The treatment modality of occipitocervical junction (OCJ) and upper cervical traumas carries great importance because of unique form of bone, complex ligamentous, and neurovascular structure.Eighty-eight patients were admitted to Mersin University Department of Neurosurgery between January 2007 and January 2017 for injuries of the OCJ and upper cervical spine and evaluated retrospectively. In the group, there were 60 male, 28 female patients in the mean age of 42.9 (18-87) years. Among those, 2 occipital condyle fractures, 28 C1 fractures (26 isolated and 2 with transverse ligament injury), 9 combined C1/C2 fractures, 6 rotatory C1/C2 dislocations, and 43 C2 fractures (32 odontoid, 5 Hangman's, and 6 miscellaneous fractures) were diagnosed. In addition to clinical cases, ten cadavers were used to study the OCJ in a step-wise manner.Occipital condyle fractures, isolated C1 fractures, and rotatory C1/C2 dislocations were treated conservatively. Two patients with C1 fracture including transverse ligament injury were operated in one of the methods of C1-C2 fusion which is posterior sublaminar wiring. Five patients having Type II odontoid fracture were treated surgically. One instable Hangman's fracture patient was treated as anterior cervical discectomy and fusion.Cases with isolated C1 fracture with intact transverse ligament should be conservatively treated without surgical approach. Atlas fractures with transverse ligament rupture, odontoid Type II fractures with dislocation >6 mm, and unstable Hangman's fractures required surgical treatment. Vital neurovascular, ligamentous, and accompanying bone structures should be evaluated for diagnosis and treatment modality. In addition, patient's health status, patient's treatment preference, and surgical team experience are the affecting factors for the decision of surgery.
Abstract Anterior clinoidal meningiomas (ACMs) remain a major neurosurgical challenge. The skull base techniques, including extradural clinoidectomy and optic unroofing performed at the early stage of surgery, provide advantages for improving the extent of resection, and thereby enhancing overall outcome, and particularly visual function. Additionally, when the anterior clinoidal meningiomas encase neurovascular structures, particularly the supraclinoid internal carotid artery and its branches, this further increases morbidity and decreases the extent of resection. Although it might be possible to remove the tumor from the artery wall despite complete encasement or narrowing, the decision of whether the tumor can be safely separated from the arterial wall ultimately must be made intraoperatively. The patient is a 75-year-old woman with right-sided progressive vision loss. In the neurological examination, she only had light perception in the right eye without any visual acuity or peripheral loss in the left eye. MRI showed a homogeneously enhancing right-sided anterior clinoidal mass with encasing and narrowing of the supraclinoid internal carotid artery (ICA). Computed tomography (CT) angiography showed a mild narrowing of the right supraclinoid ICA with associated a 360-degree encasement. The decision was made to proceed using a pterional approach with extradural anterior clinoidectomy and optic unroofing. The surgery and postoperative course were uneventful. MRI confirmed gross total resection (Figs. 1 and 2). The histopathology was a meningothelial meningioma, World Health Organization (WHO) grade I. The patient continues to do well without any recurrence and has shown improved vision at 15-month follow-up. This video demonstrates important steps of the microsurgical skull base techniques for resection of these challenging tumors. The link to the video can be found at https://youtu.be/vt3o1c2o8Z0
65 years old female patient with diagnosis of supratentorial mass was operated.F-18 FDG PET/CT was performed for determination of primary tumor of the lesion which was assumed to be metastatic.However metabolic imaging revealed multiple lesions all over the body additionally the pathology revealed this exceptional case with synovial sarcoma as the primary diagnosis.
Grisel's syndrome designates subluxation of atlanto-axial joint unrelated to trauma or bone disease. Atlanto-axial subluxation is seen after the upper neck inflammatory processes of head and neck region. Moreover, this rare clinical entity has been observed after various otolaryngological surgical approaches including adenoidectomy, tonsillectomy and mastoidectomy. An 8-year-old girl and 14 year-old boy presented with complaints of painful torticollis. The first patient was operated on at another health center due to adenoid hypertrophy. She was referred to our clinic on the postoperative 5th day with painful torticollis. The diagnosis was established by computerized tomography and three-dimensional reconstructions. The second patient had a history of throat infection. Radiological investigation demonstrated atlantoaxial subluxation. The patients were treated with external fixation, antibiotic therapy, muscle relaxants, and anti-inflammatory therapy. Early diagnosis and appropriate treatment resulted in a good outcome in our patients. Grisel's syndrome must be considered in the differential diagnosis in children with painful torticollis associated with upper respiratory tract infection and after various otolaryngological surgical procedures. We report two cases of Grisel's syndrome which emphasize on the importance of early diagnosis for appropriate and successful treatment.
Skull base is an important and a challenging area for surgeons. Success in skull base surgery depends on various factors such as pre-operative evaluation, appropriate surgical technique, anesthesia duration, intraoperative neuromonitorization and wound care.This study was performed in the Anatomy dissection laboratory of M.U. Medical Faculty (Ethical committee approval number 2010-103). Twelve fetuses between 17-33 gestational weeks fixed with formaldehyde were enrolled to the study.This study was planned to investigate the cross sectional areas of the sigmoid sinus in three levels to compare the right-left sides and the probable relationship among the levels in fetuses to further delineate the developmental factors on jugular foramen asymmetry. The cross-sectional measurements of sigmoid sinus lumen were done on 3 levels which are described as A1 level; sinodural angle, A2 level; the midpoint between the sinodural angle and endocranial orifice and A3 level as the entrance (endo-cranial orifice) of the jugular foramen. There is a strong positive correlation between left (L) A1 and L A2 and also the same for L A1 and right (R) A2. These strong and positive correlations are all valid between L A2-L A3, L A2-R A2, L A2-R A3, L A3-R A3, R A1-R A2.Multicenter studies would be beneficial to investigate the topic with greater number of fetuses also on the different regions for genetic differences.
