Multiplanar spinopelvic fracture reduction and dual triangular osteosynthesis stabilization for complex multiplanar sacropelvic fractures.

BACKGROUND: Sacropelvic fractures with multidirectional instability require complex reduction and stabilisation techniques. Triangular osteosynthesis reconstruction is an established technique but hardware failure rates remain high and screw trajectories unfamiliar to spine surgeons. Our technique allows de-rotation of the pelvis, fracture reduction in both vertical and transverse planes, immediate weight bearing and is more reproducible for complex spine surgeons. OBJECTIVE: To describe our case series of dual triangular osteosynthesis reduction and stabilisation for complex sacropelvic fractures. METHODS: Retrospective case series of patients treated for unstable multiplanar sacropelvic fractures, at a level one trauma centre in the United Kingdom. Chart review was conducted to assess clinical features, radiology (plain radiographs, CT and MRI), surgical techniques and clinical and radiological outcomes. RESULTS: A total of six patients with four male and two females were included. Mean age of the cohort was 37.5 years (range 19-61 years) and average length of follow-up was 34.5 months (range 13-75 months). Three patients had neurological injury and three were intact. Four patients had associated thoraco-abdominal or lower limb injuries requiring intervention. All patients underwent surgery with reduction and stabilisation using dual triangular osteosynthesis constructs. At final follow-up, one patient had persistent bladder dysfunction (present preoperatively), one remained ASIA A from concomitant cord injury in the thoracic spine, and one patient with L5 and S1 weakness completely recovered. There were no metalwork complications and all patients achieved radiological fusion. CONCLUSION: Our technique of reduction and stabilisation of complex multidirectional sacropelvic fractures leads to a biomechanically strong construct with immediate stability, and without risk of hardware failure.

Damage for gain: The useful damage of the Pitcher's paradox.

Introduction: Sport-specific adaptations of the glenohumeral joint may arise in adolescent overhead athletes who begin high-performance sports early in life. Research mainly addresses overuse injuries, leaving gaps in prevention, with adults studied more than youths. Objective: This study aims to investigate sport-adaptations of the glenohumeral joint in asymptomatic adolescent volleyball players to identify potential shoulder injury risk factors. Design: Observational study. Setting: Clinical screening campaign conducted at the Physical Medicine and Rehabilitation Unit of Policlinic Hospital in Catania, Italy. Participants: Forty asymptomatic under-16 athletes were evaluated. Interventions: Shoulder internal rotation (IR) and external rotation (ER), range of motion (ROM), total-rotation ROM, glenohumeral IR deficit (GIRD), general joint laxity using Beighton score, apprehension, relocation, O'Brian tests, and ultrasound (US) glenohumeral distance were tested bilaterally. Variables such as the player's position, the age they began the sport, limb dominance, weight, and height were also considered. Results: The median US glenohumeral distance was at 0.42 ± 0.26 cm, which is consistent with the range found in non-dislocated shoulders of a healthy non-athletic population. The ER ROM was significantly greater in the dominant shoulder than the contralateral one (P = 0.0001), and there was a significant correlation between the ER ROM of attackers and their US glenohumeral distance (P = 0.0413). Furthermore, shoulder IR ROM and US glenohumeral distance were not significantly different between the dominant and contralateral limbs (P = 0.05). None of the athletes presented GIRD. Other tests, including the Beighton score, apprehension, and relocation tests, yielded no significant differences between the dominant and contralateral limbs. Conclusions: Despite an increased shoulder ER in the dominant limb, the glenohumeral joint remains stable, suggesting that greater ROM in ER does not equate to instability in overhead athletes without hyperlaxity. Nevertheless, increased ER impacts glenohumeral distance in attacker volleyball players. This finding suggests that the shoulder morphological adaptation process starts early in attackers.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®.

OBJECTIVE: Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks. METHODS: This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure. RESULTS: Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection. CONCLUSIONS: Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Drop metastasis from the extradural to the intradural space in spinal Ewing's sarcoma - a novel case report.

Spinal Ewing's Sarcoma is a rare tumour predominantly affecting children and adolescents. We describe the case of an 18-year-old male patient who first presented with a primary extradural cervical Ewing's sarcoma tumour, and 5 years later had a recurrence with thoracolumbar and lumbosacral intradural extramedullary Ewing's sarcoma tumours. Both presentations were successfully treated by surgical resection and adjuvant chemo- and radiotherapy, and he remains disease-free at 12 months follow-up. This is the first reported case of seeding of tumour from an extradural primary Ewing's sarcoma to intradural metastases. Total surgical resection of his initial cervical tumour, performed at another centre, was complicated by a dural tear and CSF leak. Thus, we propose that isolated drop metastasis via CSF fistula is the most likely mechanism for tumour spread in this case. Thus, clinicians may wish to counsel patients on the possibility of such spread if a CSF leak is encountered, and potentially increase the frequency of imaging surveillance of the whole spine in this context.

A modified vertebroplasty technique for intraoperative thoracic spine localisation: a technical report.

The aim is to illustrate the modified vertebroplasty technique as a fixed marker for intraoperative thoracic spine localisation. Open and minimally invasive surgery in the thoracic spine has been correlated with a disproportionately high rate of wrong-level spinal surgery in pathologies where a focal deformity or fracture is absent. Spinal markers have evolved with time, and vertebroplasty as a spinal marker was initially described in 2008. A significant disadvantage is that the cement in the vertebral body and pedicle may preclude a more extensive osteotomy or subsequent instrumentation at the level of interest. We demonstrate the modified vertebroplasty technique, which introduces percutaneous polymethylmethacrylate cement two levels below the thoracic disc herniation on the contralateral side to the surgical approach using standard vertebroplasty methods. The vertebroplasty was performed as an outpatient procedure, and the radiopaque cement was instantaneously located on intraoperative fluoroscopy, identifying the correct level above. The modified vertebroplasty technique is a quick, safe and accurate method of thoracic spine localisation, facilitating the room required for the bony exposure and instrumentation if needed.

How Much Vitamin D is Too Much? A Case Report and Review of the Literature.

BACKGROUND: The beneficial effects of vitamin D, together with the high prevalence of vitamin D deficiency, have led to an expanding use of vitamin D analogues. While inappropriate consumption is a recognized cause of harm, the determination of doses at which vitamin D becomes toxic remains elusive. CASE PRESENTATION: A 56-year woman was admitted to our Hospital following a 3-week history of nausea, vomiting, and muscle weakness. The patient had been assuming a very high dose of cholecalciferol for 20 months (cumulative 78,000,000UI, mean daily 130,000UI), as indicated by a non-- conventional protocol for multiple sclerosis. Before starting vitamin D integration, serum calcium and phosphorus levels were normal, while 25OH-vitamin D levels were very low (12.25 nmol/L). On admission, hypercalcemia (3.23 mmol/L) and acute kidney injury (eGFR 20 mL/min) were detected, associated with high concentrations of 25OH-vitamin D (920 nmol/L), confirming the suspicion of vitamin D intoxication. Vitamin D integration was stopped, and in a week, hypercalcemia normalized. It took about 6 months for renal function and 18 months for vitamin D values to go back to normal. CONCLUSION: This case confirms that vitamin D intoxication is possible, albeit with a high dose. The doses used in clinical practice are far lower than these and, therefore, intoxication rarely occurs even in those individuals whose baseline vitamin D serum levels have never been assessed. Repeated measurements of vitamin D are not necessary for patients under standard integrative therapy. However, patients and clinicians should be aware of the potential dangers of vitamin D overdose.

Controversies regarding mobilisation and rehabilitation following acute spinal cord injury.

Spinal cord injury is a debilitating condition associated with significant physical and emotional burden for the patients and families involved. Despite advances in care of patients following spinal cord injury, rehabilitation following injury remains an underfunded area of research that is in need of significant change. Although bed rest has been suggested to improve spinal cord perfusion after acute cord injury, there is no data to suggest that long periods of bed rest following spinal cord injury (in the absence of haemodynamic or biomechanical instability) leads to better outcome. Despite paucity of evidence, prolonged flat bed rest is still practiced in many spinal cord injury rehabilitation units across United Kingdom with no consensus on timing of mobilisation. Here we review some of the controversies on mobilisation and rehabilitation following spinal cord injury with the aim to emphasise on the benefits of early mobilisation following spinal cord injury and to challenge the old practice of long periods of flat bed rest.

Case report: Noonan-like multiple central giant cell granuloma syndrome.

The purpose of this report was to: summarize the care of a child between the ages of 12 to 16 years old born with Noonan-like central giant cell syndrome and unrelated common variable immune deficiency; provide information on the dental management of patients with Noonan's syndrome; and present a brief discussion of the recent associated genetic findings. A review of the common features of Noonan syndrome and Noonan-like central giant cell syndrome is also provided.

Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations.

STUDY DESIGN: A retrospective review of a case series. OBJECTIVES: Giant thoracic disc herniations remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less-invasive approaches. With the current study, we describe a surgical technique to treat giant thoracic disc herniations while minimizing approach-related morbidity. METHODS: Demographic and radiographic data; clinical outcome and perioperative complications were retrospectively analysed for patients with single-level giant thoracic disc herniations who underwent mini-thoracotomy and selective microsurgical anterior spinal cord decompression without instrumented fusion. RESULTS: Between 2007 and 2012, 7 consecutive patients with giant thoracic disc herniations were treated (average age of 53 years; range 45-66 years). The average canal encroachment was 73.2 % (range 40-92 %) with 5 grossly calcified discs of which 3 had transdural components. All patients had gradual myelopathic progression. The average Nurick grade was 3.5 (range 2-5). All patients were successfully treated with anterior microsurgical decompression without instrumentation. Uninstrumented fusion with rib graft was performed only in one patient with advanced degenerative changes. Average time of surgery was 337.8 min (range 220-450 min). The average length of hospital stay was 7.4 days (range 6-11 days). The average neurological status at follow-up (average 23.5 months; range 9-36 months) using the modified Nurick grading scale was 1.28. No vertebral collapse or loss of spinal alignment developed. There were no neurological complications. One patient developed an acute headache and diplopia, 10 days after surgery, following sneezing associated with a post-operative thoracic cerebrospinal fluid leakage requiring revision. Two patients suffered an approach-related complication in form of intercostal neuralgia; one was persistent. CONCLUSIONS: Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment.

Minimally invasive supracondylar transtubercular (MIST) approach to the lower clivus.

OBJECTIVE: Drawbacks of the far-lateral approach to the lower clivus and pontomedullary region include the morbidity of a large incision extending into the cervical musculature and tedious exposure of the vertebral artery (VA), particularly when performing the transcondylar and transtubercular extensions. The authors describe a minimally invasive alternative to the far-lateral approach that has the potential to minimize operative morbidity and decrease the need for VA manipulation. METHODS: The minimally invasive supracondylar transtubercular (MIST) and far-lateral supracondylar transtubercular (FLST) approaches were performed in 10 adult cadaveric specimens (20 sides). The microsurgical anatomy of each step and the surgical views were analyzed and compared. In addition, the endoscopic view through the MIST was examined in five fresh cadaveric specimens (10 sides). RESULTS: The MIST approach provided exposure of the inferior-middle clivus, the anterolateral brainstem, and the premedullary cisterns, including the PICA-VA and vertebrobasilar junctions. The endoscope provided a clear view of cranial nerves III through XII, as well as the vertebrobasilar system. The FLST approach increased visualization of the anterolateral margin of the foramen magnum; otherwise, the surgical view is similar between the MIST and FLST approaches. CONCLUSIONS: The MIST approach could be considered as a potential alternative to the FLST approach in the treatment of lesions involving the inferior and middle clivus, and anterolateral lower brainstem; it does not require a C1 laminectomy, significant disruption of the atlanto-occipital joint, nor extensive exposure of the extracranial VA. Moreover, the MIST approach is an ideal companion to endoscope-assisted neurosurgery.

The V(2) segment of the vertebral artery: anatomical considerations and surgical implications.

OBJECT: Iatrogenic injury of the V(2) segment of the vertebral artery (VA) is a rare but serious complication and can be catastrophic. The purpose of this study was to characterize the relationship of the V(2) segment of the VA to the surrounding anatomical structures and to highlight the potential site and mechanisms of injury that can occur during common neurosurgical procedures involving the subaxial cervical spine. METHODS: Ten adult cadaveric specimens (20 sides) were included in this study. Quantitative anatomical measurements between selected landmarks and the VA were obtained. In addition, lateral mass screws were placed bilaterally, from C-3 to C-7, reproducing either the Magerl technique or a modified technique. The safety angle, defined as the axial deviation from the screw trajectory needed to injure the VA, and the distance from the entry point to the VA were measured at each level for both techniques. RESULTS: The VA coursed closer to the midline at C3-4 and C4-5 (mean distance [SD] 14.9 ± 1.1 mm) than at C2-3 or C5-6. Within the intertransverse space it coursed closer to the uncinate processes of the vertebral bodies (1.8 ± 1.1 mm) than to the anterior tubercle of the transverse processes (3.4 ± 1.6 mm). The distance between the VA and the uncinate process was less at C3-6 (1.3 ± 0.7 mm) than at C2-3 (3.3 ± 0.8 mm). The VA coursed on average at a distance of 11.9 ± 1.7 mm from the anterior and 4.2 ± 2.6 mm from the posterior aspect of the intervertebral disc space. Lateral mass screw angles were 25° lateral and 39.1° cranial for the Magerl technique, and 36.6° lateral and 46.1° cranial for the modified technique. The safety angle was greater and screw length longer when using this modified technique. CONCLUSIONS: The relation of the V(2) segment of the VA to anterior procedures and lateral mass instrumentation at the subaxial cervical spine was reviewed in this study. A detailed anatomical knowledge of the V(2) segment of the VA combined with careful preoperative imaging is mandatory for safe cervical spine surgery.

High anterior cervical approach to the clivus and foramen magnum: a microsurgical anatomy study.

BACKGROUND: Surgical exposure of lesions located along the ventral foramen magnum (FM) and clivus poses a unique set of challenges to neurosurgeons. Several approaches have been developed to access these regions with varying degrees of exposure and approach-related morbidity. OBJECTIVE: To describe the microsurgical anatomy of the high anterior cervical approach to the clivus and foramen magnum, and describe novel skull base extensions of the approach. METHODS: Eight adult cadaveric specimens were included in this study. The high anterior cervical approach includes a minimal anterior clivectomy and its lateral skull base extensions: the extended anterior far-lateral clivectomy and the inferior petrosectomy. The microsurgical anatomy and exposure of the various extensions of the approach were analyzed. In addition, the capability of complementary endoscopy was evaluated. RESULTS: With proper positioning, the minimal anterior clivectomy exposed the vertebrobasilar junction, proximal basilar artery, anteroinferior cerebellar arteries, and 6th cranial nerve. The lateral skull base extensions provided access to the anterior FM, mid-lower clivus, and petroclival region, up to the Meckel cave, contralateral to the side of the surgical approach. CONCLUSION: The high anterior cervical approach with skull base extensions is an alternative to the classic approaches to the ventral FM and mid-lower clivus. A minimal anterior clivectomy provides access to the midline mid-lower clivus. The addition of an extended anterior far-lateral clivectomy and an inferior petrosectomy extends the exposure to the anterior FM and cerebellopontine angle lying anterior to the cranial nerves. The approach is also ideally suited for endoscopic-assisted techniques.

Normal anatomical variations of the V3 segment of the vertebral artery: surgical implications.

OBJECT: The authors undertook this cadaveric and angiographic study to examine the microsurgical anatomy of the V3 segment of the vertebral artery (VA) and its relationship to osseous landmarks. A detailed knowledge of these variations is important when performing common neurosurgical procedures such as the suboccipital craniotomy and the far-lateral approach and when placing atlantoaxial instrumentation. METHODS: A total of 30 adult cadaveric specimens (59 sides) were studied using magnification × 3 to × 40 after perfusion of the arteries and veins with colored silicone. Seventy-three vertebral angiograms were also analyzed. The morphological detail of the V3 segment was described and measured in both the cadavers and angiograms. Transarticular screws were placed into 2 cadavers and the relationship of the trajectory to the V3 segment was analyzed. RESULTS: The authors identified 4 sites along the V3 segment that are anatomically the most likely to be injured during surgical approaches to the craniovertebral junction. In 35% of the cadaveric specimens the vertical portion of V3 formed a posteriorly oriented loop that could be injured during surgical exposures of the dorsal surface of C-2. The mean distance from the midline to the most posteromedial edge of the loop was 25.6 ± 3.5 mm (range 20-35 mm) on the left side and 30.4 ± 3.8 mm (range 23-36 mm) on the right side. On lateral angiograms, this loop projected posteriorly, with a mean distance of 9.8 ± 3.5 mm (range 0-15.7 mm) on the right side and 11.7 ± 1.2 mm (range 10-13.6 mm) on the left side. The horizontal segment of V3 can be injured when exposing the lower lateral occipital bone and when the C-1 arch is exposed. The mean distance from the inferior border of the occipital bone to the superior surface of the horizontal segment of V3 was 6 ± 2.8 mm on the right side and 5.6 ± 2.3 mm on the left. In 12% of cases the authors found no space between the horizontal portion of V3 and the occipital bone. The medial edge of the horizontal segment of V3 was located 23 ± 5.5 mm (range 10-30 mm) from the midline on the right side and 24 ± 5.7 mm (range 15-32 mm) on the left side. The transition between the V2-V3 segments after exiting the C-2 vertebral foramen is the most likely site of injury when placing C1-2 transarticular screws or C-2 pars screws. CONCLUSIONS: The normal variation of the V3 segment of the VA has been described with quantitative measurements. An awareness of the anatomical variations and the relationships to the surrounding bony anatomy will aid in reducing VA injury during suboccipital approaches, exposure of the dorsal surfaces of C-1 and C-2, and when placing atlantoaxial spinal instrumentation.

Comparative use of Invisalign by orthodontists and general practitioners.

OBJECTIVE: To test the hypothesis that there is no difference in the use of Invisalign between orthodontists and general practitioners. MATERIALS AND METHODS: A questionnaire was mailed to all Invisalign providers within a 35-mile radius of Stony Brook University. The answers were statistically analyzed. The level of significance was set at P < .05. RESULTS: Orthodontists started more Invisalign cases (P < .0001). General practitioners started more Invisalign cases in the last 12 months (P = .0012). For both groups, the percentage of cases started in the last 12 months was inversely related to the number of years certified in Invisalign (P < .0001). Significant differences in opinion (P < .001) were noted between orthodontists and general practitioners regarding the level of experience necessary to treat a Class I malocclusion with a large diastema, and whether a Class II subdivision case should be treated with Invisalign. CONCLUSION: The hypothesis is rejected. The use of Invisalign by orthodontists and general practitioners was compared, and significant differences were found.

Depression and recovery of daily life autonomy in patients with stroke receiving home rehabilitative treatment.

BACKGROUND: The object of this study was to evaluate the prevalence of post stroke depression and its possible role as a predictive negative factor in patients receiving home rehabilitation treatment. METHODS: We analyzed 103 patients with stroke by correlating comorbidities, clinical and blood test parameters and characteristics of the lesion with depression class identified according to the Hamilton scale and the outcome of the rehabilitation program. RESULTS: A significant association between hypertension and post-stroke severe depression emerged in the female patients. CONCLUSIONS: Since the literature offers conflicting data, our results may contribute a stimulus for further studies. KEYWORDS: Home care; Rehabilitation; Stroke; Depression; Hypertension.

Ultrahigh-dose intraarterial infusion of verapamil through an indwelling microcatheter for medically refractory severe vasospasm: initial experience. Clinical article.

OBJECT: Vasospasm is one of the leading causes of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). Many patients suffer devastating strokes despite the best medical therapy. Endovascular treatment is the last line of defense for cases of medically refractory vasospasm. The authors present a series of patients who were treated with a prolonged intraarterial infusion of verapamil through an in-dwelling microcatheter. METHODS: Over a 1-year period 12 patients with medically refractory vasospasm due to aneurysmal SAH were identified. Data were retrospectively collected, including age, sex, Hunt and Hess grade, Fisher grade, aneurysm location, aneurysm treatment, day of the onset of vasospasm, intracranial pressure, mean arterial pressures, intraarterial treatment of vasospasm, dosages and times of verapamil infusion, presence of a new ischemic area on CT scan, modified Rankin scale score at discharge and at the last clinical follow-up, and discharge status. RESULTS: Twenty-seven treatments were administered. Between 25 and 360 mg of verapamil was infused per vessel (average dose per vessel 164.6 mg, range of total dose per treatment 70-720 mg). Infusion times ranged from 1 to 20.5 hours (average 7.8 hours). The number of treated vessels ranged from 1 to 7 per patient. The number of treatments per patients ranged from 1 to 4. There was no treatment-related morbidity or death. Blood pressure and intracranial pressure changes were transient and rapidly reversible. Among the 36 treated vessels, prolonged verapamil infusion was completely effective in 32 cases and partially effective in 4. Only 4 vessels required angioplasty for refractory vasospasm after prolonged verapamil infusion. There was no CT scanning evidence of new ischemic events in 9 of the 12 patients treated. At last clinical follow-up 6-12 months after discharge, 8 of 11 patients had a modified Rankin Scale score ≤2. CONCLUSIONS: Prolonged intraarterial infusion of verapamil is a safe and effective treatment for medically refractory severe vasospasm and reduces the need for angioplasty in such cases.

Submandibular approach to the C2-3 disc level: microsurgical anatomy with clinical application.

OBJECT: Approaching the C2-3 disc level is challenging because of its location behind the mandible and the vital neurovascular structures overlying the area. The purpose of this study was to illustrate in a stepwise fashion the microsurgical anatomy of the submandibular approach to the C2-3 disc. METHODS: Ten adult formalin-fixed cadaveric specimens (20 sides) were studied. Particular attention was paid to the structures limiting the exposure. The authors measured the distance between the inferior border of the mandible and the marginal mandibular branch of the facial nerve running inferior to the mandible, the distance between the horizontal segment of the hypoglossal nerve and the hyoid bone, and the distance between the horizontal segment of the hypoglossal nerve and the mandible. They compared the location of the superior laryngeal nerve with regard to the submandibular and the standard Smith-Robinson approaches. A clinical case illustrating the usefulness of the surgical technique in this region is presented. RESULTS: The mean distance between the inferior border of the mandible and the lowest point of the marginal mandibular branch of the facial nerve was 6.7 +/- 1.69 mm. The hypoglossal nerve's mean distance above the hyoid bone was 8.4 +/- 1.78 mm and below the mandible was 19.6 +/- 6.39 mm. The internal branch of the superior laryngeal nerve, with respect to the cervical spine, always entered the thyrohyoid membrane just inferior to the C-3 vertebral body. The superior laryngeal nerve was found to be an impediment to approaching the C2-3 disc through the standard Smith-Robinson approach. CONCLUSIONS: The submandibular approach provides excellent exposure, with a perpendicular view of the C2-3 disc level. This approach is one of the options to be considered when dealing with high cervical pathologies.

Limitations of the transcallosal transchoroidal approach to the third ventricle.

OBJECT: The aim of this study was to determine the anatomical limitations of the transcallosal transchoroidal approach to the third ventricle. METHODS: Twenty-six formalin-fixed specimens were studied. Sagittal dissections were used to determine the anatomical relationships of the foramen of Monro, the angle of approach to landmarks, and placement of a callosotomy. Lateral ventricular dissections were performed to quantitate the forniceal anatomy. RESULTS: The foramen of Monro was found 1.07+/-0.11 cm superior and slightly anterior to the mammillary bodies, 1.48+/-0.16 cm posterosuperior to the optic recess, and 2.26+/-0.16 cm anterosuperior to the aqueduct. Relative to the genu, a callosal incision 2.64+/-0.53 cm long and angled 37+/-4.3 degrees anterior was needed to access the aqueduct, and an incision 4.92+/-0.71 cm long and angled 49+/-7.4 degrees posterior was needed to access the optic recess. The fornix progressively widened within the lateral ventricle, from 1.25+/-0.63 mm at the foramen of Monro to >7 mm at 2 cm behind the foramen. Three zones of exposure were identified, requiring unique craniotomies, callosotomies, and angles of approach. The major limiting factors in the approach included the columns of the fornix anteriorly, the width of the fornix posteriorly, and the draining veins of the parietal cortex. The choroidal fissure opening was limited to 1.5 cm posterior to the foramen of Monro; this limited opening created an aperture effect that required an anterior-to-posterior angle, an anterior craniotomy, and an anteriorly placed callosotomy to access the posterior landmarks. In contrast, a posterior-to-anterior angle, posteriorly placed craniotomy, and posteriorly placed callosotomy were required to access anterior landmarks. CONCLUSIONS: The transcallosal transchoroidal approach was ideally suited to access the foramen of Monro and the middle and posterior thirds of the third ventricle. Exposure of the anterior third ventricle was limited by the columns of the fornix and by the presence of parietal cortical draining veins.

Fenestrated vertebrobasilar junction aneurysm: diagnostic and therapeutic considerations.

Vertebrobasilar junction (VBJ) aneurysms are uncommon and are often found in association with basilar artery (BA) fenestration. The complex anatomical environment of the VBJ, and the complicated geometry of the fenestration make clipping of these aneurysms difficult. Therefore, endovascular treatment of these aneurysms is now widely accepted. The authors describe the case of a 43-year-old woman with sickle cell anemia. She presented with subarachnoid hemorrhage. Digital subtraction angiography was performed and depicted multiple intracranial aneurysms. The patient had a left superior hypophysial artery aneurysm, a right superior cerebellar artery-posterior cerebral artery aneurysm, and a VBJ aneurysm associated with a fenestration of the BA. The VBJ aneurysm was not identified on the initial angiogram and was only revealed after 3D rotational angiography was performed. The 3D reconstruction was critical to the understanding of the complex geometry associated with the fenestrated BA. The VBJ was reconstructed using a combination endovascular technique. The dominant limb of the fenestration was stented and balloon-assisted coiling was performed, followed by sacrifice of the nondominant vertebral artery using coils and the embolic agent Onyx. Postoperative angiography demonstrated successful occlusion of the aneurysm with reconstruction of the VBJ. To the authors' knowledge, this is the first report of a fenestrated VBJ aneurysm treated with the combination of stenting, balloon remodeling, coiling, and vessel sacrifice. Three-dimensional angiography was critical in making the correct diagnosis of the source of the subarachnoid hemorrhage and with operative planning.