Craniocervical Region Research Articles

Spinal and cranio-cervical mycetoma: A difficult surgery, with poor prognosis

BackgroundFew central nervous systems (CNS) cases of actinomycetoma have been recorded in the literature, and most were reported in tropical and subtropical regions. The management of this invasive infection is difficult, especially when it affects the spine and the cranio-cervical regions. CaseWe report an unusual case of a cranio-cervical junction actinomycetoma, in a patient presenting a cerebellar syndrome from brainstem compression. The CT scan showed a compressive solid osteolytic lesion in the cranio-cervical junction. The patient underwent cranio-cervical decompression and lesion resection. The diagnosis of actinomycetoma was confirmed on immune-histochemistry and molecular analysis. At 4 months’ follow-up, the patient presented a fatal recurrence disseminating within the cerebellum and the spine. ConclusionThe surgical treatment of CNS actinomycetoma presented poor prognosis and a disseminating recurrence. We believe that clinicians and surgeons must be informed about these “new” infectious pathologies that are so difficult to treat, especially with the arrival of migrant patients from endemic countries in conflict.

An investigation of biomechanics, muscle performance, and disability level of craniocervical region of individuals with temporomandibular disorder

ABSTRACT Objective To investigate biomechanics, muscle performance, and disability of the craniocervical region in temporomandibular disorder (TMD) patients and compare them with controls. Methods Craniocervical posture was evaluated using lateral photography and radiography. Range of motion, muscle performance, disability, and TMD severity were assessed using an inclinometer, Functional Strength Testing of Cervical Spine, Neck Disability Index, and Fonseca Anamnestic Index, respectively. Results Compared to the control group, the TMD group demonstrated higher cervical flexion angle (p=0.005) and neck disability (p<0.001) as well as lower cervical extension (p=0.040), right cervical rotation (p=0.005), left cervical rotation (p<0.001), and tragus-C7-horizontal (p=0.048) angles, and reduced muscle performances (p≤0.001). Most patients had higher than normal craniocervical angle (p<0.001). Muscle performance in each cervical motion (p<0.005) and disability (p<0.001) were associated with TMD severity in the TMD group. Conclusion Biomechanics, muscle performance, and disability of craniocervical region were altered in the TMD group.

Clinical characteristics of Corynebacterium simulans.

ABSTRACT Corynebacterium simulans was first reported in 2000. Its characteristics such as isolation frequency, specimen types, and antimicrobial susceptibilities are poorly understood, because identification is difficult using conventional methods. We performed a retrospective observational study of 13 and 317 strains of C. simulans and C. striatum, respectively, isolated from consecutive patients at Nagoya University Hospital from January 2017 to December 2018. We analyzed patients’ backgrounds, types of specimens, and antimicrobial susceptibilities. Antimicrobial susceptibilities were compared with those of C. striatum. The frequencies of isolation of C. simulans and C. striatum were 3.9% and 96%, respectively. C. simulans was not detected in specimens associated with mucous membranes, such as sputum and secretions from the craniocervical region, which were frequent for C. striatum. C. simulans was mainly detected in the skin (61.5%). All C. simulans isolates were susceptible to anti-MRSA drugs, as well as to numerous other antibiotics, including those that are orally administered. For example, C. simulans was significantly more susceptible to penicillin G, ceftriaxone, and ciprofloxacin than C. striatum (respective susceptibilities: 66.7% vs 5.4%, 50.0% vs 4.0%, 66.7% vs 5.9%). There was no significant difference between meropenem and erythromycin, although susceptibility to each was relatively high (100.0% vs 31.7%, 50.0% vs 11.9%). C. simulans was susceptible to numerous orally administered antibiotics and more susceptible to antimicrobial drugs than C. striatum. C. simulans was detected less frequently than C. striatum and was infrequently detected in specimens associated with mucous membranes. These characteristics will aid the selection of optimal antimicrobial therapies.

An Unrecognized Ligament and its Ossification in the Craniocervical Junction: Prevalence, Patient Characteristics, and Anatomic Evidence.

An Unrecognized Ligament and its Ossification in the Craniocervical Junction: Prevalence, Patient Characteristics, and Anatomic Evidence.

Postural and craniocervical dysfunctions and their relationship to the voice of women with cervical pain

Introduction: Altered body alignment may contribute to the onset of muscle hypertension in the cervical region. Alterations in the cervical region can generate several complications, including pain and hypertension during phonation. Objective: To relate the postural with functional alterations of the craniocervical region and the voice of women complaining of musculoskeletal pain in the cervical region. Methods: Case study with ten women complaining of cervical pain. Assessments: Craniocervical Dysfunction Index, photogrammetry, maximum vowel phonation time of the vowel /a/, and sound pressure level. Results: Craniocervical Dysfunction Index: 100% dysfunction. Maximum phonation time /a/: 100% decreased. There was a moderate significant positive correlation between these variables. Photogrammetry: all participants presented alterations in the calculated alignments. Sound pressure level: 90% altered. Conclusion: There were postural and functional dysfunctions in the craniocervical region and vocal alteration, suggesting that vocal imbalances are more related to functional than postural alterations of the craniocervical region.

Vehicle fatalities involving collisions with kangaroos.

A search was undertaken of the Forensic Science South Australia (FSSA), Australia, autopsy database over a 20-year period from 2000 to 2019 for all cases where vehicle crashes had involved kangaroos. There were six cases with an age range of 18-62 years (M=42 years) and a male-to-female ratio of 5:1. There were three crashes involving motor vehicles and three involving motorcycles. The three motor-vehicle crashes were initiated by impact with a kangaroo followed by a head-on crash with a truck (n=1) and a tree (n=2). In two of the motorcycle crashes, the cycle hit a kangaroo, resulting in the rider being unseated. In the third case, following impact with the animal, the cyclist hit a tree. In one of the latter cases, the only evidence of impact with a kangaroo was fur found by investigating officers adherent to the front-right indicator. Lethal injuries were located in the chest in six cases, the cranio-cervical region in five cases and the abdomen in three cases. Thus, in the majority of cases (n=5), death was due to multiple injuries. In the remaining case, death was caused by blunt chest trauma. This study shows that kangaroo-vehicle impacts may result in very significant blunt-force trauma. Motorcycle riders are particularly vulnerable. It may be only by careful examination of the vehicle/motorcycle for animal residues that the nature of the incident will be clarified.

JOURNEY OF THE NOTOCHORD: LINKING EMBRYOLOGY TO RADIOLOGIC INTERPRETATION OF THE CRANIOCERVICAL JUNCTION

<h3>Background</h3> The notochord is a mesoderm-derived cylindrical midline structure and a defining feature found in all chordates. In vertebrates, the notochordal process represents the initial embryologic axial skeleton and plays important structural and signaling roles in the development of the vertebral column, nervous system, and skull base. Besides persisting postnatally as the nucleus pulposus of the intervertebral disks, the remaining notochord typically regresses during fetal development after completion of its principal tasks. However, remnants of the notochord can persist along its developmental path within the craniocervical region. These remnants present as a spectrum of entities, ranging from anatomic variants, benign tumors, and malignant neoplasms of notochordal origin. Radiologists who interpret imaging in the area along the embryologic path of the notochord should be knowledgeable about its development and be able to recognize its wide array of potential pathologies. <h3>Discussion</h3> This presentation will review notochord embryology and the anatomic and pathologic relevance of notochordal remnants and demonstrate the vast range of imaging features and behavioral properties of these postnatal remnants in the area of the posterior cranial base and cervical spine. We present 3 cases of inferior median clival canal, a notochordal anatomic variant typically discovered as an incidental finding. Also known as <i>canalis basilaris medianus</i>, this notochord remnant manifests as a narrow, well-defined corticated canal passing through the sagittal plane of the clivus. Depending on its course and extent, 2 groups with 6 subtypes have been described. We also present imaging features of pathologic abnormalities, including Tornwaldt cyst, benign remnant ecchordosis physaliphora, and chordoma, a notochord malignancy. Awareness of the full spectrum of pathologic consequences of persistent notochord tissue, recognition of their imaging features, and directing appropriate referral add to the value provided by an oral and maxillofacial radiologist.

Posterior fossa decompression with duraplasty in Chiari malformation type 1: a systematic review and meta-analysis.

Surgery for symptomatic Chiari type I malformation (CM-I) patients include posterior fossa decompression (PFD) involving craniectomy with or without dural opening, and posterior fossa decompression with duraplasty (PFDD). This review aims to examine the evidence to aid surgical decision-making. A medical database search was expanded to include article references to identify all relevant published case series. Animal studies, editorials, letters, and review articles were excluded. A systemic review and meta-analysis were performed to assess clinical and radiological improvement, complications, and reoperation rates. Seventeen articles, containing data on 3618 paediatric and adult participants, met the inclusion criteria. In the group, 5 papers included patients that had the dura left open. PFDD is associated with better clinical outcomes (RR 1.24, 95% CI, 1.07 to 1.44; P = 0.004), but has a higher complication rate (RR 4.51, 95% CI, 2.01 to 10.11; P = 0.0003). In adults, clinical outcomes differences did not reach statistical significance (P = 0.07) but re-operation rates were higher with PFD (RR 0.17, 95% CI 0.03 to 0.86; P = 0.03), whilst in children re-operation rates were no different (RR 0.97, 95% CI 0.41 to 2.30; P = 0.94). Patients with a syrinx did better with PFDD (P = 0.02). No significant differences were observed concerning radiological improvement. In the absence of hydrocephalus and craniocervical region instability, PFDD provides better clinical outcomes but with higher risk. The use of PFD may be justified in some cases in children, and in the absence of a syrinx. To help with future outcome assessments in patients with a CM-I, standardization of clinical and radiological grading systems are required. not required.

Reliability and discriminative validity of a screening tool for the assessment of neuromuscular control and movement control in patients with neck pain and healthy individuals

Background To evaluate the reliability and discriminative validity of a proposed adapted tool for the assessment of movement control in patients with and without neck pain. Method A cross-sectional study at a University hospital center involving 25 pain-free healthy controls and 25 patients suffering from neck pain. Participants were assessed by two raters for inter-rater reliability and 1 week afterwards by a same rater for intra-rater reliability. The assessment involved a test for the axioscapular (adapted scapular holding test; SHT) and craniocervical (adapted craniocervical flexion test; CCFT) region for which intra-class correlation coefficients (ICCs) were computed to define the reliability. Discriminative validity to distinguish patients from controls was assessed by cross-validated computation of sensitivity, specificity, positive and negative likelihood ratios, overall accuracy, and area under the curve. Results The proposed tool was able to reliably assess sensorimotor impairment in participants at the craniocervical region (ICCintra = [0.52–0.82]; ICCinter = [0.60–0.85]), left axioscapular region (ICCintra = [0.43–0.77]; ICCinter = 0.71–0.90), and right axioscapular region (ICCintra = [0.47–0.79]; ICCinter = [0.42–0.77]). Furthermore, the tool yielded a sensitivity of 0.86, a specificity of 0.57, and accuracy of 0.71 (based on cross-validation). Conclusion The proposed tool is able to reliably evaluate patients based on their sensorimotor performance in the craniocervical and axioscapular region. Implications for rehabilitation Neck pain is related to sensorimotor impairment including neuromuscular differences and atypical sensormimotor control strategies. Clinicians should not avoid the challenging task of screening for sensorimotor impairment in patients reporting neck pain. The proposed tool supplemented with other tools might guide clinicians in the evaluation of sensorimotor impairment.

Numerical Analysis of Bicycle Helmet under Blunt Behavior

This study evaluates various safety aspects of standardized impacts that cyclists may suffer while wearing a bicycle helmet, by combining a partially validated finite element model of the cranio-cervical region and a newly developed commercial bicycle helmet model. Under EN 1078 standardized impact conditions, the results of simulated impact tests show that the helmet can absorb 40% to 50% of the total impact energy at impact velocities above 4 m/s. Further, based on a relationship between the head injury criterion and the risk of injury from field data, the results of the simulations suggest that minor injuries may occur at impact velocities of 10 km/h, serious injuries at 15 km/h, and severe injuries at 20 km/h. Fatal injuries will likely occur at impact velocities of 30 km/h and higher.

Atlantoaxial bands in small breed dogs: influence of external pressure by the endotracheal tube tie.

To determine the prevalence of dorsal cervical spinal compression in a population of dogs susceptible to caudal occipital dysplasia. To determine whether endotracheal tube ties iatrogenically alter the dorsal compression ratio in the atlantoaxial region. Prospective, randomised, controlled, cross-over, blinded cohort study of dogs weighing <15 kg and presenting for neurologic signs localised to the cervical region. In mid-sagittal T2-weighted MR images, dorsal cervical compression and cerebellar compression were evaluated. Dorsal cervical compression ratios were calculated and compared to determine the effect of the endotracheal tube tie on the atlantoaxial region depending on whether dogs were in extended or flexed neck position. Prevalence of dorsal cervical spinal compression consistent with an atlantoaxial band was 32/44 (73%) dogs without tie pressure and 37/44 (84%) dogs with tie pressure. Significantly higher compression ratios were found with tie placement over the craniocervical region. Dorsal compression ratios of dogs with cerebellar compression were significantly greater than those without it. The location of the endotracheal tube tie can influence interpretation of MR images of the craniocervical region of small breed dogs. These breeds more often had greater dorsal cervical spinal compression with tie pressure, especially when they had cerebellar compression.

Pallidal Deep Brain Stimulation in DYT6 Dystonia: Clinical Outcome and Predictive Factors for Motor Improvement

Pallidal deep brain stimulation is an established treatment in dystonia. Available data on the effect in DYT-THAP1 dystonia (also known as DYT6 dystonia) are scarce and long-term follow-up studies are lacking. In this retrospective, multicenter follow-up case series of medical records of such patients, the clinical outcome of pallidal deep brain stimulation in DYT-THAP1 dystonia, was evaluated. The Burke Fahn Marsden Dystonia Rating Scale served as an outcome measure. Nine females and 5 males were enrolled, with a median follow-up of 4 years and 10 months after implant. All benefited from surgery: dystonia severity was reduced by a median of 58% (IQR 31-62, p = 0.001) at last follow-up, as assessed by the Burke Fahn Marsden movement subscale. In the majority of individuals, there was no improvement of speech or swallowing, and overall, the effect was greater in the trunk and limbs as compared to the cranio-cervical and orolaryngeal regions. No correlation was found between disease duration before surgery, age at surgery, or preoperative disease burden and the outcome of deep brain stimulation. Device- and therapy-related side-effects were few. Accordingly, pallidal deep brain stimulation should be considered in clinically impairing and pharmaco-resistant DYT-THAP1 dystonia. The method is safe and effective, both short- and long-term.

Resection of a Meningioma at Craniocervical Junction through Far Lateral Approach: Two-Dimensional Operative Video.

Tumors located in the craniocervical junction region are significantly challenging for surgical resection. We shared our experience of a meningioma at craniocervical junction resected through far lateral approach in a 68-year-old female. The patient presented with intermittent headache with discomfort in the neck and shoulders for 3 years without any positive signs. Magnetic resonance imaging (MRI) revealed a tumor of 3.6 cm × 3.0 cm × 2.5 cm lying at the ventral side of medulla oblongata, with T1 hypointensity, T2 hyperintensity, and a significant enhancement on T1-contrast image. The far lateral approach on the right side was planned to resect the tumor with a park-bench position. The patient underwent a standard craniotomy using a lazy S -shaped incision. The transposition of vertebral artery was performed carefully therein, followed by removal of part of the arches of atlas and axis. After exposure of the tumor, vertebral artery (VA) and posterior inferior cerebellar artery (PICA) adhesive to the lesion could be seen operatively. Truncating the supplying blood vessels of the tumor was taken as the first step, followed by resecting the tumor mass in a piecemeal manner. While preserving VA, PICA, posterior nerves, medulla oblongata, and cervical cord, gross-total resection was achieved under the careful operation. The patient tolerated the procedure well without any neurological deficits. Histological examination confirmed the tumor as a meningioma (World Health Organization [WHO] grade I). Postoperative MRI scan depicted complete resection of the tumor. The patient remained symptom free without any evidence of recurrence during the follow-up period of 1 year. Informed consent was obtained from the patient. The link to the video can be found at: https://youtu.be/i9H-wS4fF10 .

Extradural Transjugular Transsigmoid Approach with High Cervical Exposure for Glomus Jugulare Tumor.

Surgical removal of glomus jugulare tumors is challenging owing to the complex anatomy of the temporal bone and craniocervical region, aggressive tumor invasion into the nearby structures, and their hypervascularity. However, recent advances in skull base techniques, intraoperative neuromonitoring, and radiological interventions have enabled their relatively safe resection, while giving priority to functional preservation. This video demonstrates a case of a glomus jugulare tumor treated by the extradural transjugular transsigmoid approach with high-cervical exposure and tympamoplasty, after preoperative embolization. A 47-year-old woman presented with progressive hearing disturbance, pulsatile tinnitus, and hemifacial spasm. Neuroimaging displayed a hypervascular tumor occupying the temporal bone, extending to the cervical region through the jugular foramen, and to the external auditory canal. Preoperative feeder occlusion was successfully performed without any additional symptoms, while carefully evaluating the provocative test. Near-total resection of the tumor was achieved through the transjugular transsigmoid approach with high-cervical exposure under detailed neuromonitoring, including continuous facial nerve monitoring and auditory brainstem response. In this patient, in whom the tumor did not invade intradurally and the sigmoid sinus was already occluded preoperatively, the sinus was managed only by coagulation, to avoid unnecessary dural opening and the risk of cerebrospinal fluid leakage. Anterior facial nerve rerouting was not required since the tumor removal was accomplished through the corridor above and below the fallopian bridge. The patient had no new neurological deficits, and her pulsatile tinnitus and hemifacial spasm disappeared after the surgery. Her hearing disturbance improved postoperatively. The link to the video can be found at: https://youtu.be/gqf3dxHlv_0 .

Modern approaches to the diagnosis and treatment of meningiomas of the craniocervical junction region

34 cases of craniocervical junction region meningiomas are analyzed. It was about 1.6% of the general number of patients with primary symptomatic intracranial meningiomas. Lateral or anterolateral meningiomas were in 31 cases (91.2%), posterior – in 2 cases (5.9%), anterior without lateralization – in 1 case (2.9%). 27 patients (79.4%) are operated on through the suboccipital approach, 7 patients (20.6%) – through the far-lateral suboccipital (transcondyllar) approach. Total removal of tumors was made in 24 cases (70.6%), subtotal removal – in 6 cases (17.6%), partial removal – in 4 cases (11.8%). Mortality was not observed. Intraoperative monitoring significantly improved the preservation of neurological functions. There were no cases of tumors recidivating during a long-term observation.The suboccipital lateralized approach with laminectomy till the level of the lower pole of the tumor was sufficient to provide an adequate microsurgical removal of meningiomas of the craniocervical junction without resection of an atlantooccipital joint. The approach to the neoplasm matrix should be carried out after partial tumor resection without traction of brain stem parts. The use of intraoperative neuromonitoring supervised the stem functions at all stages of tumor removal and during the vertebral artery allocation.

Morphometric Evaluation of Craniocervical Junction by Magnetic Resonance Imaging Method.

Purpose:Morphometric evaluation of the craniocervical region using magnetic resonance imaging method in humans and determination of the reference values that could be used in various clinics were the aims of this study.Materials and Methods:In our study, 306 (95 males and 211 females) individuals who met the necessary criteria for anatomical structure were included and taken measurements afterward. Sagittal T1- and T2-weighted images were determined as a section thickness of 3 mm, an interval of 10 mm, a matrix of 352 × 224, a field of view of 170–240 mm, and a number of excitations of 4. Measurements of anatomical structures in the craniocervical region were taken via these images.Results:Statistically significant differences were found among the findings of male and female individuals such as height of dens axis, anteroposterior distance of the dens axis (APDDA), anterosuperior distance of the dens axis (ASDDA), sagittal diameter of the foramen magnum (SDFM), total cervical vertebra length (TCVL), distance of spatium retropharyngeum, Pavlov ratio, and the ratio between sagittal diameter of canalis vertebralis (SDCV) to the APDDA. Dens axis height showed a positive correlation with ASDDA and TCVL, and a negative correlation was found between the APDDA and the spatium retropharyngeum.Conclusion:Age- and sex-related changes in the measurements of anatomical regions reveal that an increase and a decrease in the various parameters reveal that these are the normal changes presumably determined by the functional and physical demands varying on the columna vertebralis.

Effects of Head and Neck Positions on Blood Flow in the Vertebral, Internal Carotid, and Intracranial Arteries: A Systematic Review

Manual therapy interventions targeting the neck include various positions and movements of the craniocervical region. The hemodynamic changes in various spinal positions potentially have clinical relevance. To investigate the effects of craniocervical positions and movements on hemodynamic parameters (blood flow velocity and/or volume) of cervical and craniocervical arteries. A search of 4 databases (PubMed, Embase, CINAHL, and Index to Chiropractic Literature) and, subsequently, a hand search of reference lists were conducted. Full-text experimental and quasi-experimental studies on the influence of cervical positions on blood flow of the vertebral, internal carotid, and basilar arteries were eligible for this review. Two independent reviewers selected and extracted the data using the double-screening method. Of the 1453 identified studies, 31 were included and comprised 2254 participants. Most studies mentioned no significant hemodynamic changes during maximal rotation (n = 16). A significant decrease in hemodynamics was identified for the vertebral artery, with a hemodynamic decrease in the position of maximum rotation (n = 8) and combined movement of maximum extension and maximum rotation (n = 4). A similar pattern of decreased hemodynamics was also identified for the internal carotid and intracranial arteries. Three studies focused on high-velocity thrust positioning and movement. None of the studies reported hemodynamic changes. The synthesized data suggest that in the majority of people, most positions and movements of the craniocervical region do not affect blood flow. The findings of this systematic review suggest that craniocervical positioning may not alter blood flow as much as previously expected. Therapy, level 2a. J Orthop Sports Phys Ther 2019;49(10):688-697. Epub 5 Jul 2019. doi:10.2519/jospt.2019.8578.

Quantification of changes in brain morphology following posterior fossa decompression surgery in women treated for Chiari malformation type 1.

While 84% of patients surgically treated for Chiari malformation type 1 (CM1) demonstrate improved quality of life after posterior fossa decompression surgery, there are many risks associated with this surgery. Surgical planning to identify candidates likely to improve postoperatively may benefit from an improved understanding of morphological changes after decompression surgery. To evaluate these changes, we quantified 59 morphological parameters on 42 CM1 adult female patients before and after CM1 decompression surgery. Fifty-nine morphological parameters in the posterior cranial fossa, cranio-cervical, and intracranial regions in the midsagittal plane were evaluated using 42 T1-weighted magnetic resonance images of female CM1 patients before and after surgery, and 42 healthy female controls. Morphological differences before and after surgery were compared through the development of a technique to establish the opisthion location, a key reference point not present after surgery. In addition to the expected reduction of the cranio-caudal dimension of the cerebellum, objective analyses showed a significant increase in the area of the cerebrospinal fluid spaces, posterior (6×) and inferior (2.6×) to the cerebellum (+ 112 ± 102 and + 140 ± 127mm2, respectively). This increased area was primarily impacted by an average reduction in the occipital bone length of 24.5 ± 7.3mm following surgery. Based on multiple angles, results demonstrated a 2°-4° anterior rotation of the cerebellum after surgery. Our results show that decompression surgery results in significant changes in the cerebellum and cerebrospinal fluid spaces. Further investigation should determine how these morphological changes impact clinical outcomes.

Neck pain in episodic migraine: a cross-sectional study.

Purpose: It has been reported that neck pain is more prevalent in episodic migraineurs (EM) than in the general population. Subjects with episodic migraine exhibited widespread hypersensitivity in cranio-cervical region. Our objectives were to explore the potential factors associated with the presence of neck pain for EM, and whether there were differences in pericranial muscle tenderness between EM with and without neck pain.Patients and methods: Fifty EM with neck pain (34.76±8.04) and 50 age- and sex-matched EM without neck pain (34.26±9.39) were enrolled. The characteristics of headaches and some lifestyle factors were assessed in two groups. The migraine disability score and neck disability index were also recorded. During migraine-free period, cranio-cervical muscle tenderness scores and mechanical pain threshold were assessed for all patients.Results: There were no significant differences in pain intensity (p=0.44), migraine disability (p=0.71), duration (p=0.44) or frequency (p=0.85) of headache between EM with and without neck pain. The lifestyle factors including smoking, alcohol, coffee, body mass index≧23kg/m2, poor sleeping (<8 h/day) and time spent on TV and computers (>2 h/day) were not associated with the presence of neck pain in this study. Compared with EM without neck pain, those with neck pain had higher neck tenderness (p<0.01) and higher cephalic tenderness scores (p<0.01). Neck Disability Index scores were positively correlated with neck and total muscle tenderness scores.Conclusion: There was a significant difference in cranio-cervical muscle tenderness scores between EM with and without neck pain. For EM, the factors studied in the current research seemed not associated with the onset of neck pain, and further studies including other factors are needed.

P103 Chiari malformation type I: a review of literature to compare bony posterior fossa decompression with and without duraplasty

ObjectivesTwo main surgical approaches for symptomatic Chiari type I malformation (CM-I) patients are posterior fossa decompression (PFD) involving craniectomy alone, and posterior fossa decompression with duraplasty (PFDD). The aim of this review was to outline the indications, advantages and disadvantages of each surgical approach, with guidance regarding surgical decisions.MethodsWe reviewed pertinent articles. Data on the clinical improvement, radiological improvement, complications and reoperations were compared.ResultsSeventeen articles containing data on 3713 paediatric and adult participants met the inclusion criteria. PFDD was associated with more favourable clinical improvement in CM-I patients with syringomyelia (RR 1.59, 95% Cl, 1.09 to 2.31; p&lt;0.05), but had a higher complication rate (RR 3.34, 95% Cl, 1.66 to 6.73; p&lt;0.05) when compared with PFD. Regarding radiological improvement and reoperation rates, no significant differences were observed between the two surgical approaches.ConclusionsBoth PFD and PFDD are effective and safe surgical strategies for symptomatic CM-I associated with posterior fossa volume mismatch, in the absence of hydrocephalus and craniocervical region instability. Bony PFD has a lower complication rate and seems to be good option when carried out in those without major tonsillar impaction and in the absence of a syrinx. However, these patients should be adequately counseled regarding the requirement for possible further intra-dural decompression.