Prevalence of Forward Head Posture and its Effect on Active Mouth Opening in Young Female Weightlifters

Background: To objectively assess the prevalence of forward head posture and its effect on active mouth opening. Material & Methods: Correlational study design. Setting – Subjects were selected from various gyms and fitness centers located in South Delhi. Subjects were selected for the study according to the following inclusion and exclusion criteria. Method of Sampling- Sample of convenience. Instrumentation / Tools/ Scales/ Outcome Measure- Markers, UTHSCSA Software version 3.0, Calibrated Ruler, Digi Cam; 16 Mega Pixel with stand, Laptop, Liquid Disinfectant, Calibrated Ruler to measure active mouth opening. Craniovertebral angle was measured using UTHSCSA Image tool program. Statistical analysis was done using SPSS 20.0 version software. Descriptive statistics was used to compute means. The Pearson’s coefficient of correlation was used to examine the relationships between craniovertebral angle and active mouth opening. Results were considered significant at ‘p’ < 0.05. Results: The purpose of conducting this study was to find out the effect on active mouth opening in female weightlifters which was conducted on females performing weight lifting task in the gyms and fitness centers situated in South Delhi. It was observed that there was a statistically significant correlation with CV angle with active mouth opening. Conclusion: By the virtue of this study, we can conclude that our participant group of weightlifters had a below normal craniovertebral angle. The result demonstrated that there is a significant effect on active mouth opening.

Research Progress on the Application of Goel Technique in Craniovertebral Junction Anomalies / 中国医学科学院学报

Craniovertebral junction anomalies are a group of diseases characterized by the pathological changes of occipital bone,atlantoaxial bone,cerebellar tonsil,surrounding soft tissue,and nervous system,which are caused by a variety of factors.Chiari malformation is a common type of craniovertebral junction anomalies,the conventional surgical therapy of which is posterior fossa decompression.Currently,scholars represented by Goel have proposed a new theory on the classification,pathogenesis,and treatment of Chiari malformation based on posterior atlantoaxial fixation (Goel technique).This article introduces the progress in Goel technique,aiming to provide reference for the clinical work.

Transtubular Transoral Approach for Irreducible Ventral Craniovertebral Junction Compressive Pathologies: Surgical Technique and Outcome

@#Introduction: To investigate the use of a tubular retractor to provide access to the craniovertebral junction (CVJ) sparing the soft palate with the aim of reducing complications associated with traditional transoral approach but yet allowing adequate decompression of the CVJ. Materials and methods: Twelve consecutive patients with severe myelopathy (JOA-score less than 11) from ventral CVJ compression were operated between 2014-2020 using a tubular retractor assisted transoral decompression. Results: All patients improved neurologically statistically (p=0.02). There were no posterior pharynx wound infections or rhinolalia. There was one case with incomplete removal of the lateral wall of odontoid and one incidental durotomy. Conclusions: A Tubular retractor provides adequate access for decompression of the ventral compression of CVJ. As the tubular retractor pushed away the uvula, soft palate and pillars of the tonsils as it docked on the posterior pharyngeal wall, the traditional complications associated with traditional transoral procedures is completely avoided.

Congenital atlanto-occipital fusion and its effect on the myodural bridge: a case report utilizing the P45 plastination technique / Fusión atlanto-occipital congénita y su efecto sobre el puente miodural: reporte de un caso utilizando la técnica de plastinación P45

SUMMARY: The atlanto-occipital joint is composed of the superior fossa of the lateral masses of the atlas (C1) and the occipital condyles. Congenital Atlanto-occipital fusion (AOF) involves the osseous union of the base of the occiput (C0) and the atlas (C1). AOF or atlas occipitalization/assimilation represents a craniovertebral junction malformation (CVJM) which can be accompanied by other cranial or spinal malformations. AOF may be asymptomatic or patients may experience symptoms from neural compression as well as limited neck movement. The myodural bridge (MDB) complex is a dense fibrous structure that connects the suboccipital muscular and its related facia to the cervical spinal dura mater, passing through both the posterior atlanto-occipital and atlanto-axial interspaces. It is not known if atlas occipitilization can induce structural changes in the MDB complex and its associated suboccipital musculature. The suboccipital region of a cadaveric head and neck specimen from an 87-year-old Chinese male having a congenital AOF malformation with resultant changes to the MDB complex was observed. After being treated with the P45 plastination method, multiple slices obtained from the cadaveric head and neck specimen were examined with special attention paid to the suboccipital region and the CVJM. Congenital atlanto-occipital fusion malformations are defined as partial or complete fusion of the base of the occiput (C0) with the atlas (C1). In the present case of CVJM, unilateral fusion of the left occipital condyle with the left lateral mass of C1 was observed, as well as posterior central fusion of the posterior margin of the foramen magnum with the posterior arch of C1. Also noted was a unilateral variation of the course of the vertebral artery due to the narrowed posterior atlanto-occipital interspace. Surprisingly, complete agenesis of the rectus capitis posterior minor (RCPmi) and the obliques capitis superior (OCS) muscles was also observed in the plastinated slices. Interestingly, the MDB, which normally originates in part from the RCPmi muscle, was observed to originate from a superior bifurcation within an aspect of the nuchal ligament. Therefore, the observed changes involving the MDB complex appear to be an effective compensation to the suboccipital malformations.

RESUMEN: La articulación atlanto-occipital está compuesta por las caras articulares superiores de las masas laterales del atlas (C1) y los cóndilos occipitales. La fusión atlanto-occipital congénita (FAO) implica la unión ósea de la base del occipucio (C0) y el atlas (C1). La FAO u occipitalización/asimilación del atlas representa una malformación de la unión craneovertebral (MUCV) que puede presentar otras malformaciones craneales o espinales. La FAO puede ser asintomática o los pacientes pueden experimentar síntomas de compresión neural así como movimiento limitado del cuello. El complejo del puente miodural (PMD) es una estructura fibrosa densa que conecta el músculo suboccipital y su fascia relacionada con la duramadre espinal cervical, pasando a través de los espacios intermedios atlanto-occipital posterior y atlanto-axial. No se sabe si la occipitilización del atlas puede inducir cambios estructurales en el complejo PMD y en la musculatura suboccipital. Se observó en la región suboccipital de un espécimen cadavérico, cabeza y cuello de un varón chino de 87 años con una malformación congénita de FAO con los cambios resultantes en el complejo PMD. Se examinaron múltiples cortes obtenidos de la muestra de cabeza y cuello después de ser tratados con el método de plastinación P45, con especial atención a la región suboccipital y la MUCV. Las malformaciones congénitas por fusión atlanto-occipital se definen como la fusión parcial o completa de la base del occipucio (C0) con el atlas (C1). En el presente caso de MUCV se observó la fusión unilateral del cóndilo occipital izquierdo con la masa lateral izquierda de C1, así como fusión posterior central del margen posterior del foramen magnum con el arco posterior de C1. También se observó una variación unilateral del curso de la arteria vertebral por el estrechamiento del espacio interatlanto-occipital posterior. Se observó además agenesia completa de los músculos Rectus capitis posterior minor (RCPmi) y oblicuos capitis superior (OCS) en los cortes plastinados. Curiosamente, se observó que el MDB, que normalmente se origina en parte del músculo RCPmi, se origina en una bifurcación superior dentro de un aspecto del ligamento nucal. Por lo tanto, los cambios observados en el complejo PMD parecen ser una compensación de las malformaciones suboccipitales.

Comparando o efeito da liberação miofascial e técnica de energia muscular no ângulo craniovertebral e cefaleia em pacientes com cefaleia tensional / Comparing the effect of myofascial release and muscle energy technique on craniovertebral angle and headache in tension-type headache patients

INTRODUÇÃO: Cefaleias tensionais podem ser induzidas pela postura da cabeça para frente, e há uma grande quantidade de evidências disponíveis para o manejo de cefaleias crônicas. Os dados corroboram uso de abordagens de terapia manual para gerenciar dores de cabeça do tipo tensional. Devido à postura anterior da cabeça, a região do músculo suboccipital torna-se curta, resultando em aumento da lordose e dor no pescoço. Pacientes com uma postura de cabeça ainda mais para frente têm um ângulo craniovertebral menor, o que, por sua vez, causa cefaleia do tipo tensional. OBJETIVO: O objetivo deste estudo é comparar os efeitos da terapia de liberação miofascial (LMF) e da técnica de energia muscular (TEM) com exercícios gerais do pescoço no ângulo crânio-vertebral e na cefaleia em pacientes com cefaleia do tipo tensional. MÉTODOS: No total, 75 indivíduos com cefaleia tensional e sensibilidade muscular suboccipital foram recrutados e randomizados cegamente em três grupos: o grupo LMF, o grupo TEM e o grupo controle (25 indivíduos em cada grupo). Um ângulo pré-crânio vertebral foi obtido por método fotográfico e um questionário de índice de incapacidade pré-cefaleia foi preenchido. O grupo LMF recebeu liberação crânio-basal na região suboccipital com exercícios de pescoço; o grupo TEM recebeu relaxamento pós-isométrico na região suboccipital com exercícios, e o grupo controle recebeu apenas exercícios por 2 semanas. Após duas semanas, o ângulo pós-craniano e o questionário de cefaleia foram coletados e medidos. RESULTADOS: O ângulo crânio-vertebral e o índice de cefaleia mostraram melhora significativa nos grupos TEM e LMF. Não houve diferença significativa quando os grupos TEM e LMF foram comparados. Quando comparados com o grupo controle, tanto o TEM quanto o LMF apresentaram aumento significativo do ângulo crânio-vertebral. Houve melhora significativa no índice de cefaleia após TEM, LMF ou exercício de rotina no pescoço. CONCLUSÃO: Comparado ao grupo controle, o LMF apresenta melhores resultados do que o TEM no ângulo crânio-vertebral e cefaleia.

INTRODUCTION: Tension headaches can be induced by forward head posture, and there is a wealth of evidence available for managing chronic headaches. The data support the use of manual therapy approaches to manage tension-type headaches. Because of the forward head posture, the suboccipital muscle region becomes short, resulting in an increase in lordosis and neck pain. Patients with an even more forward head posture have a smaller craniovertebral angle, which in turn causes tension-type headache. OBJECTIVE: This study aims to compare the effects of Myofascial release therapy (MFR) and Muscle energy technique (MET) with general neck exercises on the craniovertebral angle and headache in tension-type headache patients. METHODS: In total, 75 subjects with tension-type headache and suboccipital muscle tenderness were recruited and randomized blindly into three groups: the MFR group, the MET group, and the control group (25 subjects in each group). A pre-craniovertebral angle was taken by photographic method, and a pre-headache disability index questionnaire was filled in. The MFR group receives cranio-basal release in the suboccipital region with neck exercises, the MET group receives post­isometric relaxation in the suboccipital region with exercises, and the control group receives only exercises for two weeks. After two weeks, the postcranial angle and the headache questionnaire were taken and measured. RESULTS: Craniovertebral angle and headache index showed significant improvement in both the MET and MFR groups. There was no significant difference when MET and MFR groups were compared. When compared with the control group, both MET and MFR showed a significant increase in craniovertebral angle. There was a significant improvement in the headache index following MET, MFR, or routine neck exercise. CONCLUSION: Compared to the control group, MFR shows better results than MET on craniovertebral angle and headache.

Labiomandibular glossotomy approach for craniocervical pathologies - spine reconstruction / Acesso por glossotomia labiomandibular em patologias craniocervicais - reconstrução da coluna / Acceso por glosotomía labiomandibular en patologías craneocervicales - reconstrucción de la columna

ABSTRACT Objectives: Exposing the clivus and upper cervical spine should, ideally, provide an adequate surgical field in which the surgeon can safely decompress and stabilize the craniovertebral junction (CVJ). We present a series of four cases with a narrative review of the literature in which Median Labiomandibular Glossotomy was used to treat CVJ disorders, in order to highlight the importance and indications of this access. Methods: We performed a retrospective analysis of patients who underwent MLMG for several pathologies. The group comprised four patients (two men and two women). Five approaches were performed (one revision surgery). Results: The approach was suitable for all cases, clivus was achieved when necessary. Distally, C4 was exposed to obtain satisfactory osteosynthesis. Laterally, we had a good view of the tumor borders and control of the vertebral artery. Complications encountered were a superficial wound infection that was easily healed, a later pharyngeal wound dehiscence and pseudoarthrosis, all in the same patient. There are 3 main anterior surgical techniques for managing lesions of the clivus, foramen magnum or upper cervical vertebrae. We chose Median Labiomadibular Glossotomy (MLMG) as a primary option, which provided a direct view of the clivus, C3 - C4 caudally and a wider surgical field. The main advantages of the MLMG technique include direct access to spinal pathology, an avascular plane through the median pharyngeal raphe, and a wider surgical field in both the transverse and sagittal dimensions. Conclusion: This approach provides excellent exposure of the craniocervical junction and upper cervical spine. Level of evidence IV; Series of cases analyzed retrospectively.

RESUMO Objetivos: A exposição do clivo e da coluna cervical alta deve, de modo ideal, proporcionar um campo cirúrgico adequado, no qual o cirurgião possa descomprimir e estabilizar a junção craniovertebral (JCV) com segurança. Apresentamos uma série de quatro casos, com revisão narrativa da literatura, nos quais a glossotomia labiomandibular mediana foi utilizada para tratamento de afecções da JCV, com o objetivo de destacar a importância e as indicações desse acesso. Métodos: Foi realizada uma análise retrospectiva dos pacientes submetidos a GLMM para diversas patologias. O grupo foi composto por quatro pacientes (dois homens e duas mulheres). Cinco abordagens/procedimentos<??> foram realizados (uma cirurgia de revisão). Resultados: O método/via de acesso/técnica foi adequado para todos os casos e o clivo foi alcançado quando necessário. Distalmente, C4 foi exposta para obter a osteossíntese satisfatória. Lateralmente, obteve-se boa visão das margens tumorais e controle da artéria vertebral. As complicações encontradas foram infecção superficial da ferida, com fácil cicatrização, deiscência tardia da parede posterior da faringe e pseudoartrose, todas no mesmo paciente. Existem três técnicas cirúrgicas principais com acesso anterior para o tratamento de lesões do clivo, forame magno ou vértebras cervicais superiores. Escolhemos a glossotomia labiomadibular mediana (GLMM) como opção primária, que proporcionou uma visão direta do clivo, de C3-C4 caudalmente e campo cirúrgico mais amplo. As principais vantagens da GLMM incluem acesso direto à patologia espinhal, plano avascular através da parte mediana da rafe da faringe e um campo cirúrgico ampliado nas dimensões transversa e sagital. Conclusões: Esta abordagem proporciona excelente exposição da junção craniocervical e da coluna cervical alta. Nível de evidência IV; Série de casos analisados retrospectivamente.

RESUMEN Objetivos: La exposición del clivus y de la columna cervical alta debe, de modo ideal, proporcionar un campo quirúrgico adecuado, en que el cirujano pueda descomprimir y estabilizar de manera segura la unión craneovertebral (UCV). Presentamos una serie de cuatro casos con revisión narrativa de la literatura, en los que se utilizó la glosotomía labiomandibular mediana para el tratamiento de afecciones de la UCV, con el objetivo de destacar la importancia y las indicaciones de ese acceso. Métodos: Se realizó un análisis retrospectivo de los pacientes sometidos a GLMM para diversas patologías. El grupo fue compuesto por cuatro pacientes (dos hombres y dos mujeres). Fueron realizados cinco abordajes/procedimientos (una cirugía de revisión). Resultados: El método/vía de acceso/técnica fue adecuado para todos los casos y el clivus fue alcanzado cuando fue necesario. Distalmente, C4 fue expuesta para obtener la osteosíntesis satisfactoria. Lateralmente, se obtuvo buena visión de los márgenes tumorales y control de la arteria vertebral. Las complicaciones encontradas fueron infección superficial de la herida, con fácil cicatrización, dehiscencia tardía de la pared posterior de la faringe y pseudoartrosis, todas en el mismo paciente. Existen tres técnicas quirúrgicas principales con acceso anterior para el tratamiento de lesiones del clivus, foramen magno o vértebras cervicales superiores. Elegimos la glosotomía labiomandibular mediana (GLMM) como opción primaria, que proporcionó una visión directa del clivus, C3-C4 caudalmente y campo quirúrgico más amplio. Las principales ventajas de la GLMM incluyen acceso directo a la patología espinal, plano avascular a través de la parte mediana del rafe de la faringe y un campo quirúrgico ampliado en las dimensiones transversa y sagital. Conclusiones: Este abordaje proporciona excelente exposición de la unión craneocervical y de la columna cervical alta. Nivel de evidencia IV; Serie de casos analizados retrospectivamente.

Efecto de un protocolo de entrenamiento de fuerza con característica socializadora sobre el ángulo cráneovertebral en adultos mayores / Effect of a strength training protocol with a socializing characteristic on the craniovertebral angle in older adults

OBJETIVO: El propósito del estudio fue evaluar el efecto de un protocolo de entrenamiento de fuerza con característica socializadora sobre el ángulo cráneovertebral en adultos mayores. MATERIAL MÉTODOS: El presente estudio tiene un diseño experimental, longitudinal, basado en la medición del ángulo cráneovertebral previo y posterior a la aplicación de un protocolo de entrenamiento de fuerza con característica socializadora de 4 meses. Se estudió a 3 grupos de 44 participantes elegidos al azar: dos grupos experimentales y un grupo control. A un grupo experimental se le realizó un protocolo de entrenamiento de fuerza convencional, al otro grupo experimental se le realizó el protocolo de entrenamiento de fuerza con característica socializadora y al grupo control, no se le aplicó entrenamiento. Los 132 participantes cumplieron los criterios de inclusión y exclusión: adultos mayores > 60 años, ángulo cráneovertebral < 50 grados, sin patologías de columna vertebral, reumatológicas, neurológicas y sistémicas. RESULTADOS: Hubo cambios estadísticamente significativos en el aumento del ángulo cráneovertebral en el grupo que realizó entrenamiento de fuerza convencional y en el grupo que realizó entrenamiento de fuerza con característica socializadora (P < 0.05). CONCLUSIÓN: El protocolo de entrenamiento de fuerza con característica socializadora aumentó en promedio 14,6 grados el ángulo cráneovertebral y fue un 21% más efectivo que el grupo que realizó entrenamiento de fuerza convencional en el aumento del ángulo cráneovertebral en adultos mayores.

OBJECTIVE: Evaluate the effect of a strength training protocol with a socializing characteristic on the craniovertebral angle in older adults. MATERIAL AND METHODS: The present study has an experimental, longitudinal design, based on the measurement of the craniovertebral angle before and after the application of a 4 month long strength training protocol with a socializing characteristic. Three groups of 44 randomly chosen participants were carried out: two experimental groups and a control group. A conventional strength training protocol was performed in one experimental group, the strength training protocol with a socializing characteristic was performed in the other experimental group, and no training was applied to the control group. The 132 participants fulfilled the inclusion and exclusion criteria: older adults > 60 years, craniovertebral angle < 50 degrees, without spinal, rheumatic, neurological and systemic pathologies. RESULTS: There were statistically significant changes in the increase of the craniovertebral angle in the group that performed conventional strength training and in the group that performed strength training with a socializing characteristic (P <0.05). CONCLUSION: The strength training protocol with socializing characteristic increased the craniovertebral angle by an average of 14.6 degrees and was 21% more effective than the group that performed conventional resistance training in increasing the craniovertebral angle in older adults.

Beethoven´s illnesses and a craniovertebral junction variant? / As doenças de Beethoven e variante da junção craniovertebral?

Ludwig van Beethoven, the great composer, born 250 years ago, had several health problems and a progressive hearing loss. Gastrointestinal symptoms prevailed among his physical complaints, but there were also frequent headaches, eye pain, and polyarthralgia. Likewise, there are many reports about his alcohol intake and frequent walks. There were also peculiar behavioral and awkward physical aspects of the famous composer. All may take part as a determinant for the communicative aspects of his music. Spite Beethoven's corporal structure could be considered just a developmental variant, it can also be congenitally related to many bone-nervous abnormalities such as craniovertebral junction malformation with interference in the Genius' health. In reality, it is almost impossible to cover Beethoven's entire health problem with just one underlying disease. Most likely, he had comorbidities, one of which, although not fatal, was that related to abnormalities in the development of the skull and cervical spine worsened by a baseline autoimmune disorders that injured joints, and maybe even the VIII cranial nerve and inner ear.

Ludwig van Beethoven, o grande compositor, nascido há 250 anos, teve vários problemas de saúde e uma perda auditiva progressiva. Os sintomas gastrointestinais prevaleceram entre suas queixas físicas, mas também houve frequentes episódios de cefaleia, dores nos olhos e poliartralgia. Da mesma forma, há muitos relatos sobre sua ingestão de álcool e caminhadas frequentes. Havia também aspectos físicos peculiares e estranhos do famoso compositor. Todos podem tomar parte como um determinante para os aspectos comunicativos de sua música. Apesar da estrutura corporal de Beethoven poder ser considerada apenas uma variante de desenvolvimento, pode também estar relacionada a algumas anormalidades ósseo- neural, tais como a malformação da junção craniovertebral com interferência na saúde do Gênio. Na realidade, é quase impossível cobrir todo o problema de saúde de Beethoven com apenas uma doença subjacente. Muito provavelmente, ele tinha comorbidades, uma das quais, embora não fatal, era aquela relacionada a anormalidades no desenvolvimento do crânio e da coluna cervical agravadas por uma desordem auto-imune de base que lesionava as articulações, e talvez até o VIII nervo craniano e o ouvido interno.

Craniometric parameters for the evaluation of platybasia and basilar invagination on magnetic resonance imaging: a reproducibility study / Parâmetros craniométricos para platibasia e invaginação basilar na ressonância magnética: estudo de reprodutibilidade

Abstract Objective: The present study aims to perform a reproducibility study of the clivus-canal angle (CCA), Welcker's basal angle (WBA), and the distance from the odontoid process to Chamberlain's line (DOCL) on magnetic resonance imaging (MRI). Materials and Methods: Two medical students and two radiologists respectively evaluated 100 and 50 consecutive MRI scans of adult skulls, selected randomly. Each examiner, working independently and blinded to the previous results, performed readings for each patient on two different occasions. Measurements were performed in T1-weighted sequences acquired in the midsagittal plane. The levels of intraobserver reproducibility and interobserver agreement were evaluated by calculating the intraclass correlation coefficients (ICCs) and the corresponding 95% confidence intervals. Results: The mean values obtained by the examiners were 150° for the CCA, 130° for the WBA, and 2.5 mm for the DOCL. The ICC for interobserver agreement was 0.980, 0.935, and 0.967, for the CCA, WBA, and DOCL, respectively, for the students, compared with 0.977, 0.941, and 0.982, respectively, for the radiologists, and 0.980, 0.992, and 0.990, respectively, for all of the examiners together. In the analysis of intraobserver agreement, the ICC ranged from 0.929 to 0.959 for the CCA, from 0.918 to 0.964 for the WBA, and from 0.918 to 0.981 for the DOCL. Conclusion: The measurement of the CCA, WBA, and DOCL appears to show excellent intraobserver reproducibility and interobserver agreement on MRI.

Resumo Objetivo: Realizar um estudo de reprodutibilidade do ângulo clivocanal (ACC), ângulo basal de Welcker (ABW) e distância do odontoide à linha de Chamberlain (DOLC) em ressonância magnética (RM). Materiais e Métodos: Quatro examinadores, dois graduandos de medicina e dois radiologistas, avaliaram, respectivamente, 100 e 50 indivíduos adultos submetidos a RM de crânio, consecutiva e aleatoriamente. Cada um realizou duas leituras para cada paciente em diferentes ocasiões, de forma cega e independente. As análises de concordância intraobservador e interobservador foram realizadas pelo coeficiente de correlação intraclasse (CCI), com intervalo de confiança de 95%. Resultados: As medidas médias, considerando todos os examinadores, foram: ACC = 150°, ABW = 130°, DOLC = 2,5 mm. A análise interobservador entre os estudantes revelou CCI de 0,980, 0,935 e 0,967 para ACC, ABW e DOLC, respectivamente, e para os radiologistas, CCI de 0,977, 0,941 e 0,982, respectivamente. A análise interobservador entre estudantes e radiologistas revelou CCI de 0,980, 0,992 e 0,990, respectivamente. Em relação à análise intraobservador, as medidas do ACC tiveram CCI variando entre 0,929 e 0,959, ABW entre 0,918 e 0,964 e DOLC entre 0,918 e 0,981. Conclusão: ACC, ABW e DOLC obtiveram excelentes reprodutibilidades intraobservador e interobservador na RM.

Observational outcome in surgery for Chiari malformation patients

Chiari malformation is the commonest anomaly of the craniovertebral junction involving both the skeletal as well as the neural structures. It is congenital anomaly of the hindbrain characterised by downward elongation of the brain stem and cerebellum into the cervical portion of spinal cord. Most common presenting symptoms was pain in the nape of neck with sub-occipital headache and weakness. If not intervened early in these cases they may progress to quadriparesis and respiratory failure. This study includes authors experience of 30 surgical corrections of Chiari malformation performed at civil hospital Ahmedabad from 2017 to 2019. The age and sex of the patient, the presence of syrinx, the type of surgical procedure and the clinical outcome were determined post-operatively and on follow up. Cerebro spinal fluid leak and collection were observed in patient who undergone duroplasty only with no leakage in patient undergone syringo-subarachnoid shunt. Overall, tingling/numbness had best improvement showed improvement in 13 out of 16 patients. Power showed improvement in 20 out of 27 patients and pain showed improvement in 18 patients. Wasting, clawing and cerebellar signs and bony deformity showed no improvement in any of the above procedures. Authors can conclude for Chiari malformation decompression with or without duroplasty with additional procedure with post-operative physiotherapy and analgesia is the suitable treatment.

An observation on risk of infection in treatment of craniovertebral junction disorders by transoral approach operation / 中国修复重建外科杂志

Objective: To study the changes of bacterial flora after a series of preoperative oral disinfection and the postoperative recovery of patients with craniovertebral junction disorders who were treated with transoral approach operations. And to provide a theoretical basis for the prevention of postoperative complications such as infection. Methods: The clinical data of 20 cases with craniovertebral junction disorders and treated with transoral approach operations between October 2009 and May 2010 were analyzed. There were 8 males and 12 females, aged 2-66 years (median, 34.5 years). According to the classification of American Spinal Injury Association (ASIA)，there were 4 cases of grade B, 8 of grade C, 6 of grade D, and 2 of grade E. The Japanese Orthopedic Association (JOA) score was 10.3±3.0. The mucosa samples of the posterior pharyngeal wall were sent for bacteria culture. These samples were collected by sterile cotton swabs at four crucial points including 3 days before operation/before gargling (T1), 3 days after continuous gargling by chlorhexidine acetate/after anesthesia intubation on the day of operation (T2), after intraoperative cleaning and washing of the mouth (T3), and after intraoperative iodophor immersion for 5-10 minutes (T4). The microflora was stained by means of smear and further counted after an investigation by microscope. The ASIA classification and the JOA scores were applied to evaluate the postoperative nerve function of the patients. A regular reexamination of cervical vertebra with X-ray film, CT, and MRI was conducted after operation to evaluate the reduction of atlantoaxial dislocation, internal fixation position, bone graft fusion, inflammatory lesion, and tumor resection in the craniovertebral junction. Results: After a series of oral disinfection, the mucosa of the posterior pharyngeal wall of all the patients was in a sterile state, which was considered as type Ⅰ incision. All these 20 patients were treated with successful operations, without any intraoperative injury in vertebral artery and spinal cord, or any postoperative complications such as plate loosening, incision infection, or intracranial infection. All the patients were followed up 3-23 months, with an average of 5.15 months. The symptoms such as neck pain, limb numbness and weakness, neural symptoms, etc. were improved to different degrees after operation. The JOA score was improved to 13.4±1.9 at 3 months after operation, showing significant difference when compared with preoperative score ( t=8.677, P=0.000); and the atlantoaxial joints had been fused. At last follow-up, the ASIA grades were improved when compared with those before operation. Conclusion: It is safe and effective to cut the posterior pharyngeal muscle layer and implant internal fixation by means of transoral approach in the treatment of craniovertebral junction disorders.

An application of posterior cervical and transoral approaches to treating primary malignant osseous tumors in craniovertebral junction / 中国修复重建外科杂志

Objective: To investigate the surgical method for primary malignant osseous tumors in the craniovertebral junction (CVJ) and its effectiveness. Methods: The clinical data of 7 patients with primary malignant osseous spinal tumors in CVJ, which collected between September 2010 and April 2019, were retrospectively analyzed. There were 5 males and 2 females, aged 23 to 75 years (median, 56 years). All patients were diagnosed as chordoma in 4 cases, plasmacytoma in 2 cases, and fibrosarcoma in 1 case. The disease duration ranged from 0.7 to 36.0 months, with an average of 12.2 months. Lesion location: 1 case of C 0, 1, 3 cases of C 2, 1 case of C 1, 2, 1 case of C 2, 3, and 1 case of C 0-2. Preoperative visual analogue scale (VAS) score was 6.7±2.1, the Japanese Orthopaedic Association (JOA) score was 15.6±2.4. According to American Society of Spinal Cord Injury (ASIA) grading system, there was 1 case of grade C, 1 case of grade D, and 5 cases of grade E. According to Enneking stage of spinal malignant tumor, there was 1 case of stage ⅠB, 2 cases of stage ⅡB, and 4 cases of stage Ⅲ. According to Weinstein-Boriani-Biagini (WBB) stage, there was 1 case of 5-8/A-D, 1 case of 4-9/A-D, 1 case of 6-7/B-D, 1 case of 6-7/A-D, 2 cases of 1-12/A-D, and 1 case of 3-10/A-D. All these patients were treated with tumor extended resection, bone graft fusion, and internal fixation via posterior cervical approach, as well as tumor (stage Ⅰ or stage Ⅱ) boundary resection via transoral or submandibular approach. Meanwhile, anterior reconstructive fusion was procedured with bone grafting Cage needed to place the internal fixation. Results: The operation time was 307-695 minutes (mean, 489.57 minutes), and the intraoperative blood loss was 400-2 000 mL (mean, 1 107.14 mL). There was no intraoperative injury in vertebral artery and spinal cord or any related postoperative complications, including incision infection, intracranial infection, and pulmonary infection. All the patients were followed up 3-57 months (mean, 21 months). Postoperative X-ray film and CT showed that the internal fixation screw was firm and in a satisfactory position, and the bone graft was fused at 3-6 months after operation. Symptoms such as neck pain, limb numbness, and fatigue relieved to different degrees after operation. At 3 months after operation, the VAS score improved to 1.7±0.8 ( t=7.638, P=0.000); while the JOA score improved to 16.1±1.5, but no significant difference was found when compared with preoperative score ( t=1.549, P=0.172). According to ASIA grading system, 1 patient with grade C had upgraded to grade D after operation, while the remaining patients had no change. There were 4 cases of recurrence after operation, in which those patients were with high malignancy of tumors before the first surgery. Their tumors also affected a wide range of slope or surrounding soft tissues and could not be completely removed. Among the 4 cases, 1 patient underwent transoral tumor removal operation again, while the other 3 cases gave up further treatment. There was no recurrence among the remaining 3 cases. Conclusion: Primary malignant osseous tumors in the CVJ can be completely exercised via means of trabsoral or submandibular approach. Meanwhile the anterior reconstruction can be achieved by placing special Cage specimen. These two methods together with postoperative adjuvant treatments such as radiotherapy and chemotherapy can improve the survival time of patients and reduce tumor recurrence.

Bilateral Accessory C1 and C2 Facet Joints; Clinical, Neuroradiological and Peroperative Findings in an Adult with Quadriparesis

Objectives Accessory C1 and C2 facet joints are very rare. Only few cases were reported in the literature.We report a case of bilateral accessory facets in an adult with special attention to clinical, neuroradiological, as well as peroperative findings. Case report A 37-year-old male presented with progressive quadriparesis. Radiology revealed bilateral posterior accessory C1 and C2 facet joints compressing the spinal cord with craniovertebral junction (CVJ) instability. Both accessory C1 and C2 facets with the posterior arch of the C1 were removed. Lateral mass screws and plates fixation at the C1 and C2 level, as well as fusion, were performed. Postoperatively, the patient recovered well. Conclusion In accessory C1 and C2 facet joints, when symptomatic, neuroradiological findings can guide to the proper diagnosis, to pathological understanding, and, ultimately, to management strategy.

Effectiveness Of Cervical Stabilization Exercises With Feedback On Respiratory Status In Chronic Neck Pain Patients With Forward Head Posture

Background: Chronic neck pain is observed to be commonly kindred with forward head posture (FHP). Rib cage mechanics is found to be altered that decreases thoracic mobility. This reduced mobility of thorax reduces the effectiveness of diaphragm, intercostals, and abdominal muscles in terms of ventilation. Therefore this study was done to evaluate the effectiveness of exercises meant for enhancing the stability of the neck with feedback on neck stabilization exercises with feedback in improving the respiratory status. Methods: This was an experimental study. Based on inclusion & exclusion criteria, 100 subjects (54 males and 46 females) enrolled for the study, which was further allotted into Experimental and Control groups. The experimental group was given Cervical Stabilization Exercise with feedback in addition to routine Physiotherapy treatment. Control group was given only regular Physiotherapy treatment for six weeks. The digital camera assessed the FHP by measuring of Craniovertebral Angle (CVA). Spirometry assessed pulmonary function (FEV1) and Micro RPM assessed inspiratory muscle strength (PImax). All measurements were taken on the day of study, on 3rd and 6th week Results: Significant reduction in forward head posture measured by improvement in Craniovertebral angle, improvement in Inspiratory muscle strength (PIMax) and pulmonary functions (FEV1) were found in the group that received cervical stabilization exercises with feedback along with the conventional Physiotherapy (p< 0.05). Therefore it is suggested that cervical stabilization exercises correct the head posture and helps to improve the biomechanics of respiratory muscles. Conclusion: Cervical stabilization exercise is an effective approach to correct the forward head posture, and it should be included in the intervention measures of patients with forward head posture.

The Effects Of Smartphone Addiction On Childrens Cervical Posture And Range Of Motion

Background: This study examined the effects of smartphones addiction on cervical posture, and compared the cervical range of motion (ROM) between addicted and non-addicted boys and girls 8 to 13 years of age. Methods: Twenty-four boys and 26 girls were assigned to 2 groups; addicted group (score > 32, n=32) and non-addicted group (score ≤ to 32, n=18). Craniovertebral Angle (CVA) was assessed using side view photographs, forward head posture (FHP) was measured using ImageJ 64 software, and cervical ROM in each direction was measured using a cervical (CROM) device. Results: A forward multiple regression showed that addiction score and body mass index (BMI) were significant predictors of CVA (R2 =0.31, p<0.001). Twenty-three percent of the variability in CVA was related to addiction score. A forward logistic regression showed that addiction to smartphone use and BMI were significant predictors of having FHP, and participants who were addicted were more than four times as likely to have FHP than those who were not: Odds Ratio (OR) with 95 % confidence interval (CI)=4.5 (1.2, 10.7), p= 0.03. A significant reduction was found in mean cervical angle in addicted versus non-addicted boys (49.4±6.7 vs. 55.5±7.6,η2=0.5, p=0.03) and girls (47.3±6.3 vs. 52.9±6.1,η2=0.9, p=0.02). A significantly more limited cervical ROM found in most neck movements in addicted participants with FHP compared to participants without FHP. Conclusion: Children who are addicted to smartphones may develop faulty habitual posture due to constant neck flexion downward, which may place them at high risk of spine abnormalities.

Morphometric Study Of Dry Human Occipital Bone And Its Clinical Relevance

Background: Anomalies of craniovertebral junction (CVJ) are of interest both to an anatomist as well as to theclinicians because many of these deformities produce clinical symptoms. The stability of this CVJ dependslargely on the morphometric parameters of the occipital condyles (OCs). Most of the surgical approaches suchas, the lateral trans-jugular approach, trans-tubercular approach and transcondylar approach require resectionof the condyles.Materials and methods: The measurements of 30 occipital condyle length, width, height, Size and the anteriorand posterior intercondylar distances, Distance between the anterior tip of OC & Basion, Distance between theposterior tip of OC & Opisthion, Anterior intercondylar distance (AID), Posterior intercondylar distance (PID),non-metric parameters including Shape was done.Results: Mean length, width and height of the occipital condyle were found to be 23.2, 12.39 and 9.16 mm on theright and 23.43, 12.31 and 8.95 mm on the left respectively. The anterior and posterior intercondylar distanceswere 21.28 and 40.61 mm respectively.Conclusion: The occipital condyles are integral part of neck and base of the skull. In the present study an effortwas made to measure various parameters related to occipital condyle. The data may be used as a morphometricdata base for posterior and lateral approaches to the craniovertebral junction by neurosurgeons andorthopaedicians

Morphometric Analysis Of The Occipital Condyles And Their Correlation With Hypoglossal Canal In Dry Skulls Of South Indians

Background: Morphometric analysis of the occipital condyles is essential for craniovertebral junction surgeries.There are no studies done yet on correlation of hypoglossal canal and occipital condyle, therefore the presentstudy is carried out to find differences of parameters of OC in different races and to find out the correlation ofvarious parameters of occipital condyle with orifices of hypoglossal canal.Method: The size, shape and anterior, posterior inter condylar distances of occipital condyles and the locationsof the extracranial and intracranial orifices of the 108 hypoglossal canal were studied in 55 dry skulls.Result: The Mean length, height, width were 21.64±2.97, 11.06±2.2, 6.15±1.44 respectively.Anterior, posteriorinter condylar distances mean were ranged between 13.30-32.93 and 21.46– 46.77 respectively and most commonshape of occipital condyles was oval. Location of hypoglossal canal extra cranially was 3,whereas intra craniallyit was 4 for both right and left sides. There was strong correlation between length of occipital condyle and widthbut the same was not with location of hypoglossal canal.Conclusion: The measurements of occipital condyles were found to have some similarities and some dissimilariesamong different races. These differences could be useful for anthropometric analysis and forensic sciencesstudies. Significant correlation was found between length and width, width and height, height and length.However no correlation could be found between various parameters of occipital condyle and orifices of hypoglossalcanal.

Basilar invagination associated with chiari malformation type I: A literature review

Basilar invagination (BI) and Chiari malformation type I (CM-I) are very important anomalies that introduce instability and compression in the occipitocervical transition region and have complex clinical characteristics. These anomalies vary according to the affected structures. The present study revises current knowledge regarding the anatomy, anatomo-physiology, clinical manifestations, and radiological findings of these entities and the associated surgical treatment approaches. A bibliographic survey was performed through a search in the Medline, PubMed, SciELO, Science and LILACS databases. When associated, these craniovertebral malformations result in neurological deficits due to neural parenchyma compression; however, the presence of microtraumas due to repetitive lesions caused by the bulb and cervical marrow instability has been highlighted as a determinant dysfunction. Surgical treatment is controversial and has many technical variations. Surgery is also challenging due to the complex anatomical characteristics and biomechanics of this region. Nevertheless, advances have been achieved in our understanding of related mechanisms, and compression and atlantoaxial instability are considered key elements when selecting the surgical approach.

Comparison of Occipital Condyle Morphometry in Various Populations with Respect to Skull Base Surgery

Background: The craniovertebral junction is made up of the occiput, upper two cervical vertebrae. Occipital condyle is one the landmarks on the skull base. Morphometric values of these condyles in a specific population is to be known by surgeons to deal with pathologies affecting the cranial base without disturbing the neurovascular structures by doing appropriate condylectomy and to ensure occipito-cervical fusion in case of instability. Methods: The study was performed by comparing the morphometric values of occipital condyles with other populations (Greek, Turkish, Korean, Chinese, American, European and Indian). The data regarding the morphometric values of occipital condyles was taken from our previously published article with a sample of hundred occipital condyles of unsexed dry human skulls of unknown age and compared with the studies of other population. The measurements compared were the length, breadth and thickness of the occipital condyle, intercondylar distance in anterior, middle and posterior parts of the occipital condyles, the angle of the occipital condyle to the sagittal plane and coronal planes and shape of the occipital condyles. Results: Most of the morphometric values of OC in South Indian were lesser than the other populations like breadth, thickness,anterior intercondylar distance, posterior intercondylar distance, angle of the occipital condyle to the sagittal plane. Conclusion: This information has to borne in mind while performing surgical procedures like occipito-cervical screw fixation, condylar drilling in cranial base surgery in South Indian population.

Additional Surgical Method Aimed to Increase Distractive Force during Occipitocervical Stabilization : Technical Note

OBJECTIVE: Craniovertebral junctional anomalies constitute a technical challenge. Surgical opening of atlantoaxial joint region is a complex procedure especially in patients with nuchal deformity like basilar invagination. This region has actually very complicated anatomical and functional characteristics, including multiple joints providing extension, flexion, and wide rotation. In fact, it is also a bottleneck region where bones, neural structures, and blood vessels are located. Stabilization surgery regarding this region should consider the fact that the area exposes excessive and life-long stress due to complex movements and human posture. Therefore, all options should be considered for surgical stabilization, and they could be interchanged during the surgery, if required.METHODS: A 53-year-old male patient applied to outpatients’ clinic with complaints of head and neck pain persisting for a long time. Physical examination was normal except increased deep tendon reflexes. The patient was on long-term corticosteroid due to an allergic disease. Magnetic resonance imaging and computed tomography findings indicated basilar invagination and atlantoaxial dislocation. The patient underwent C0–C3–C4 (lateral mass) and additional C0–C2 (translaminar) stabilization surgery.RESULTS: In routine practice, the sites where rods are bound to occipital plates were placed as paramedian. Instead, we inserted lateral mass screw to the sites where occipital screws were inserted on the occipital plate, thereby creating a site where extra rod could be bound. When C2 translaminar screw is inserted, screw caps remain on the median plane, which makes them difficult to bind to contralateral system. These bind directly to occipital plate without any connection from this region to the contralateral system. Advantages of this technique include easy insertion of C2 translaminar screws, presence of increased screw sizes, and exclusion of pullout forces onto the screw from neck movements. Another advantage of the technique is the median placement of the rod; i.e., thick part of the occipital bone is in alignment with axial loading.CONCLUSION: We believe that this technique, which could be easily performed as adjuvant to classical stabilization surgery with no need for special screw and rod, may improve distraction force in patients with low bone density.