Abstract
Proper craniocervical alignment during craniocervical reduction, stabilization, and fusion optimizes cerebrospinal fluid (CSF) flow through the foramen magnum, establishes the appropriate “gaze angle”, avoids dysphagia and dyspnea, and, most importantly, normalizes the clival-axial angle (CXA) to reduce ventral brainstem compression. To illustrate the metrics of reduction that include CXA, posterior occipital cervical angle, orbital-axial or “gaze angle”, and mandible-axial angle, we present a video illustration of a patient presenting with signs and symptoms of the cervical medullary syndrome along with concordant radiographic findings of craniocervical instability as identified on dynamic imaging and through assessment of the CXA, Harris, and Grabb-Oakes measurements.
Highlights
Craniocervical reduction, stabilization, and fusion are performed after suboccipital craniotomy for Chiari I malformation with basilar invagination, craniocervical instability due to trauma or neoplasm, and connective tissue disorders [1,2,3]
The authors introduce a direct measure of gaze angle: the orbital-axial angle (OAA) and a mandible-axial interval (MAI) metric of the pharyngeal space to avoid dyspnea and dysphagia
To illustrate the metrics of reduction, we present a patient with signs and symptoms of the cervical medullary syndrome, which included severe head and neck pain, spasticity, weakness, sensory loss, and radiological indices of ventral brainstem compression, a kyphotic clivalaxial angle (CXA), craniocervical instability, along with pathological translation between flexion and extension images [4,7,8,9]
Summary
Craniocervical reduction, stabilization, and fusion are performed after suboccipital craniotomy for Chiari I malformation with basilar invagination, craniocervical instability due to trauma or neoplasm, and connective tissue disorders [1,2,3]. To illustrate the metrics of reduction, we present a patient with signs and symptoms of the cervical medullary syndrome, which included severe head and neck pain, spasticity, weakness, sensory loss, and radiological indices of ventral brainstem compression, a kyphotic CXA, craniocervical instability, along with pathological translation between flexion and extension images [4,7,8,9]. We present a chronically disabled patient with severe head and neck pain who presented with symptoms of cervical medullary syndrome, including hyperreflexia, weakness, sensory deficits, Romberg sign, and inability to perform tandem gate Both CT scan and upright flexion/extension MRI demonstrated a kyphotic CXA of 120°, considered pathological since it was less than 135°, raising concern for abnormal stretching of the brainstem, out-of-plane loading, and pathological deformative stress.
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