaluation was performed using the parameters pain (visual analog scale), range of motion (ROM), subjective improvement and Health Assessment Questionnaire (HAQ). The neurologic deficit was defined according to the classification proposed by Ranawat. Radiographs including lateral flexion and extension views, and MRI scans were obtained. The average clinical and radiographic follow-up of all patients was 50.7 +/- 19.3 months (range 21-96 months). No perioperative fatality occurred. Postoperative pain was significantly relieved in all groups (P < 0.001). In group II a slight improvement in the HAQ was obtained. In groups I and II the ROM of all patients increased significantly (average gain of motion in group I: 11.3 degrees +/- 7. 8 degrees for rotation; 7.8 degrees +/- 5.6 degrees for bending; average gain of motion in group II: 21.5 degrees +/- 14.0 degrees for rotation; 17.2 degrees +/- 5.5 degrees for bending), while it decreased significantly in group III (10.7 degrees +/- 18.1 degrees for rotation; 6.7 degrees +/- 18.5 degrees for bending). Preoperatively 27 patients had a manifest neurologic deficit. At follow-up four patients remained unchanged, all others improved by at least one Ranawat class. All patients, except one, showed solid bony fusion. According to the significantly improved postoperative subjective self-assessment and the clinical and radiological parameters, transoral plate fixation combined with posterior wire fixation after transoral odontoid resection represents an effective reliable and safe procedure for the treatment of irreducible AAK in rheumatoid arthritis. (+info)
Fetal acalvaria with amniotic band syndrome.
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A case of amniotic band syndrome (ABS) presenting with acalvaria is reported. ABS includes a spectrum of non-genetic anomalies, varying from simple digital band constriction to major craniofacial and visceral defects, and even fetal death. Acalvaria is a rare congenital malformation characterised by the absence of the dome-like superior portion of the cranium comprising the frontal, parietal, and occipital bones and dura mater, in the presence of a normal skull base and facial bones with complete cranial contents. No two cases are the same. Acrania or absence of the flat skull bones with disorganised cerebral hemispheres have been reported in the presence of amniotic bands. ABS is an aetiological factor in acalvaria. Appropriate counselling for affected families needs to be given after prenatal diagnosis. (+info)
Fracture of the occipital condyle: the forgotten part of the neck.
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A case of occipital condylar fracture in a multiply injured and unconscious motorcyclist is reported. This injury was clinically unsuspected but found on the lowest cuts of head computed tomography. It is shown that this site is often inadequately imaged when scanning the head and neck in victims of trauma. The Anderson and Montesano classification of occipital condylar fracture is described. It is noted that types 1 and 2 are stable injuries but type 3 is potentially unstable. A retrospective analysis of 30 head computed tomography scans in trauma cases revealed that in only 16 were the occipital condyles adequately imaged. It is emphasised that vigilance is required to detect fractures of the occipital condyle and that it should be standard practice to include this area when performing computed tomography of the head in trauma victims. (+info)
Location of the glenoid fossa after a period of unilateral masticatory function in young rabbits.
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Changes in glenoid fossa position and skull morphology after a period of unilateral masticatory function were studied. The right-side maxillary and mandibular molars in twenty-seven 10-day-old rabbits were ground down under general anaesthesia. The procedure was repeated twice a week, until the rabbits were 50 days old. Fourteen rabbits were then killed and 13 left to grow to age 100 days. Nine 50-day-old and sixteen 100-day-old rabbits with unmodified occlusions served as controls. Three-dimensional measurements were made using a machine-vision technique and a video-imaging camera. The glenoid fossa position become more anterior in both groups of animals subjected to molar grinding as compared with controls (P < 0.01 in the 50-day-old group and P < 0.05 in 100-day-old group). In the 100-day-old group the right-side fossa was also in a more inferior position (P < 0.01). The glenoid fossa was more anteriorly located on the right than on the left side of individual animals in the group in which the right-side molars had been ground down (P < 0.001). (+info)
The prenatal cranial base complex and hand in Turner syndrome.
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From early childhood, Turner syndrome patients have a flattened cranial base, maxillary retrognathism, and short hands. There are, however, no studies that show when these genotype-determined abnormalities occur prenatally. The purpose of the present study was to measure craniofacial profile and hand radiographs of second trimester foetuses with Turner syndrome and compare the results with similar measurements from normal foetuses. The subjects consisted of 12 Turner syndrome foetuses, gestational age (GA) varying between 15 and 24 weeks, and crown-rump length (CRL) between 108 and 220 mm. The mid-sagittal block of each cranium was analysed as part of the requested brain analysis (pituitary gland analysis). This block and the right hand from seven foetuses were radiographed, and the skeletal maturity of the cranial base complex, i.e. the cranial base and the maxilla, was evaluated from the profile radiographs. Shape and size measurements in the cranial base were performed, and compared with normal values according to cranial maturity and to CRL. The cranial base angle in Turner syndrome was greater and the maxillary prognathism was reduced compared with the normal group. The dimensions in the cranial complex and in the hand showed that the bone lengths and distances in relation to CRL were generally smaller compared with normal foetuses. This investigation showed that the abnormal shape of the cranial base complex and the short hands in Turner syndrome are present prenatally. (+info)