Neurosurgical Literature Research Articles

Measuring outcome after severe TBI

Objectives: To review current scales for measuring outcome following traumatic brain injury (TBI) and discuss changes in the types and use of these scales for the purposes of facilitating comparative effectiveness research. Methods: Functional, psychosocial/neurocognitive, and quality of life (QOL) scales used for assessing outcome following TBI are presented, along with the limitations of each. Core common data element scales are noted, and parametric, preference-based scales for performing comparative effectiveness research are discussed. Results: Many of the common outcome scales used in TBI research, including the Glasgow outcome scale (GOS), are functional measures. The emotional, cognitive, and psychosocial aspects of recovery are increasingly recognised, and metrics assessing these domains are becoming more common. Quality of life scales, which can be either directly used or translated into parametric preference-based indices for comparative effectiveness research are important for assessing patient-oriented outcomes, and in the upcoming years may yield information that improves medical decision-making, and ultimately outcomes following TBI. Discussion: Traumatic brain injury disrupts normal physical, cognitive, emotional, and social processes. Despite the dominance of functional scales like the GOS in the neurosurgical and neurocritical care literature, the use of other outcome modalities, including emotional, cognitive, psychosocial, and health-related QOL domains will be essential to improve patient care in the future.

A Proposed Method to Comprehensively Define Outcomes in Acoustic Tumor Patients Undergoing CyberKnife Management

Background: Vestibular assessment in patients with acoustic tumor (so-called vestibular schwannoma, VS) via ocular vestibular-evoked myogenic potential (oVEMP) and cervical VEMP (cVEMP) tests are not often discussed in the neurosurgical literature. Objectives: This study conducted physiological and morphological assessments for VS patients before and after CyberKnife radiosurgery. Methods: Twenty patients with unilateral VS underwent a battery of tests comprising facial nerve function test, audiometry, and caloric, oVEMP and cVEMP tests before and 2 years after CyberKnife treatment at a mean dosage of 18 Gy in 3 fractions. Results: The abnormal percentages of caloric, oVEMP and cVEMP tests did not significantly differ before and after Cyberknife treatment, indicating that preservation of the superior and inferior vestibular nerves can be achieved after radiosurgery. Median tumor volumes, 1.49 cm³ before treatment versus 0.97 cm³ at 2 years after treatment, differed significantly. Conclusions: The use of oVEMP and cVEMP tests in VS patients before stereotactic radiosurgery may help to evaluate the tumor origin from the superior or inferior vestibular nerve. It takes a short time and costs less, and it would be practical to make this a routine examination in VS patients having stereotactic radiosurgery.

Intraoperative magnetic resonance imaging for high grade glioma resection: Evidence-based or wishful thinking?

Dear Editor, In their review, Liang and Schulder provide an update on the role of intraoperative magnetic resonance imaging (iMRI) in gliomas.[3] Whereas the authors do provide an overview of iMRI technology, it could have been a more critical review. After the first publications on iMRI, which appeared 15 years ago, the topic has been prominently visible in neurosurgical literature. However, during the past few years there seems to be a decline in interest in this technology, based on a reduced number of publications, but also from informal communicates. How did this happen? First, we all know that gliomas in general, and high grade gliomas in particular, are a generalized disease of the brain instead of a localized process. This means that surgery can never be curative, and the (relative) merit of increased extent of tumor resection (EOTR) needs to be seen in this context. Still, if increased EOTR is associated with prolonged survival,[4] technology that supports to achieve this goal in a safe manner is attractive. Of such technologies, iMRI is by far the most expensive, and convincing data on its added value are still limited. In our review,[2] we demonstrated several forms of bias that exist in the literature on the topic, limiting the evidence level for iMRI guided resection. The only class I evidence on this topic comes from the randomized controlled trial by Senft et al.,[5] but even this study is less convincing than the abstract suggests. The authors defined gross total resection (GTR) as less than 0.175 cc residual tumor, leading to 96% GTR in the iMRI group vs. 68% GTR in the control group. When looking at postoperative tumor volume, the median results are 0 cm3 vs. 0.03 cm3, respectively, and it is debatable whether this difference is of clinical relevance. Besides, one can argue, whether the measured postoperative tumor volumes are within the confidence limits of the methods used for measuring this volumes. The authors did not find a difference in progression-free survival between both treatment arms, which might confirm that the clinical difference is less than the suggested difference based on GTR alone. To continue, we do not have a valid endpoint for postoperative tumor volume. Interobserver agreement has been demonstrated to be unacceptably low in a pilot study on this topic,[1] and the lack of a valid method for (postoperative) tumor volumetry further undermines the robustness of the data supporting iMRI. Even if measurements were correct, it is still unclear what to measure. The correlation between contrast enhancement and tumor presence is also limited, and other imaging modalities like 5-aminolevulinic acid (5-ALA)_or positron emitted tomorgraphy (PET) might be more cost-effective options in this context. Another consideration is workflow integration, which is partially related to cost. iMRI guided surgery takes significantly more time, and can more or less interfere with the surgical workflow (e.g., compatibility of instruments or equipment) depending on the sort of iMRI technology used. To conclude, despite class I evidence that iMRI guided surgery of high grade gliomas leads to increased EOTR, the clinical advantage is much less clear, and is limited by the nature of gliomas in itself. If we add the lack of a valid volumetric endpoint, and other modalities that offer comparable effectiveness for much less cost (like 5-ALA), then it becomes more understandable why iMRI seems to be losing interest in the international community. In our opinion, narrative reviews on iMRI ornated with literature references but without a critical reflection, do not deserve a place in modern neurosurgical literature anymore, and the article's conclusion[3] that there is “compelling evidence” favoring iMRI seems more like wishful thinking than a critical reflection on the current evidence.

Isolated basilar artery dissection associated with subarachnoid haemorrhage. traumatic or spontaneous?

Intracranial vertebral dissection associated with subarachnoid haemorrhage is well recognised in forensic practice, basilar artery dissection does not feature in standard forensic textbooks. Although recognised in the neurosurgical and neurology literature, isolated basilar artery dissection (IBAD) is rare and is either traumatic or spontaneous. IBAD is usually fatal, however may have a good prognosis. In the majority of cases the basilar artery is involved by extension of a vertebral artery dissection. Clinically patients present with brainstem or cerebellar ischaemic strokes and less commonly with subarachnoid haemorrhage. There is a temporal relationship to unaccustomed neck movement or other trauma. IBAD should be considered at post-mortem examinations where widespread subarachnoid haemorrhage over the anterior brainstem and cerebellum is encountered where an aneurysm is not identified. The basilar artery is easily accessible at post-mortem allowing detailed serial examination of the vertebral and basilar arteries. Two of three cases were trauma related with skull fracturing in the region of the basilar artery dissection (fall and motor vehicle crash). The third case presented with headache and was spontaneous with no pre-existing vasculopathy. In all three cases, the basilar artery dissection was the cause of the death. Failure to recognise IBAD as an entity and confining examination only to the vertebral arteries may result in the source of the subarachnoid haemorrhage not being identified.

Innovations in the surgical treatment of gliomas

Gliomas are common brain tumors that have historically carried a dire prognosis with few useful treatment options. However, modern neurosurgical literature supports a strong role for aggressive surgical resection in some cases. Technical advances in neuroimaging and neuronavigation have changed the way surgeons approach these tumors, and intraoperative technology aimed at improving extent of resection without compromising safety has led to improved long-term results. Here, the authors review the state-of-the-art surgical approach to this challenging disease.

Desmoid Tumour of the Brachial Plexus

Desmoid tumours of the brachial plexus are rare and may occur in extra-abdominal sites. The tumours are of fibroblastic origin and, although benign, are locally aggressive. Their relationship to critical neurovascular structures in their anatomic locations presents a challenge to the operating surgeons trying to adhere to the principles of surgery. Surprisingly little neurosurgical literature exists which was devoted to this topic despite the challenge these lesions present in surgery both at surgery and in choosing adjuvant therapies. We report a case of a large brachial plexus tumour in a patient which was diagnosed radiologically and histopathologically and the patient underwent surgical excision with good outcome. Desmoid tumours histologically are benign and are usually composed of proliferating, benign fibroblasts in an abundant matrix of collagen. They do not transform into malignant tumours or metastasize. Surgery is the mainstay of treatment; however, adjuvant radiation and chemotherapy remain controversial.

Levels of Evidence in the Neurosurgical Literature

The importance of evidence-based medicine has been well documented and supported across various surgical subspecialties. To quantify the levels of evidence across publications in the neurosurgical literature, to assess the change in evidence over time, and to indicate predictive factors of higher-level evidence. We reviewed the levels of evidence across published clinical studies in 3 neurosurgical journals from 2009 to 2010. Randomized trials were evaluated by use of the Detsky quality of reporting scale. Levels-of-evidence data for the same journals in 1999 were obtained from the literature, and regression analysis was performed to identify predictive factors for higher-level evidence. Of 660 eligible articles, 14 (2.1%) were Level I, 54 (8.2%) were level II, 73 (11.1%) were Level III, 287 (43.5%) were level IV, and 232 (35.2%) were level V. The number of level I studies decreased significantly between 1999 and 2010 (3.4% vs. 2.1%, respectively; P = .01). Seven randomized clinical trials were identified, and 1 trial had significant methodological limitations (mean Detsky index = 16.3; SD = 1.8). Publications with larger sample size were significantly associated with higher levels of evidence (levels I and II; odds ratio, 1.7; 95% confidence interval, 1.45-2.05; P = .001). The ratio of higher levels of evidence to lower levels was 0.11. Higher levels of evidence (levels I and II) represent only 1 in 10 neurosurgical clinical papers in the top neurosurgical journals. Increased awareness of the need for better evidence in the field through education and adoption of the levels of evidence may improve the conduct and publication of prospective studies.

Augmented Autologous Pericranium Duraplasty in 100 Posterior Fossa Surgeries—A Retrospective Case Series

Primary closure of the dura in posterior fossa (p-fossa) surgeries is technically difficult and usually requires the use of a dural substitute. A variety of substitutes are currently available and data suggest that autologous materials are preferred in comparison with nonautologous substitutes. To report our experience using locally harvested autologous pericranium as a dural substitute in patients who underwent p-fossa surgeries. Retrospective analysis of patients who had undergone p-fossa craniotomies between 2005 and 2011. All patients received locally harvested autologous pericranium for duraplasty augmented with a dural sealant. Data were reviewed for complications including: surgical site infection, meningitis, cerebrospinal fluid leak, the radiographic formation of a pseudomeningocele, and any new neurological symptoms related to the incision or repair. One hundred patients were identified. Indications for surgery included tumor, vascular lesions, or hemorrhage requiring surgical intervention, symptomatic Chiari I malformation, microvascular decompression for trigeminal neuralgia, and trauma requiring surgical decompression. The complication rate was 1% with 1 patient developing an nonsteroidal anti-inflammatory drug-induced aseptic meningitis and graft dehiscence requiring surgical revision. Autologous pericranium with dural sealant augmentation is an effective way to repair the durotomy in p-fossa surgeries. To the best of our knowledge, this is currently the largest study using this technique in the adult neurosurgical literature. Our results report a much lower rate of complications in comparison with other duraplasty studies.

Cerebral capillary telangiectasias: a meta-analysis and review of the literature

As a result of their presumed benign natural history, cerebral capillary telangiectasias (CCTs) are infrequently addressed in the neurosurgical literature. We performed a comprehensive review of CCTs via the PubMed database to synthesize overall epidemiological, radiographic, natural history, and treatment results. Across ten series with 203 patients, mean age was 47, and 45% were male [95% confidence interval (CI), 0.30-0.65]. Notably, 78% of CCTs were in the pons (95% CI, 0.58-1.0). Six percent of CCTs were symptomatic. Across five radiographic series, all lesions enhanced after gadolinium, and all were hypointense on gradient echo sequences. Thirty-three percent were hypointense on T1-weighted pre-contrast imaging (95% CI, 0.2-0.51), 49% were hyperintense on T2-weighted imaging (95% CI, 0.31-0.72), and 74% were hypointense on diffusion-weighted imaging (95% CI, 0.5-1.0). Notably, 37% were associated with a prominent draining vein (95% CI, 0.21-0.6), and 11% with a developmental venous anomaly (95% CI, 0.04-0.25). Across four observational studies with 47 patients, there was no observed change in lesion morphology or hemorrhage in 65.7 patient-years of follow-up. Although the vast majority of CCTs are managed conservatively, we found ten cases of patients treated with surgical excision. We confirm that CCTs are a benevolent entity with a predilection for the pons. They have distinctive radiographic features including their lack of mass effect, consistent enhancement on T1-weighted sequences and hypointensity on gradient echo sequences, and common isointensity on pre-contrast T1-weighted and T2-weighted images. Management for these lesions has been nonoperative in almost all cases.

Surgical debriefing: a reliable roadmap to completing the patient safety cycle

Morbidity and mortality due to preventable medical errors are a disastrous reality in medicine. Debriefing, a process that allows individuals to discuss team performance in a constructive, supportive environment, has been linked to improved performance in various medical and surgical fields, including improvements in specific procedures, teamwork and communication, and error identification. However, the neurosurgical literature on this topic is limited. The authors review the debriefing literature in the field of medicine, with a specific emphasis on the operating room, and they report their own institutional experience with a debriefing module, from invention to pilot implementation, at Vanderbilt University Medical Center. The authors share the challenges and lessons learned from their quality improvement project. The field of neurosurgery would undoubtedly benefit from embracing debriefing, as its potential has been established in other medical specialties and can serve as a valuable role in immediately learning from mistakes. The authors hope that their colleagues can learn from this experience and improve their own.

Medial wall of the cavernous sinus: dural or fibrous layer?

To the Editor: I read with great interest the article by Goncalves et al. “Cavernous sinus medial wall: dural or fibrous layer? Systematic review of the literature” [4], recently published in your journal. As the authors of this article found a variation among several studies without conclusive answer to their research question, I would like to provide some comments on their study and highlight a possible explanation for their results. Goncalves et al. conducted a systematic literature review to find out the microanatomy of the medial wall of the cavernous sinus (CS) and its clinical importance on sellar pathologies. Based on 14 experimental studies, four studies found that the medial wall of the CS is composed of a loose, fibrous structure, and according to ten studies, medial wall is composed of a dural layer that constitutes the lateral wall of the sella. They explain the variation in the results section by lacking in definition standards and methodological criteria. First, I am grateful for the Goncalves et al. methodology in their article as they support and establish a step toward the concept of evidence-based morphology [1, 3]. The articles based on this concept are still rare in neurosurgical literature, yet available data about the anatomy, especially in the terms of variation, can be obtained from this kind of study. It can also highlight a hidden anatomical problem that can be utilized to refine the neurosurgical approaches seen in Goncalves et al. work and in the comments on their paper. With regard to medial wall of the CS, to make it understandable, I believe it should always be divided into two parts; sphenoidal and sellar. Even though, at the sphenoidal part there is one layer of dura (osteoperiosteal dura) that adheres to the bone and forms the inferomedial wall of the cavernous space. At the sellar part or the superior medial wall, I do not believe that there is any dural layer that belongs to the CS itself or to the CS as an anatomical entity. To clarify this point, and to give an explanation to that type of anatomical variation which Goncalves et al. found in several studies, there are two facts we need to keep in mind; first, the CS is an extradural anatomical entity [5, 6]. The hypophysis compartment is isolated from all surrounding structures by what is called the pituitary bag. A detailed description of the pituitary bag was reported by Francois et al. using electron microscopic-based methodology [2]. Having said that, we can make a more useful conclusion with regard to the medial wall of the CS; there is no dural layer for superior medial wall of the CS itself. The dural layer that have been reported belong to the pituitary bag and was misinterpreted as it belongs to the CS itself according to some studies. Furthermore, this explains the presence of easy surgical cleavage plane between the medial wall and the suprasellar dura (diaphragma sellae) that was reported by Professor Kawase in his comment at the end Goncalves et al. paper.

Minimally invasive presacral retrieval of a failed AxiaLIF rod implant: technical note and illustrative cases

There are few reported cases of failed axial lumbar interbody fusion (AxiaLIF) in the existing neurosurgical literature, and an anecdotal case of open paramedian retroperitoneal approach to L5-S1 level for retrieval of AxiaLIF rod has been published. The object of this study is to illustrate a minimally invasive presacral rod retrieval technique in cases with failed AxiaLIF causing lumbosacral instability. Retrospective case series. A retrospective analysis of the initial 26 cases of AxiaLIF done at our institution was performed; two cases of failed AxiaLIF that required rod removal were identified for detailed study. Available literature on the minimally invasive presacral techniques for rod retrieval was researched, and the use of a novel rod retrieval device with an expanding hex tip is discussed. Using a minimally invasive presacral approach through the previous surgical corridor, the authors were able to retrieve the AxiaLIF rod implant and then proceed with an alternative fusion technique. Both patients improved clinically and radiographically after revision. Removal of the presacral rod was not associated with vascular or bowel complications and required minimal operating room time with minimal blood loss. To the authors' knowledge, this is the first report demonstrating the safety and efficacy of minimally invasive presacral approach for removal of AxiaLIF rods in patients with failed AxiaLIF. As the AxiaLIF procedure is rapidly gaining acceptance among spine surgeons, we can expect to see increasing numbers of failed procedures as well. Understanding options for revision strategies is important for surgeons considering the use of this technique.

Sport-Related Concussion

Sport-Related Concussion

Current approaches to management of nonsyndromic craniosynostosis

Surgical alternatives to traditional cranial vault remodeling for the treatment of craniosynostosis are being discussed in recent plastic and neurosurgical literature. This review highlights recent developments and discusses the risks as well as benefits of each. Surgical treatment of craniosynostosis has evolved from simple suturectomy, to extensive cranial vault remodeling, and now back to the minimally invasive. Options today include endoscopic suturectomies, spring-mediated cranioplasties, and distraction osteogenesis as well as cranial vault remodeling. There are disagreements among centers on the most optimal timing and best operative procedure. Clinicians should be aware that different surgical treatments are rapidly being developed for nonsyndromic craniosynostosis.

Case of a 4-Year-Old Boy Who Underwent Staged Resection of an Atypical Hemangiopericytoma Arising from Meckel's Cave

Intracranial hemangiopericytoma is a rare entity, accounting for less than 1% of CNS tumors; it is exceptionally infrequent among the pediatric population. We describe a case of an atypical hemangiopericytoma arising from Meckel's cave in a 4-year-old boy. The patient was in remission for acute lymphoblastic leukemia when he developed progressive gait difficulty, nausea, and vomiting. He was found to have a 6-cm dumbbell-shaped lesion extending from Meckel's cave to the root entry zone of the trigeminal nerve, which was not appreciated on a screening MRI done 12 months prior. Notably, the patient also had elevated parathyroid hormone levels. An external ventricular drain was placed to treat clinical hydrocephalus and confirm negative cytology for leukocytic disease. Initially, a retrosigmoid craniectomy was performed for resection of the tumor within the cerebellopontine angle and to obtain tissue for diagnosis. Final pathology returned as infantile hemangiopericytoma with recommendation for complete surgical resection. The patient underwent a preauricular infratemporal craniotomy with anterior petrosectomy for removal of the tumor within the middle fossa. The patient had improvement in his left-sided hemiparesis, but did sustain permanent injury to the trigeminal nerve secondary to infiltration of tumor within the trigeminal nerve. His hyperparathyroidism normalized following the procedure. Skull base tumors in the pediatric population are generally rare, and this subtype in particular is represented by a paucity of data in the neurosurgical literature. This is the first description of treatment of this type of tumor in this location in the pediatric population.

The remarkable medical lineage of the Monro family: contributions of Alexander primus, secundus, and tertius

Among the families that have influenced the development of modern medicine into what it is today, the Monro lineage stands as one of the most notable. Alexander Monro primus (1697-1767) was the first of 3 generations with the same name, a dynasty that spanned 126 years occupying the Chair of Anatomy one after the other at the University of Edinburgh. After becoming Professor of Anatomy at the University of Edinburgh in 1719, Monro primus played a principal role in the establishment of the University of Edinburgh School of Medicine and the Edinburgh Royal Infirmary. In 1726, he published The Anatomy of the Humane Bones, of which 8 editions were printed during his lifetime. His son, Alexander Monro secundus (1733-1817), arguably the most notable of the 3 men, succeeded him as Professor of Anatomy. A highly regarded lecturer and anatomist, Monro secundus studied under many great physicians, including William Hunter and Johann Friedrich Meckel the Elder, and was also teacher to other well-known figures at the time, such as Joseph Black and Thomas Trotter. His most notable contributions include his work with the lymphatic system, the interventricular foramen (of Monro), and the Monro-Kellie doctrine. Alexander Monro tertius (1773-1859), the last of the dynasty, also succeeded his father as Professor of Anatomy. His work included insights into abdominal aortic aneurysms and the anatomy of the genitourinary system. The prominent association of the Monro family with the University of Edinburgh and the effects of a tenured professorship under the concept of "Ad vitam aut culpam" over successive generations are also described. To the best of the authors' knowledge, this historical review of the Monro family is among the few published in neurosurgical literature. A vivid historical overview of the medical contributions of the most famous and influential dynasty of physicians in Edinburgh at that time is provided, with relevant excerpts from original publications.

Intracranial cotton ball gossypiboma mimicking recurrent meningioma: Report of a case with literature review for intentional and unintentional foreign body granulomas

Gossypiboma, or textiloma, is an unusual complication followng invasive surgical procedures. From the latin gossypium, the enus of cotton plant types, and boma, a Kiswahili word meaning place of concealment”, the term is used to describe the inflamatory response that occurs in response to the introduction of foreign body in tissue. As the name suggests, the objects are sually cotton balls or surgical gauze either inadvertently or delibrately left behind during surgery as in the case of muslin wrapping f aneurysms [1]. Inflammatory responses around these cotton alls develop leading to foreign body granulomas (FBG) that can e detected on magnetic resonance imaging (MRI) and computerzed topography (CT) as enhancing masses [2–4]. The timeline of linical presentation also varies greatly, ranging from immediately ostoperative to decades after surgery [1–4]. Compared to general surgery, textilomas have been reported ar less frequently in neurosurgical literature. A Medline search f gossypiboma or textiloma reveals 27 reports and about 50 ases associated with intracranial foreign body granulomas since 973 [1–5]. Rarely, seizures have been shown to be caused by

Posterior clinoid process as a landmarker in current endoscopic-assisted neurosurgical approaches

Summary Background/Introduction The morphologic variations of posterior clinoid process (PCP) anatomy have rarely been documented in the neurosurgical literature. Purpose(s)/Aim(s) We investigated the PCP in terms of the endoscopic perspective, which will guide surgeons for safely maneuvering within the paraclinoid region and during the transcavernous approach. Methods Four alcohol-immersed cadaveric heads injected with pigmented silicone rubber were prepared for skull base dissections. We evaluated the three-dimensional reconstructed anatomy of PCPs. Bilateral pterional and endonasal transclival approaches were performed. In pterional corridors, we advanced the dissection through the optic-carotid triangle to observe the PCP; whereas in transclival approaches, we applied a transclival route to expose the dorsum sellae and PCP. Two angled (0 and 30°) rigid endoscopes with outer diameters of 4 mm were introduced. By endoscopically viewing the surgical anatomy, the PCP and dorsum sellae were seen with ease in both approaches. Results All of the specimens showed an intact dorsum sellae and both posterior clinoid processes. Morphologic variation was described and recorded in each specimen. The posterior clinoid process is a landmark in important neurosurgical approaches. In our study we described the spatial guidance in either transcranial or transnasal endoscopic routes. Conclusion Taking advantage of the innovative integration of the video processing system, it facilitates the surgeons to work in a limited confined intracranial space. We are convinced that it provides practical information concerning the trans-PCP maneuver.

Update on Pituitary Surgery

Transsphenoidal surgery has an important role in the management of pituitary tumors and remains the primary treatment for most adenomas, with the exception of prolactinomas. This update will review the recent neurosurgical literature; modifications to the traditional microscopic approach, including the potential utility of endoscopy and intraoperative magnetic resonance imaging, are discussed. The value of experienced surgical judgment and expertise remains clear, over and above the possible advantages of current technology. Preliminary data on the relative cost-effectiveness of surgery vs. medical treatment suggest that surgical approaches compare favorably. It will be important to incorporate future technological advances in surgical technique with new medical therapies in a combined multidisciplinary approach for improved treatment algorithms.

Analysis of the uncinate processes of the cervical spine: an anatomical study

Although the uncovertebral region is neurosurgically relevant, relatively little is reported in the literature, specifically the neurosurgical literature, regarding its anatomy. Therefore, the present study aimed at further elucidation of this region's morphological features. Morphometry was performed on the uncinate processes of 40 adult human skeletons. Additionally, range of motion testing was performed, with special attention given to the uncinate processes. Finally, these excrescences were classified based on their encroachment on the adjacent intervertebral foramen. The height of these processes was on average 4.8 mm, and there was an inverse relationship between height of the uncinate process and the size of the intervertebral foramen. Degeneration of the vertebral body (VB) did not correlate with whether the uncinate process effaced the intervertebral foramen. The taller uncinate processes tended to be located below C-3 vertebral levels, and their average anteroposterior length was 8 mm. The average thickness was found to be 4.9 mm for the base and 1.8 mm for the apex. There were no significant differences found between vertebral level and thickness of the uncinate process. Arthritic changes of the cervical VBs did not necessarily deform the uncinate processes. With axial rotation, the intervertebral discs were noted to be driven into the ipsilateral uncinate process. With lateral flexion, the ipsilateral uncinate processes aided the ipsilateral facet joints in maintaining the integrity of the ipsilateral intervertebral foramen. A good appreciation for the anatomy of the uncinate processes is important to the neurosurgeon who operates on the spine. It is hoped that the data presented herein will decrease complications during surgical approaches to the cervical spine.