Upper Cervical Spine Research Articles

Atlantoaxial Instability in Children, 26 Years of Experience

Study Design: Retrospective case study.
 Objective: To determine the history, clinical and imaging signs, diagnosis, treatment and clinical follow-up.
 Summary of Background Data: The cranio vertebral junction (CVJ) is a complex transitional area between the skull, the upper cervical spine, the brain and the upper cervical cord. It concerns all ages. Instability can be the result of congenital malformations or traumatic injury.
 Methods: It is a retrospective study of patients files in department of paediatricneurosurgery and the department of pediatric orthopedic of Marseille, during 26 years , Between 16th October 1981 and 16th June 2007 In each medical record, we determined identity, circumstances of instability discovery, clinical and paraclinical signs, diagnosis, therapeutic protocol and patient's outcome after treatment.
 The inclusion criteria were the medical records with complete information regarding the patients, who were treated for atlantoaxial instability (AAI). Patients presenting clinical instability with incomplete files, have been excluded.
 Results: In our retrospective study, 22 children have been treated for AAI, with 10 boys (45%) and 12 girls (55%), aged 5 to 17 years old, mean age was 10.
 the main circumstance of lesion was accident 45,5%, sport accident 27,3%, road accident 18,2%), the others circumstances are 55,5%.
 The past history included : congenital malformation in 18,2% (Down’s syndrome, Klippel- Fiel’s syndrome, cardiac malformation), sport accident(9,0%), neurological deficit (13,7%), cervical trauma already treated(4,5%), learning deficit (4,5%), and plagiocephaly (4,5%); for 45,6%, there was no evidence etiology.
 The clinical signs were quadriparesis (31,9%), quadriplegia (13,6%), torticoli (9,1%), quadriplegia and priapism (4,5%), headache and dizziness (4,5%), abnormal head position attitude (4,5%). Clinical exam was normal for 31,9%.
 Standard X-ray was performed for 50,0%, CT scan for 50,0% and MRI for 40,8%.
 These paraclinical examination showed that AAI were traumatic in 59,1% (luxation 36,4%, odontoïdum fracture 13,7%, C1C2 dislocation 4,5 %, C2 arch, articular fracture and pseudoarthrosis 4,5%), congenital malformation in 40,9%.
 The orthopedic treatment was used for 13,5% of the patients and surgical treatment was used for 86,5% of the patients (posterior approach72,8 %, anterior approach 9,2%, anterior and posterior approach 4,5%).
 Complications were observed in 33% of the patients (consisted of infections 14%, Medulla oblongata compression 5%, basilar impression)
 72% of the patients recovered without sequela after 15years of follow up, 28% had a neurological deficit during the same time .13% conserved their deficit 5 years after treatment.
 Conclusion: In many cases, AAI is an insidious affliction in many cases. A neurological deficit is a sinister presentation often leading to significant sequela even after treatment.

How Do You Treat Trigeminal Neuralgia in Your Practice?

How Do You Treat Trigeminal Neuralgia in Your Practice?

Effects of osteopathic manipulative treatment of the pivots on lower limb function in young professional football players

IntroductionThe most frequent injuries in professional soccer players are those pertinent to the lower limbs. In particular, strains of the hamstrings and ligamentous injuries of the knee. Therefore, preventive measures are aimed to reduce such events. We aimed to investigate if an osteopathic manipulative treatment (OMT) of the pivots could improve lower limb function in young professional football players. MethodsThirty-eight young male professional football players were recruited (mean age 17.8 ± 0.44 years). These were randomly assigned to an OMT or control group (n = 20 and 18, respectively). Both groups underwent osteopathic evaluation. A sit-and-reach test, a vertical jump test, a hand-grip strength test, a cervical ROM test and a balance evaluation were also performed. ResultsA significant improvement (p < 0.01) was observed between pre and post measures in the OMT for dysfunctional assessment of the pivots. However, only L3 and C2 also differed from the control group post evaluation (p < 0.0001). No differences were present for any functional measure in the control group. Only the sit-&-reach of the OMT increased significantly (p < 0.001). Static balance with open eyes in the OMT, but not in the control group, improved during post evaluation (p < 0.01). ConclusionThe OMT of the pivots was able to increase the sit-and-reach measure, improve postural control with open eyes and improve dysfunctional patterns of the lumbosacral and upper cervical spine in young professional football players.

Is Cervical Stabilization Exercise Immediately Effective in Patients with Chronic Neck Pain and Upper Cervical Spine Dysfunction? Randomized Controlled Trial.

Purpose: To compare the effectiveness of a single exercise session with manual therapy techniques in the segments of the upper cervical spine (C0–1, C1–2 and C2–3), against a single exercise session in patients with chronic neck pain and mobility deficits in the upper cervical spine. Methods: A single-blind randomized controlled trial was performed. Fifty-eight patients were recruited (29 for the manual therapy and exercise group and 29 for the exercise group) who presented chronic neck pain and upper cervical spine dysfunction. The exercise focused on the deep muscles. The manual therapy combined manipulations and mobilizations with these exercises. Cervical range of motion, flexion-rotation test, pressure pain threshold and pain intensity were measured by a blind evaluator before and after the intervention. Results: Compared to pre-intervention, after intervention, the exercise group was significantly lower in terms of the range of motion, flexion-rotation test, and pressure pain threshold (p < 0.05). The manual therapy and exercise group improved in upper cervical flexion, the flexion-rotation test and intensity of pain (p < 0.05). Conclusions: It may be necessary to normalize the mobility of the upper cervical spine before cervical stabilization training, in patients with chronic neck pain and mobility deficits in the upper cervical spine.

Only cervical vertebrae C0-C2, not C3 are relevant for subgrouping migraine patients according to manual palpation and pain provocation: secondary analysis of a cohort study

BackgroundSubgrouping of migraine patients according to the pain response to manual palpation of the upper cervical spine has been recently described. Based on the neuroanatomy and the convergence of spinal and trigeminal nerves in the trigeminocervical complex, the cervical segments C1 to C3 are potentially relevant. To date it has not been investigated whether palpation results of all upper cervical segments are based on one underlying construct which allows combining the results of several tests. Therefore, the aim of this secondary analysis of a cohort study was to determine whether results from all three segments form one construct.MethodsSeventy-one migraine patients with chronic or frequent episodic migraine diagnosed according to the international headache society classification version 3 were examined by one physiotherapist. Manual palpation using a posterior to anterior pressure was performed on the upper three cervical vertebrae unilaterally left and right. The results of the palpation according to the patients’ responses were combined using factor analysis. In addition, item response theory (IRT) was used to investigate the structure of the response pattern as well as item difficulty and discrimination.FindingsFactor analysis (principal component) showed that the palpation of C3 loads less onto the underlying construct than the palpation of C1 and C2. Considering a cut-off value > 1.0, the eigenvalues of all three segments do not represent one underlying construct. When excluding the results from C3, remaining items form one construct. The internal consistency of the pain response to palpation of C1 and C2 is acceptable with a Cronbach’s alpha of 0.69. IRT analysis showed that the rating scale model fits best to the pain response pattern. The discrimination value (1.24) was equal for all items. Item difficulty showed a clear hierarchical structure between the palpation of C1 and C2, indicating that people with a higher impairment are more likely to respond with referred pain during palpation of C2.ConclusionStatistical analysis confirms that results from the palpation of the cervical segments C1 and C2 in migraine patients can be combined. IRT analysis confirmed the ordinal pattern of the pain response and showed the higher probability of a pain response during palpation of C2. The pain response to C3 palpation is not relevant for unidimensional IRT analysis.Trial RegistrationGerman registry of clinical trials (DRKS00015995), Registered 20. December 2018, https://www.drks.de/drks_web/setLocale_EN.do

Craniocervical Junction Visualization and Radiation Dose Consideration Utilizing Cone Beam Computed Tomography for Upper Cervical Chiropractic Clinical Application a Literature Review.

ObjectivesTo highlight the detail obtained on a Cone Beam Computed Tomography (CBCT) scan of the craniocervical junction and its usefulness to Chiropractors who specialize in the upper cervical spine. A review of the dose considerations to patients vs radiography in a chiropractic clinical setting and to review the effective radiation dose to the patient.MethodsA review of studies discussing cervical biomechanics, neurovascular structures, and abnormal radiographic findings, was discussed in relation to chiropractic clinical relevance. Further studies were evaluated demonstrating radiation dose to the patient from radiographs compared to CBCT.ResultsIncidental and abnormal findings of the craniocervical junction were shown to have superior visualization with CBCT compared to radiography. The radiation dose to the patient for similar imaging protocols to the craniocervical junction and cervical spine was equal or less utilizing CBCT when compared to radiographs.ConclusionsThe use of CBCT for visualization of the craniocervical junction and cervical spine in the chiropractic clinical setting allows for adjunctive visualization of the osseous structures which is germane to clinical protocol. Further with CBCT the effective dose to the patient is equal or less than similar imaging protocols utilizing radiographs to evaluate the craniocervical junction.

Primary Melanocytic Tumors of the Central Nervous System in Children: Imaging Features with Pathologic Correlation

Primary melanocytic tumors of the central nervous system are rare neoplasms arising from proliferation of multipotent melanin-containing neural crest cells found in the leptomeninges. This review describes the imaging appearance of the entire spectrum of primary melanocytic tumors of the brain and spine in the pediatric population, in correlation with histopathology, clinical features, and prognosis, using sample cases from our institution. These tumors are subclassified by the World Health Organization on the basis of disease distribution and pathologic aggressiveness into the following 4 subtypes: meningeal melanocytoma, meningeal melanoma, meningeal melanocytosis, and meningeal melanomatosis. They can occur in any age group, though the diffuse form of the disease is more prevalent in children and has an association with giant cutaneous melanocytic nevi. Imaging is characterized by hyperattenuation on CT and intrinsic T1 hyperintensity on MR imaging from the presence of melanin and/or hemorrhage. The focal forms usually manifest as dural-based hemorrhagic masses, and the diffuse forms demonstrate dural thickening and enhancement, with or without hydrocephalus. There is a predilection for the medial temporal lobes, posterior fossa, and upper cervical spine. The prognosis is often poor, with a high incidence of malignant transformation of benign disease.Learning Objective: To describe the imaging appearance of the spectrum of primary melanocytic tumors of the brain and spine in the pediatric population and to review the histopathology, clinical, and prognostic data available

Recurrent Cervical Subdural Bleeding Because of Atlantoaxial Instability in a Patient with Rheumatoid Arthritis: A Case Report.

Atlantoaxial instability (AAI) is a frequent complication of rheumatoid arthritis (RA), but its involvement in intracranial bleeding is unclear. We present a young woman with history of systemic lupus erythematosus and RA who developed 3 episodes of subdural bleeding at the upper cervical spine and cranial level. Imaging tests showed signs of AAI with odontoid deformity. The case was interpreted as recurrent traumatic cervical subdural hemorrhage because of AAI. No new episodes occurred after surgical C1-C2 fixation. We report a case that had the association of hemorrhage and C1-2 instability in a patient with RA and lupus erythematosus.

C1 lateral mass screw insertion using cannulated, navigated screws: preliminary results of a novel technique

Purpose The upper cervical spine region is densely populated by neural and vascular structures impeding the approach for fusion surgery. Technological advancement simplify the approach to C1-C2 fusion, thus reduce risks. The current paper purpose is to describe initial experience with a novel technique modification for C1 lateral screw insertion that incorporates cannulated-navigated screw system with intra-operative 3D imaging. Methods A single-center single surgeon database was reviewed to identify all patients who underwent placement of C1 lateral mass screw insertion using the novel technique modification described below, on 2020. This cohort was retrospectively analyzed and compared with a cohort of patients who were operated on by the same surgeon with non-cannulated, navigated screws with intra-operative 3D imaging (O-arm, Medtronic, USA) between 2011 and 2019. Following navigated starting hole and drilling of the C1 lateral mass, a blunt guide-wire is used to palpate the hole and cannulated screw is advanced to the correct position over the wire. After initial purchase, a navigated screw driver is used for final screw depth position. Results Twelve C1 lateral mass screws were inserted in six patients using this novel cannulated-navigated screw placement technique and compared to 24 patients operated using navigated non-cannulated screws. Minimal Estimated Blood Loss (EBL) was recorded in five of six cases undergoing the novel cannulated navigated placement of C1 lateral mass screws. Comparison to non-cannulated cohort demonstrated an EBL of 83CC vs. 354CC (Not significant). Mean surgery time was 97min and 118min for the cannulated-navigated and navigated only procedures (p = 0.03, statistically significant) respectively. In the current cohort, all screws were rated in optimal position and no repositioning procedures were performed. Conclusion The new method presented allows for faster and possibly safer and more accurate C1 lateral mass screw insertion.

Novel technique for intraoperative imaging of the vertebral artery in patients undergoing dorsal osteosynthesis of the cervical spine

Background: The incidence of fractures in the upper cervical spine is a common entity among elderly patients. The incidence depends on the health care system and the adopted protocols for a computer tomogram in the emergency unit, in order to assure an easier and earlier detection. Injuries to the vertebral artery could occur with devastating consequences, due to this type of fracture. The aim of the current surgical strategies is to stabilize the fractures and avoid further injuries to the vertebral arteries. Methods: We adopted a previously hypothesized method for intraoperative imaging of the vertebral artery when performing an O-Arm navigated cervical osteosynthesis. Three patients were included in this group: one patient with dens fracture type II after Anderson and D’Alonzo, one patient with a complex C1/C2 fracture and dissection of the vertebral artery on the left side and one patient with a kyphotic deformity due to Larynx carcinoma Metastasis in C4-C6. After positioning the patients, a 100 ml contrast was applied prior to the primary O-Arm scan, thus obtaining real-time imaging of the vertebral artery in the navigational CT series. Results: A total of 18 screws were placed. None of the screws bridged the vertebral canal. The average operative time was 174 mins. No new neurological deterioration was observed in the postoperative period. Conclusions: With the development of this technique, it is possible to reduce the surgery-related injury of the vertebral artery to 0%. Further studies are necessary to assess the feasibility of this technique. This technique could be especially helpful in the cases of distorted anatomical relations.

Surgical outcome of Occipitocervical Fixation for Craniocervical Instability

Background: The occipitocervical junction is a unique area between the cranium and the upper cervical spine. Treating pathologies of this region require a good knowledge and understanding of the anatomy, biomechanics of this region and nature of the disease.&#x0D; Objective: To evaluate the efficacy of Occipitocervical Fixation (OCF) in patients with craniocervical instability in two tertiary care hospitals.&#x0D; Metrial and Methods: This study was conducted at Combined Military Hospital Rawalpindi and Hayatabad Medical Complex, Peshawar from April 2005 to December 2016. All patients with craniocervical instability were included in our study, and those having occipital bone fractures or previously operated patients with same technique were excluded from this study. The patients were compared using lateral static and dynamic X-ray taken before the operation, after the operation, and during last follow-up. The Nurick score was used to assess neurological function pre and postoperatively.&#x0D; Results: A total of 49 cases with craniocervical instability underwent OCF. The mean age of the patients was 40.5 + 1.2 SD years. There were 31 male patients and 18 female patients. Majority patients showed improvements in myelopathic symptoms after the operation. The mean preoperative Nurick score was 3.0. At the end of follow-up after surgery, the mean Nurick score was 2.1. &#x0D; Conclusions: Occipitocervical fixation is a reasonable option to have spinal stability, achieve bone fusion and to get neurological improvement. The procedure can be complicated by certain conditions but these can safely be handled in experience hands.&#x0D;

Cervical Sprain With Residual C1-C2 Laxity as Source of Fibromyalgia and Multiple Sclerosis Symptoms?

Research Objectives To evaluate the upper cervical segmental mobility in patients with a remote history of trauma presenting with persistent fibromyalgia symptoms with evidence of persistent cervical sprain pain. Design Chart review. Setting Outpatient clinic. Participants Patients with history diagnosed with fibromyalgia and demonstrating (1) frequent headache on awakening, (2) pain/increased symptoms with neck range of motion, (3) pain with resistance to neck motion, (4) relief during cervical traction, (5) and typical fibromyalgia symptoms. Interventions CT of the cervical spine including rotation views. Main Outcome Measures Skeletal mobility per CT scan including Cranium, C1, and C2 rotation in degrees Results Analysis reveals that only one of the individuals had < 30 degrees rotation of C1 on C2, versus 14 of 20 having > 35 degrees and 7 of 20 having > 40 degrees rotation of C1 on C2 suggesting ligamentous laxity. Of note, none of the individuals had > 5 degrees rotation of cranium on C1, suggesting greater stability when compared to C1-C2. Conclusions In addition to upper spinal cord, the vertebral-basilar arteries supply the cerebellum, medulla oblongata, midbrain, pons, thalamus, and other areas in the posterior cranium. Symptoms of ischemia involving these areas include dizziness, gait disturbance, limb weakness, dysarthria, headache, nausea, cranial nerve, visual and other sensory dysfunctions. This sampling of persistent neck pain patients demonstrates significant rotational mobility that may involve the vertebral arteries at C1 and C2 in particular, contributing to symptoms similar to those with documented ischemia in the vertebrobasilar distribution. Alternatively, direct compression at cervical spinal cord-medullary junction from C1-2 laxity is illustrated in sagittal view MRI image. Here is seen anterior cranial migration relative to spinal canal compressing the spinal cord at its medullary junction. It is noteworthy that 4 individuals in this small sample developed plaque in the vertebrobasilar distribution and subsequently confirmed to have multiple sclerosis. Whether or not there is a relationship between ligamentous laxity in the upper cervical spine and development of fibromyalgia and/ or multiple sclerosis remains to be demonstrated. Author(s) Disclosures None to declare. To evaluate the upper cervical segmental mobility in patients with a remote history of trauma presenting with persistent fibromyalgia symptoms with evidence of persistent cervical sprain pain. Chart review. Outpatient clinic. Patients with history diagnosed with fibromyalgia and demonstrating (1) frequent headache on awakening, (2) pain/increased symptoms with neck range of motion, (3) pain with resistance to neck motion, (4) relief during cervical traction, (5) and typical fibromyalgia symptoms. CT of the cervical spine including rotation views. Skeletal mobility per CT scan including Cranium, C1, and C2 rotation in degrees Analysis reveals that only one of the individuals had < 30 degrees rotation of C1 on C2, versus 14 of 20 having > 35 degrees and 7 of 20 having > 40 degrees rotation of C1 on C2 suggesting ligamentous laxity. Of note, none of the individuals had > 5 degrees rotation of cranium on C1, suggesting greater stability when compared to C1-C2. In addition to upper spinal cord, the vertebral-basilar arteries supply the cerebellum, medulla oblongata, midbrain, pons, thalamus, and other areas in the posterior cranium. Symptoms of ischemia involving these areas include dizziness, gait disturbance, limb weakness, dysarthria, headache, nausea, cranial nerve, visual and other sensory dysfunctions.

Three-Dimensional Morphology and Configuration Analyses of the Craniovertebral Junction in Children with Hemifacial Microsomia.

Observational and morphological study with three-dimensional (3D) computed tomography (CT) analysis. To discover the morphology and configuration deformities of craniovertebral junction (CVJ) and upper cervical spine in children with unilateral hemifacial microsomia (HFM). To determine whether there are specific HFM patients who are at higher risk of certain cervical vertebral anomaly. The evaluation for cervical vertebrae anomaly in HFM children, especially in CVJ region, is underreported. Eighty-eight unilateral HFM children (64 males, 24 females) with four Pruzansky-Kaban types (I, Ila, Ilb, and III) underwent cranial and cervical CT scanning from skull to C5 in neutral position. The 3D morphology and configuration of the occipital condyle, atlas, and axis, etc. were evaluated on the presence of deformed detailed structures of CVJ region. No C1 deformation was found in type I group. Six (14.3%) type Ila cases, seven (33.3%) type IIb cases, and six (37.5%) type Ill cases had lateral masses asymmetry of C1 (P < 0.05). Five (55.6%) type I cases, 17 (40.5%) type Ila cases, 12 (57.1%) type Ilb cases, and 10 (62.5%) type Ill cases had C2 anomaly (P > 0.05). The incidence rate of C1-C2 instability for four groups were 33.3% (type I), 33.3% (type IIa), 33.3% (type IIb), and 31.3% (type Ill), respectively (P > 0.05). For HFM children, the incidence of C1 deformation increased from type I to type Ill. The probability of C2 anomaly and C1-C2 instability in children with different types of HFM is nearly the same. The craniovertebral junction of every HFM child must be monitored carefully for C1-C2 instability before any surgical procedure to avoid atlantoaxial dislocation and spinal cord injury.Level of Evidence: N/A.

Endoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion for the treatment of upper cervical spine tuberculosis: a retrospective feasibility study

BackgroundThis retrospective study aimed to determine the feasibility and efficacy of endoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion in patients with upper cervical spine tuberculosis.MethodsBetween June 2008 and January 2016, 17 patients (10 men and 7 women) with upper cervical spine tuberculosis underwent endoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion. Anti-tuberculosis treatment was administered for 2–4 weeks preoperatively and 12–18 months postoperatively. The clinical and radiographic data of the patients were analyzed.ResultsThe operation was successfully completed in all patients. Neck pain and stiffness were relieved after the surgery in all patients. The mean operation time was 210.0 ± 21.2 min, and the mean intraoperative blood loss was 364.7 ± 49.6 mL. The mean follow-up duration was 68.1 ± 6.7 months. The erythrocyte sedimentation rate returned to normal by 3 months postoperatively. Visual analog scale scores for neck pain were significantly lower postoperatively than preoperatively. All patients had significant postoperative neurological improvement. Patient-reported outcomes, as measured using the Kirkaldy-Willis criteria, were as follows: excellent, 12 patients; good, 4 patients; fair, 1 patient; and poor, 0 patients. Bone fusion was achieved at 10.9 ± 1.9 months after the surgery; no cases of instrument loosening or fracture occurred.ConclusionEndoscopy-assisted anterior cervical debridement combined with posterior fixation and fusion is a feasible and effective surgical method for the treatment of upper cervical spine tuberculosis. It can be used to restore upper cervical spine stability and facilitate spinal healing.

Oxyhaemoglobin Level Measured Using Near-Infrared Spectrometer Is Associated with Brain Mitochondrial Dysfunction After Cardiac Arrest in Rats.

Cerebral blood oxygenation (CBO), measured using near-infrared spectroscopy (NIRS), can play an important role in post-cardiac arrest (CA) care as this emerging technology allows for noninvasive real-time monitoring of the dynamic changes of tissue oxygenation. We recently reported that oxyhaemoglobin (oxy-Hb), measured using NIRS, may be used to evaluate the quality of chest compressions by monitoring the brain tissue oxygenation, which is a critical component for successful resuscitation. Mitochondria are the key to understanding the pathophysiology of post-CA oxygen metabolism. In this study, we focused on mitochondrial dysfunction, aiming to explore its association with CBO parameters such as oxy-Hb and deoxyhaemoglobin (deoxy-Hb) or tissue oxygenation index (TOI). Male Sprague-Dawley rats were used in the study. We applied NIRS between the nasion and the upper cervical spine. Following 10 min of CA, the rats underwent cardiopulmonary resuscitation (CPR) with a bolus injection of 20μg/kg epinephrine. At 10 and 20 min after CPR, brain, and kidney tissues were collected. We isolated mitochondria from these tissues and evaluated the association between CBO and mitochondrial oxygen consumption ratios. There were no significant differences in the mitochondrial yields (10 vs. 20 min after resuscitation: brain, 1.33±0.68 vs. 1.30±0.75mg/g; kidney, 19.5±3.2 vs. 16.9±5.3mg/g, respectively). State 3 mitochondrial oxygen consumption rates, known as ADP-stimulated respiration, demonstrated a significant difference at 10 vs. 20 min after CPR (brain, 170±26 vs. 115±17nmol/min/mg protein; kidney, 170±20 vs. 130±16nmol/min/mg protein, respectively), whereas there was no significant difference in ADP non-dependent state 4 oxygen consumption rates (brain, 34.0±6.7 vs. 31.8±10nmol/min/mg protein; kidney, 29.8±4.8 vs. 21.0±2.6nmol/min/mg protein, respectively). Consequently, the respiratory control ratio (RCR=state 3/state 4) showed a significant difference over time, but this was only noted in the brain (brain, 5.0±0.29 vs. 3.8±0.64; kidney, 5.8±0.53 vs. 6.2±0.25nmol/min/mg protein, respectively). The oxy-Hb levels had a dynamic change after resuscitation, and they had a significant association with the RCR of the brain mitochondria (r=0.8311, p=0.0102), whereas deoxy-Hb and TOI did not (r=-0.1252, p=0.7677; r=0.4186, p=0.302, respectively). The RCRs of the kidney mitochondria did not have a significant association with CBO (oxy-Hb, r=-0.1087, p=0.7977; deoxy-Hb, r=0.1565, p=0.7113; TOI, r=-0.1687, p=0.6896, respectively). The brain mitochondrial respiratory dysfunction occurred over time, and it was seen at the time points between 10 and 20 min after CPR. The oxy-Hb level was associated with brain mitochondrial dysfunction during the early post-resuscitation period.

Physical Therapy and Migraines

Migraine is a most common type of headache that has been seen in almost every age group. This is the chemical imbalance within the brain causing substantial disability and pain. It is usually a pulsating sensation or a throbbing pain at one side of head. The main symptoms of migraine headache along with pain are nausea, vomiting, photosensitivity and extreme sensitivity to sounds. Lethargy in the body and tightness in the muscles around the head has also been seen. It involves almost 4 stages including prodrome, aura, migraine and postdrome lasting from one day to sometimes a week. But this is more common for one or two days. Dehydration, direct sunlight, skipping meals, hunger and stress sometimes may aggravate the migraines. Stress induced migraines are of extreme importance as it affects the muscles such as trapezius, sternocleidomastoid, levator scapulae and facial muscles due to pressure hypersensitivity.&#x0D; This is a neurological disorder but physical therapy may help in population with migraine. Some techniques could be quite useful such as:&#x0D; &#x0D; Soft tissue release&#x0D; Posterior-anterior cervical joints mobilization&#x0D; Upper cervical spine manipulation&#x0D; Needling therapy in the affected muscles&#x0D; Therapeutic exercises&#x0D; &#x0D; Soft tissue release technique may involve myofacsial trigger points release in the trapezius and sternocleidomastoid muscles as these get the tightness allover. Manual stroking by addressing the muscles and stroking away the trigger point from the center. Tender point release has also its utmost importance for releasing the migraines. Interestingly, by releasing the muscles over temporomandibular joint can reduce the migraine pain&#x0D; Posterior-anterior approach for upper cervical mobilization should be used for C1-C3. In this approach the thumbs of therapist glide over the zygophageal joints posterior-anteriorly. Upper cervical spine manipulations is applied by localizing the target area in the rotation position and then perform a low amplitude and high velocity thrust towards the contralateral eye of the patient. Spinal mobilization and manipulation actually targets the musculoskeletal disorders caused by the migraines. It directly cannot lessen the migraine but may aid to reduce it by relaxing the muscles. &#x0D; Therapeutic exercise may affect the pain positively by releasing the pressure such as cervical flexion; side bending and lateral flexion are some of the types of cervical isometrics may help to lessen the pain. This basically targets the deep neck muscles that can only be approached through therapeutic exercises. These fore mentioned techniques may help to reduce the migraine pains.

An anatomical model for studying cerebellar tonsillar herniation related to raised intracranial pressure

Brain herniation is one of the most feared complications of many neurological pathologies. However, current understanding of the mechanisms behind brain herniation syndromes is poor. By investigating the correlations between raised intracranial pressure (ICP) and herniation of the cerebellar tonsils, we hope to develop a model that can be used to study intracranial fluid dynamics and its effects on brain tissue. This will facilitate evaluation of patients with elevated ICP and development of novel treatments including surgical approaches for decompressing the posterior cranial fossa and upper cervical spine. A standard suboccipital surgical approach was used to expose the foramen magnum and observe movements of the cerebellar tonsils in fresh cadavers. A urinary Foley catheter balloon in the parietal extradural space was used to simulate a mass effect while ICP was monitored. The baseline anatomy differed widely among the cadaver specimens. However, and overall, we found that as ICP rises, the cerebellar tonsils descend through the foramen magnum at a rate of 0.3 mm per 1 mmHg increase in ICP. A mean descent of 6.2 mm was observed for a mean ICP increase of 17 mmHg. In this cadaveric study, we present a method and model for exploring brain herniation syndromes in the context of ICP changes. This could allow for further models to study the effects of other neuropathologies on the cerebellar tonsils, including posterior cranial fossa mass lesions and cerebellar hemorrhage.

Trabecular volumetric bone mineral density of the occipital bone at preferred screw placement sites measured by quantitative computed tomography.

This study aimed at quantifying trabecular volumetric bone mineral density (vBMD) at the external occipital protuberance (EOP) and the upper cervical spine. A retrospective review of patients who underwent non-contrast enhanced computed tomography of the cervical spine that included the occipital bone up to the EOP between 2007 and 2020 was conducted. Measurements of trabecular vBMD were performed in the occipital midline area, with the region of interest extending 4.5 mm above and below the center of the EOP, as well as the C1 lateral masses and the C2 vertebral body using asynchronous quantitative computed tomography. Eighty-six patients (female, 37.2%) were included for analysis. The patient population was 81.4% Caucasian with a mean ± SD age of 62.3 ± 13.1 years. Total bone thickness at the EOP was 16.7 ± 3.4 mm, with a ratio of trabecular to total bone thickness of 0.44. Trabecular vBMD (mean ± SD) was significantly higher at the EOP than at C1 and C2 (EOP = 612.3 ± 145.8 mg/cm3 , C1 average = 290.3 ± 66.5 mg/cm3 , C2 = 305.8 ± 78.8 mg/cm3 ; p < 0.001). A significant strong correlation between trabecular vBMD of C1 and C2 was observed (r = 0.744; p < 0.001), but only low correlations between the EOP and C1 (r = 0.295; p = 0.008) and C2 (r = 0.413; p < 0.001). In individuals > 65 years of age, cervical vBMD was significantly lower, but remained high at the EOP. Clinical significance: Trabecular vBMD at the EOP is significantly higher than at the upper cervical vertebrae and remains high in older populations. Together with morphological information about the occipital bone, these results might be helpful for occipitocervical fixation when deciding about uni- or bicortical screw placement at the EOP.

Validation and application of a novel in vivo cervical spine kinematics analysis technique

To validate the accuracy of Cone beam computed tomography (CBCT) cervical spine modeling with three dimensional (3D)-3D registration for in vivo measurements of cervical spine kinematics. CBCT model accuracy was validated by superimposition with computed tomography (CT) models in 10 healthy young adults, and then cervical vertebrae were registered in six end positions of functional movements, versus a neutral position, in 5 healthy young adults. Registration errors and six degrees of freedom (6-DOF) kinematics were calculated and reported. Relative to CT models, mean deviations of the CBCT models were < 0.6 mm. Mean registration errors between end positions and the reference neutral position were < 0.7 mm. During flexion–extension (F–E), the translation in the three directions was small, mostly < 1 mm, with coupled LB and AR both < 1°. During lateral bending (LB), the bending was distributed roughly evenly, with coupled axial rotation (AR) opposite to the LB at C1–C2, and minimal coupled F–E. During AR, most of the rotation occurred in the C1–C2 segment (29.93 ± 7.19° in left twist and 31.38 ± 8.49° in right twist) and coupled LB was observed in the direction opposite to that of the AR. Model matching demonstrated submillimeter accuracy in cervical spine kinematics data. The presently evaluated low-radiation-dose CBCT technique can be used to measure 3D spine kinematics in vivo across functional F–E, AR, and LB positions, which has been especially challenging for the upper cervical spine.

Letter to the Editor: The Trend of “Neurosurgery Interested” Among Omani Medical Students and Interns Despite the Absence of a Neurosurgery Residency Program: Does This Indicate It's Time to Change?

The extreme lateral infrajugular transcondylar-transtubercular exposure (ELITE) is a surgical approach developed in the late 1980s by Prof. T. Fukushima and represents the dorsolateral inferior skull base procedure of choice to approach lesion located ventrolaterally at the level of the craniocervical junction (CCJ). This approach consist in a suboccipital craniotomy/craniectomy with partial condylectomy and jugular tubercule drilling that can be extended providing for subtotal condylectomy and vertebral artery transposition. The “limited” variation of the ELITE approach consist in a lateral suboccipital craniectomy opening the foramen magnum and removal of at least half of the posterior arch of the atlas without condyle drilling. This surgical technique was recently demonstrated to be particularly suitable for the surgical management of spinal tumor located ventrolaterally in the upper cervical spine. This operative video illustrates step-by-step the surgical technique adopted for the microsurgical resection of a C1-C2 intradural schwannoma located antero-laterally (Video 1). ELITE approach offers a wide and adequate exposure and access to the CCJ, allowing direct visualization and access to the tumor with minimal neural manipulations, early detection of the vertebral artery and, for tumor located at C1-C2 level, without drilling the occipital condyle. In our experience, ELITE procedure is the preferred surgical approach for resection of tumors located ventrally or ventrolaterally to the first 2 cervical levels.