Occipitocervical Region Research Articles

Congenital extra calvarial plexiform neurofibroma in occipito-cervical region with Occipital bone defect with neurofibromatosis type 1 and segmental neurofibromatosis: Case report and review of literature.

Plexiform neurofibroma (PNF) of the scalp is an extremely rare lesion reported in association with neurofibromatosis (NF). Occipital location of PNF is even more infrequent; we reported one pediatric case of PNF in occipito-cervical region with multiple small occipital bone defects and associated with NF-1.

Dandy Walker syndrome with giant occipital meningocele with craniovertebral anomalies: Challenges faced during anaesthesia.

Sir, The coexistence of rare congenital neurodevelopmental and craniofacial abnormalities make proper positioning for endotracheal intubation difficult and alternative methods of positioning and intubation must be sought for. Although difficult airway cart should be in hand, one must give emphasis on proper positioning of patient. A sound knowledge and proper laryngoscopy by experienced anaesthesiologist results in successful intubation even in cases of anticipated difficult airway and thus, prevents the need of surgical airway. We report a rare case of an 8-month-old child weighing 5 kg with Dandy–Walker syndrome (DWS) associated with a giant occipito-cervical meningocele and craniovertebral anomalies, and posted for shunt surgery. Pre-anaesthetic check-up suggested no history of seizure, vomiting, difficulty in feeding, cyanosis or respiratory distress. There were no cardiac or respiratory signs. Power in all limbs was equal. The child had a large head and a giant occipital cervical meningocele measuring 10 cm × 10 cm, extending from occipital protuberance to mid scapula, causing fixed flexion of the neck [Figure 1]. Magnetic resonance imaging (MRI) of the brain showed enlarged posterior fossa with multiple craniovertebral anomalies with meningocele in occipital and upper cervical region communicating with fourth ventricle, hypoplasia of inferior vermis coupled with hypoplasia of cerebellar hemisphere, suggestive of DWS with occipital meningocele. MRI spine [Figure 2] showed multiple craniovertebral anomalies such as cranial bifida and spina bifida in upper cervical vertebrae coupled with occipito-cervical meningocoele. Figure 1 Extension of occipita cervical swelling along with large head Figure 2 Magnetic resonance imaging spine showing huge occipita cervical meningocele On arrival of the child in the operation theatre, monitoring was established with an electrocardiogram pulse oximeter non-invasive blood pressure (BP) and temperature probe. Baseline parameters included BP of 94/70 mmHg pulse rate of 118/min and oxygen saturation of 100%. Injection glycopyrrolate 0.02 mg intravenous (IV) and injection fentanyl 5 μg was given in the cannula in situ. As there was a large and firm swelling at occipito-cervical region along with flexed neck with no neck movement, supine positioning could not be done in our case. The patient was positioned in the left lateral position with head beyond the edge of the table with an assistant stabilising the head of the baby from below and other supporting the body. After pre-oxygenation with 100% oxygen, injection thiopentone IV was administered in titrated manner, and a total of 20 mg was injected. Check laryngoscopy in lateral position was done with Miller's straight blade one by the senior anaesthesiologist. Laryngoscopy revealed Cormack–Lehane laryngeal view Grade 2. Injection succinylcholine, 10 mg IV was administered and eventually trachea was intubated with no. 3.5 mm uncuffed endotracheal tube. After confirmation of bilateral equal air entry, the endotracheal tube was fixed. Injection atracurium 2.5 mg was given, and anaesthesia was maintained with nitrous oxide-oxygen and sevoflurane (1%). Paracetamol 80 mg suppository was placed for post-operative analgesia. Once the tube was properly fixed, the patient was positioned supine by placing large ring under the head and large cotton roll under shoulder for proper surgical field view. All the pressure points were adequately padded. Intraoperative course was uneventful. After completion of surgery, neuromuscular blockade was reversed with injection neostigmine 0.4 mg and injection glycopyrrolate 0.008 mg. Extubation was performed once the patient became awake. After satisfactory recovery, the patient was shifted to paediatric Intensive Care Unit. DWS although a rare clinical entity with incidence being about 1 in 25000-30000 live births with a slight female predominance.[1,2] It is often associated with other congenital anomalies such as cleft lip, cleft palate, hypertelorism and micrognathia making airway management challenging.[3] Ewart and Oh reported a case of 2 weeks old DWS patient with micrognathia and anterior larynx in whom they found difficulty in awake intubation.[4] Our child was positioned laterally during induction and intubation. An alternative technique such was suggested by Mowafi et al.[5] in which child was placed supine in silicon platform so that height of silicon platform equals the size of the sac. We did not go for this technique as the occipital swelling was extending until mid-scapula, making positioning more difficult. Other major concern in patients of DWS is avoidance of further rise in intracranial pressure (ICP). Endotracheal intubation should be as gentle as possible. Inhalational agent causes a dose-dependent rise in intracranial pressure and so better avoided. However, it has been shown that isoflurane and sevoflurane in <1 MAC concentration do not cause a significant rise in ICP.[6] In conclusion, patients with DWS with other associated anomalies can be successfully managed by a thorough evaluation of airway, emphasis on proper positioning during laryngoscopy, preparation for difficult intubation, avoidance of rise in ICP during anaesthesia and proper post-operative care. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Morphometric Analysis of Atlas and Its Clinical Significance: An Anatomical Study of Indian Human Atlas Vertebrae

The morphometry of atlas is very important for surgeries in the occipitocervical region. There are studies explicitly differing in the results concerning some key anatomic measurements, mandating an additional evaluation of anatomic landmarks of atlas. Therefore, this study was aimed to evaluate the various dimensions of the atlas quantitatively relevant for various surgeries. A total of 30 adult atlas vertebrae of Indian origin were studied. The distances were measured by digital vernier calliper. The transverse diameter and maximum anteroposterior dimension of vertebral canal of atlas had a mean of 27.31 ± 2.74 and 29.44 ± 2.54 mm, respectively. The vertebral artery groove thickness on atlas is 3.79 ± 1.08 mm on right and 4.05 ± 00.86 mm on left, respectively. The mean distance from sagittal midline to the innermost edge of the vertebral artery groove is 10.73 ± 2.92 mm on right side and 09.72 ± 2.56 mm on left side. Overall, 74% of superior articular facets were found to be oval in shape and 26% in kidney shape. On the basis of these findings, we concluded that the thickness of the vertebral artery groove is satisfactory for surgical fixation techniques and the dissection on the posterior arch of atlas can be extended to 12 mm from the midline through the posterior approach.

The Causes and Treatment Strategies for the Postoperative Complications of Occipitocervical Region: A 636-Case Retrospective Analysis

Disorders in occipitocervical region are difficult to treat. Complications often occur after fusion surgery and may be life-threatening in severe cases.

Linear headache: a recurrent unilateral head pain circumscribed in a line-shaped area.

BackgroundA headache circumscribed in a line-shaped area but not confined to the territory of one particular nerve had ever been described in Epicrania Fugax (EF) of which the head pain is moving and ultrashort. In a 25-month period from Feb 2012 to Mar 2014, we encountered 12 patients with a paroxysmal motionless head pain restricted in a linear trajectory. The head pain trajectory was similar to that of EF, but its all other features obviously different from those of EF. We named this distinctive but undescribed type of headache linear headache (LH).MethodsA detailed clinical feature of the headache was obtained in all cases to differentiate with EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia. Similarities and differences in clinical features were compared between LH and migraine.ResultsThe twelve LH patients (mean age 43.9 ± 12.2) complained of a recurrent, moderate to severe, distending (n = 9), pressure-like (n = 3) or pulsating (n = 3) pain within a strictly unilateral line-shaped area. The painful line is distributed from occipital or occipitocervical region to the ipsilateral eye (n = 5), forehead (n = 6) or parietal region (n = 1). The pain line has a trajecory similar to that of EF but no characteristics of moving. The headache duration would be ranged from five minutes to three days, but usually from half day to one day in most cases (n = 8). Six patients had the accompaniment of nausea with or without vomiting, and two patients had the accompaniment of ipsilateral dizziness. The attacks could be either spontaneous (n = 10) or triggered by noise, depression and resting after physical activity (n = 1), or by stress and staying up late (n = 1). The frequency of attacks was variable. The patients had well response to flunarizine, sodium valproate and amitriptyline but not to carbamazepine or oxcarbazepine. LH is different from EF, trigeminal autonomic cephalalgias (TACs) and cranial neuralgia, but it had couple of features similar to that of migraine.ConclusionsThe clinical picture of LH might be a subtype of migraine, or represent a novel syndrome.

The causes and treatment strategies for the postoperative complications of occipitocervical fusion: a 316 cases retrospective analysis.

Disorders in occipitocervical region are difficult to treat. Complications often occur after fusion surgery and may be life-threatening in severe cases. This study is to investigate the causes and treatment strategies for the postoperative complications of occipitocervical fusion. Between May 1985 and May 2011, 316 patients with various occipitocervical diseases underwent occipitocervical surgery, with or without internal fixation. Two physicians were assigned for patients follow-up. Their medical records and radiographs were reviewed and the postoperative complications, including those at the occipitocervical region and donor site, were analyzed. Three hundred cases were followed up from 24 months to 26 years with an average of 9 years and 8 months, and the follow-up rate was 94.9%. There were 16 cases with complications after surgery in the uninstrumented fusion group; the incidence was 33.3%. These included 11 patients (22.9%) with complications in occipitocervical region and five patients (11.9%) with donor-site complications. 45 complications presented in the instrumented fusion group, the incidence was 17.9%. These included 30 patients (11.9%) with complications in occipitocervical region and 15 patients (5.9%) with donor-site complications. Perioperative complications included vertebral artery injury, spinal cord injury, nerve root injury, suffocation, cerebrospinal fluid leakage, and infection. Mid- to long-term complications included bone-graft displacement or absorption, aggravated vertebral dislocation, improper screw placement, spinous process fracture, and internal fixation breakage. Donor-site complications were hematoma, pain and infection. The surgery of occipitocervical fusion carries a relative high risk for complications, especially if no instrumentation is used. The key points in reducing complications are the surgeon's familiarity with the anatomy of occipitocervical region and the appropriate internal fixation.

A computed tomography morphometric study of occipital bone and C2 pedicle anatomy for occipital-cervical fusion.

Background:Occipital-cervical fusion (OCF) has been used to treat instability of the occipito-cervical junction and to provide biomechanical stability after decompressive surgery. The specific areas that require detailed morphologic knowledge to prevent technical failures are the thickness of the occipital bone and diameter of the C2 pedicle, as the occipital midline bone and the C2 pedicle have structurally the strongest bone to provide the biomechanical purchase for cranio-cervical instrumentation. The aim of this study was to perform a quantitative morphometric analysis using computed tomography (CT) to determine the variability of the occipital bone thickness and C2 pedicle thickness to optimize screw placement for OCF in a South East Asian population.Methods:Thirty patients undergoing cranio-cervical junction instrumentation during the period 2008-2010 were included. The thickness of the occipital bone and the length and diameter of the C2 pedicle were measured based on CT.Results:The thickest point on the occipital bone was in the midline with a maximum thickness below the external occipital protuberance of 16.2 mm (±3.0 mm), which was thicker than in the Western population. The average C2 pedicle diameter was 5.3 mm (±2.0 mm). This was smaller than Western population pedicle diameters. The average length of the both pedicles to the midpoint of the C2 vertebral body was 23.5 mm (±3.3 mm on the left and ±2.3 mm on the right).Conclusions:The results of this first study in the South East Asian population should help guide and improve the safety in occipito-cervical region instrumentation. Thus reducing the risk of technical failures and neuro-vascular injury.

A Posterolateral Approach to Occipitoatlantoaxial Ventral Lesions

A retrospective study of consecutive patient series. To report a technique of odontoidectomy using a transoccipitocervical posterolateral approach for occipitoatlantoaxial ventral lesions in a long-term follow-up study. Occipitoatlantoaxial malformation and old traumatic dislocation usually cause compression of the high cervical spinal cord from a variety of different directions and angles, leading to high morbidity. The main objective of treatment is to relieve the anteroposterior compression and to restore the stability of the occipitocervical region. Currently, there are 2 approaches to perform the surgical procedure: (1) posterior decompression by suboccipital and occipitocervical fusion and internal fixation; and (2) decompression by a transoral approach to an odontoid resection. However, there are some short points, which need to be changed, such as the incomplete decompression (the former), narrow view, cerebrospinal fluid leakage, and the high infection rates. From 1999 to 2006, 23 patients with occipitoatlantoaxial ventral lesions were treated using a transoccipitocervical posterolateral approach for decompression. The procedure included an expansion of the foramen magnum, a resection of the posterior arch of atlas, a lateral occipitocervical epidural exposure to the odontoid and the C2 vertebra, and an excision of the odontoid. Thus, an anteroposterior decompression and occipitocervical spinal fusion was achieved. Neurological function, daily living ability, and the work ability of patients were assessed in a follow-up study. A 28-year-old woman died of respiratory and circulatory failure 10 hours after operation. The remaining patients survived without postoperative infection. The neurological injury in 17 patients did not deteriorate, whereas 5 patients had decreased sensation in the upper limbs, and the elbow flexor muscle strength in 2 patients declined by 1 grade on the operation side. Short-term follow-up (3-6 mo, 22 cases) indicated that 19 patients recovered normal sensation with decreased limb muscle tension. Motor function was improved by >1 grade (5 patients with postoperative nerve injury recovered to preoperative levels or better). Long-term follow-up (>4 y) of 15 patients (10 patients by clinic visit and 5 patients by correspondence) indicated that the occipitoatlantoaxial regions were stable without local discomfort or loss of nerve function. Fourteen patients were able to care for themselves and some patients regained their ability to work. One patient felt no significant improvement after surgery and had no improvement in the quality of life. Transoccipitocervical posterolateral approach to occipitoatlantoaxial ventral lesions provides a broad and sterile operating field to perform anteroposterior decompression and occipitocervical spinal fusion simultaneously. Neurological improvement is significant, and the long-term follow-up results are satisfactory.

Atypical Cluster and Migraine Headache Starting with a Reverse Epicrania Fugax

Dear Editor, Epicrania fugax (EF) and its variant, reverse EF (rEF), have been recently identified as novel syndromes in several reports ⇓. EF is characterized by paroxysmal unilateral epicranial pain that starts in a particular focal area of the posterior scalp and radiates forward along a linear or zigzag trajectory to reach the ipsilateral eye or nose in seconds. rEF has a character similar to EF, but it radiates backward in an opposite direction. Here, we report, for the first time, that rEF occurred as an initial symptom of cluster and migraine headache. Patient 1: A 29-year-old man had a 10-year history of episodic headache attacks. Each attack would begin with a brief moderate-to-severe epicranial pain that always started unilaterally in a frontoparietal point and then moved backwards following a linear trajectory to reach the occipitocervical region in 10–30 seconds. This brief backward radiating epicranial pain would occasionally occur without evolving into a different headache. However, in most circumstances, once this epicranial pain reached and fixed in the occipitocervical region, the patient would suffer an attack of excruciating pressure-like headache on the ipsilateral side. This headache usually started in the periorbital and frontal area, and subsequently spread to the temporal area. This headache …

Higroma quístico – Diagnóstico pré-natal, prognóstico obstétrico e pediátrico

IntroductionFetal cystic hygroma (CH) is a congenital malformation prenatally diagnosed by the demonstration of a cystic structure in the occipitocervical region on ultrasound. It may appear isolated or in association with chromosomal abnormalities, fetal malformations or genetic syndromes, with a poor overall prognosis.The main purpose of this work was the evaluation of the obstetric management and paediatric outcome for the survivors of CH. Material and methodRetrospective analysis of 224 pregnant women with fetal CH, diagnosed or referred to our prenatal diagnosis centre, from January 1991 to July 2011. ResultsThe mean gestational age at diagnosis was 13 weeks and 77.7% of cases were diagnosed in the first trimester. On ultrasound, 66 cases were associated with hydrops. Fetal karyotype was obtained in 206 cases, and chromosomal abnormalities were found in 107. Fetal karyotype was normal in 99 cases, detected 12 cases of genetic diseases and 18 cases of fetal malformations. Elective pregnancy termination was undertaken by 111 patients. There were 39 cases of spontaneous fetal demise and 61 live births. The mean follow-up of survivors was 75 months, and normal paediatric outcome was confirmed in 30 cases. ConclusionIt is essential to clarify the underlying aetiology of CH in order to establish a prognosis and counselling. There is a strong association with fetal aneuploidy and significantly worse outcome in contrast in cases without evidence of chromosomal or structural abnormalities, most of them carrying good prognosis.

Giant occipitocervical lipomas: Evaluation with two cases

Lipomas are capsulated benign tumours that are commonly found in all body parts. A lipoma is a well-defined mesenchymal tumour that arises from the adipose tissue. Although giant lipomas are rare in the head and neck regions, when they are located here, they are most commonly found in the subcutaneous posterior neck area. Recurrence as well as invasion is very rare after total surgical excision. In this article, we present two rare cases of giant lipomas in the posterior occipitocervical region, which is an exceptional location.

Traumatic Left Lateral C2 Epiphysiorhexis in a 3-year-old Girl – A Case Report

Spinal injuries in the occipito-cervical region are rare in children and, in most cases, are associated with high-speed deceleration trauma such as car accidents. Injuries predominantly occur at the C2 level as odontoid fractures, but cases of epiphysiolysis have been reported, too [1] [2] [3] [4] [5] [6].

C1 Lateral Mass Screw Insertion With Protection of C1-C2 Venous Sinus

This is a technical note and review of the literature. We propose to describe a revised surgical technique of C1 lateral mass screw insertion with protection of C1-C2 venous sinus surrounding the C2 nerve root. During C1 lateral mass screw insertion and in posterior C1-C2 fixation, iatrogenic injury of C1-C2 venous sinus results in bleeding, which is troublesome. Appropriate management of the venous sinus in this region is critical to successful surgery in this complex anatomic region. We reviewed 48 patients who underwent posterior C1-C2 fixation at our institution between September 2001 and October 2008. Twenty-four atlas screws were inserted by the originally described C1 lateral mass screw technique (group A), and 28 through a revised posterior arch and lateral mass screw technique (C1 transpedicular screw) (group B). The final group of 44 atlas screws was placed with our newly revised technique (group C). Bleeding of venous sinus was encountered in 3 group A, 2 group B, and 1 group C atlas screw insertions. The incidence rate was 12.50% (A), 7.14% (B), and 2.27% (C). Statistical comparison showed no significant difference between the groups. All the cases were followed for a mean period of 28.1 month. Four patients in group A complained of postoperative numbness in occipitocervical region. No patients in group B or group C voiced this complaint. A high fusion rate was found in all 3 groups with no signs of implant failure. Bleeding of C1-C2 venous sinus is vigorous and frustrating. The revised technique we describe provides theoretical and practical protection of venous sinus. In addition, the firm bony purchase of screws afforded by this technique contributes to achieving stabilization of the upper cervical spine and a high fusion rate.

Prognostic Factors in Patients with Occipital Encephalocele

Background: An encephalocele is a herniation of the brain and the meninges through a skull defect protruding towards the exterior. The condition is not rare when compared to spinal dysraphisms, but the worldwide incidence is not precisely known. The cases involving occipital encephaloceles which we have diagnosed in our clinic and the surgical approaches for this rare condition are presented herein. Methods: Thirty patients who were diagnosed with occipital encephaloceles and referred to our Neurosurgery Clinic at the Yuzuncu Yil University, Faculty of Medicine Research Hospital between 2000 and 2009 were enrolled in this study. The age of the patient, size of the sac, pathologies that accompanied the condition, and treatments applied were assessed. Results: In the present study, 30 patients (22 girls and 8 boys), whose ages varied between newborn and 14 months, were evaluated. The encephalocele sac was located in the occipital region in 27 patients (90%) and in the occipitocervical region in 3 patients (3%). Nine (30%) of the 30 patients died; 2 in the preoperative period, 2 in the postoperative early period (0–7 days) and 5 in the late postoperative period (first week to 3 months). With the exception of the 2 patients who died preoperatively, surgery was performed on all of the patients. The mortality rate in our study was 29%. Conclusions: Our study demonstrated that factors which determine the prognosis of patients diagnosed with occipital encephaloceles include the size of the sac, the contents of the neural tissue, hydrocephaly, infections, and pathologies that accompany the condition. An occipital encephalocele is a congenital neurologic condition with an extremely high morbidity and mortality in spite of the treatments rendered pre- and postoperatively.

Occipito-Atlanto-Axial Osteoarthritis

A cross-sectional clinico-radiologic evaluation of occipito-atlantoaxial (OC1C2) region of 2 population groups. Determine the prevalence of OC1C2 osteoarthritis in porters involved in carrying loads on the head and general male population. Describe its clinico-radiologic manifestations. In addition to age, head loading is a known cause of degeneration affecting the occipito-cervical region. The impact of head loading in the population aged between third and sixth decade is unknown. Head loading is a common custom in the developing countries. Study group (n = 107) included randomly selected male porters from railway stations who underwent computed tomography (CT) study of the OC1C2 region, plain radiographs of the cervical spine and detailed clinical examination. Control group (n = 107) included randomly selected male patients undergoing CT scan study for diseases of paranasal sinuses with coincidental screening of OC1C2 region along with clinical assessment. The data were analyzed using SPSS 15 software. Mean age for study group was 32.6 years and controls was 34.6 years (P = 0.156). In the study group, duration of occupational exposure was 10.9 (+/-8.7) years; 81.3% porters being symptomatic with an age of 33.4 (+/-9.6) years. Radiologic prevalence of OC1C2 osteoarthritis in study group was 91.6% and in control group was 6.8%; age of affected individuals was 33.4 (+/-9.3) and 47.9 (+/-8.0) years, respectively. Most common complaint was suboccipital neck pain (69.7%); while the CT finding was decreased joint space with sclerosis and irregularity of the margins (81.3%). No statistically significant association was found between presence of radiologic changes and symptoms. Age, duration of occupational exposure and its relationship with various clinico-radiologic manifestations was studied. This condition has significant prevalence in porters, beginning at an early age. Diagnosis is based on the clinico-radiologic presentation. CT is the investigation of choice. Resultant functional limitations make early identification of this condition imperative.

Evaluation of Occipitocervical Subluxation in Rheumatoid Arthritis Patients, Using Coronal-View Reconstructive Computed Tomography

Reconstructive computed tomography (CT) study of occipito-atlanto and atlantoaxial joints in RA patients. The occipitocervical region is one of the most common sites of rheumatoid arthritis (RA). Although lateral radiography has been used for the diagnosis of atlantoaxial subluxation and vertical subluxation, reconstructive CT imaging of the occipito-atlanto and atlantoaxial joints is more sensitive in detecting morphologic changes in this region. We investigated this region in RA patients, using coronal-view reconstructive CT images, and examined the relationship between the morphology and other radiographic parameters. The occipitocervical region was examined in 58 female RA patients by reconstructive CT, plain radiography, and MRI. The degree of destructive change on reconstructive CT was compared to that on other radiographic evaluations. Coronal-view reconstructive CT revealed primary destructive changes before detection by lateral radiography, using Redlund-Johnell or Ranawat values. A Redlund-Johnell value less than 34 mm was diagnostic for occipitocervical subluxation in female RA patients. Coronal-view reconstructive CT is useful for the diagnosis of occipitocervical joint subluxation in RA.

Ein Fall mit komplexer okzipitozervikaler Übergangsstörung

Only very few complete aplasias of the posterior atlas arch have been described. Aplasia combines with assimilation of the anterior atlas arch and a basilar impression is an even rarer variant of this developmental anomaly in the occipitocervical region. The clinical symptoms in the case described were limited to persistent nuchal pain and severely limited function of the cervical spine.

Die kinderorthopädische Bedeutung der Achondroplasie und Hypochondroplasie

Achondroplasia and hypochondroplasia are the most common forms of short stature. The leading sign is the diminished body height. Most cases of achondroplasia can be detected by clinical examination. Hypochondroplasia is more often not diagnosed until preschool age.In achondroplasia many different orthopaedic problems can arise, which influence the ADL. Mainly pathologic alterations of the occipitocervical region or a stenosis of the medullary cavity should be expected. In the limbs a bow-leg deformity and hyperlaxity of the ligaments often can be seen, which in some cases restrict walking capacity. Even if many people of short stature contemplate a lengthening procedure, the correction of deformities is much more important. The CORA method should be used in planning any osteotomy.

Migraine Pain Location at Onset and During Established Headaches in Children and Adolescents: A Clinic-Based Study from Eastern India

Literature documenting the location of pain at onset of migraine attacks and during established headaches in children and adolescents is sparse. Through a prospective study (2003-2005) of 200 children with migraine (ICHD-2: 1.1 and 1.2.1), we set out to document (i) the site of onset of pain and (ii) the location of pain during established attacks (on >50% of occasions) through semistructured interviews of patients and parents. Of the 200 children, the male:female ratio was 118 : 82 (1 : 0.69), the age range was 7-15 years (mean 11.8 years) and the duration of migraine 6 months to 4 years (mean 1.6 years). Ninety-three percent of subjects were ethnic Bengalis from the eastern Indian state of West Bengal, capital city Calcutta. Migraine types were: 1.1, 197 (98.5%); 1.2.1, three (1.5%). Location of pain at onset: 20.5% of subjects had unilateral onset; of these, 26.8% had eye pain, 65.9% frontal and 12.3% temporal pain. Thirty-three percent had bilateral location of pain, mostly bifrontal or ocular. None had vertex onset pain. However, in 35% of subjects, pain was holocranial at onset. Only 11.5% experienced pain in the occipito-cervical region at onset. Location of established headaches: in 53.7% of subjects with unilateral onset, headaches subsequently became holocranial. Hemicranial headaches occurred in only 19.5%. Of bilateral onset pains, 57.8% also became holocranial subsequently. In all, 73.5% of children ultimately experienced holocranial headaches. This study documents pain location at onset and during established headaches in children with migraine largely from a specific ethnic group.

CERVICAL TUMORAL CALCIUM PYROPHOSPHATE DIHYDRATE DEPOSITION DISEASE 28 YEARS AFTER SUBOCCIPITAL CRANIOTOMY

To describe a rare case of tumoral cervical chondrocalcinosis that appeared 28 years after the patient had undergone suboccipital craniotomy. A 42-year-old woman suffered from cervicalgia associated with a firm mass at the occipitocervical region. Plain x-ray and computed tomographic and magnetic resonance images revealed a calcified lesion in a scar from a previous suboccipital craniotomy. The patient underwent tumorectomy and histopathology, which revealed an exuberant tumoral chondrocalcinosis. Laboratory test results revealed no secondary cause for the chondrocalcinosis. Identification of chondrocalcinosis beyond the cervical region is very rare. Localization of chondrocalcinosis in a scar from a previous suboccipital craniotomy has not been previously reported. Surgery appears to be the treatment of choice for this form of chondrocalcinosis.