Low-Pressure Hydrocephalus and Shunt Malfunction Following a Lumbar Puncture in an Adult Reversed by an Epidural Blood Patch.

BACKGROUND: Low-pressure hydrocephalus (LPH) is a relatively rare condition, and its presentation is similar to the classically seen high-pressure hydrocephalus, with headaches, cranial nerve dysfunction, ataxia, and disturbances of consciousness. Cerebral cerebrospinal fluid loss in the presence of altered brain viscoelastic properties has previously been suggested as the pathophysiologic process leading to ventriculomegaly, despite low or negative intracranial pressures and patent shunts. More recently, cerebral venous overdrainage has been proposed as a possible explanation in the pathogenesis of LPH, although its connection to lumbar punctures in patients with shunts has not been contemplated yet. The effectiveness of epidural blood patch in the management of post-lumbar puncture LPH has been shown in children but has not been reported in adults. CASE DESCRIPTION: Herein we detail 2 episodes of shunt malfunction in a 30-year-old female patient with a history of hydrocephalus related to a posterior fossa tumor diagnosed during childhood. In both instances, imaging studies demonstrated ventricular dilation along with perimedullary cistern enlargement and brainstem distortion, which occurred following a lumbar puncture despite a patent shunt. A lumbar blood patch was effective in both episodes, enabling resolution of the ventriculomegaly and a good outcome. CONCLUSIONS: A blood patch can be efficient in adults with post-lumbar puncture LPH. Some symptoms may be explained by brainstem compression caused by enlarged cerebrospinal fluid spaces at the skull base. The role of cerebral venous overdrainage in the setting of post-lumbar puncture LPH is further supported.

Fluoroscopy only for the placement of long iliac screws: A study on 14 patients.

BACKGROUND: Iliac screw placement is challenging due to the particular anatomy of the ilium. Most series have reported the use of relatively short (≤90 mm in length) screws despite a long iliac buttress, which has an average length of 129 mm in females and 141 mm in males. This study describes a series of 14 patients who underwent placement of long iliac screws (≥100 mm in length) as part of a spinopelvic fusion utilizing fluoroscopy alone. METHODS: All patients who received at least one long iliac screw were included in this study. Placement accuracy, the average distance from the screw tip to the anterior inferior iliac spine (AIIS), neurovascular injuries, acetabulum and/or sciatic notch violations, and screw prominence were all measured. RESULTS: Fourteen patients received 38 iliac screws, with 31 screws being ≥100 mm in length. The accuracy rate was 87.1% (27/31) for the long iliac screws. The average shortest distance from the iliac screw tip to the AIIS was 15.5 mm for the right-sided and 17.1 mm for the left-sided ilia. There were no neurovascular injuries, acetabulum, or sciatic notch violations, and no screws loosened or fractured. Of interest, only one patient required off-set connectors to link the rods to the iliac screws. CONCLUSIONS: Placement of long iliac screws under intraoperative fluoroscopy only was shown to be feasible, with a high accuracy rate and few complications, in this series of patients.

Cerebellar Proliferative Angiopathy Associated with a Pontine Telangiectasia and a Developmental Venous Anomaly.

Various mixed associations between arteriovenous malformations, cavernous malformations, developmental venous anomalies, and capillary telangiectasias have been described, and a common pathophysiologic event has been suggested to be present, although it is yet to be elucidated. We depict herein the imaging features of a patient who presented with a spontaneous cerebellar hemorrhage, in whom radiologic studies demonstrated a pontine telangiectasia, a brainstem/cerebellar developmental venous anomaly, and a cerebellar proliferative angiopathy. This unique, not previously reported combination of lesions shows that the spectrum of mixed vascular malformations continues to expand. A pathophysiologic mechanism related to the angiogenesis seen in these malformations is also hypothesized.

Progressively Enlarging Cerebellar Hematoma Concurrent with T-DM1 Treatment.

BACKGROUND: Trastuzumab emtansine, an antibody-drug conjugate commonly abbreviated as T-DM1, is accepted as effective therapy for trastuzumab-resistant metastatic HER2-positive breast cancer. T-DM1 significantly increases progression-free and overall survival when compared with lapatinib plus capecitabine in patients with HER2-positive breast cancer previously treated with trastuzumab and a taxane. Among the common side effects related to T-DM1, thrombocytopenia and mucosal hemorrhage are seen, although they are infrequently judged to be clinically significant. Intracranial hemorrhages are extremely rare, and only 3 cases of hematomas have been reported in association with T-DM1 and remote radiotherapy, 2 of them with progressive enlargement. OBJECTIVE: Herein we describe a patient who presented with a cerebellar hematoma that progressively enlarged over 8 months during treatment with T-DM1 and only a few months after whole-brain radiation therapy plus a stereotactic radiosurgery boost for a HER2-positive breast cancer cerebellar metastasis. The pathology of the hematoma was similar to that in previous cases and suggested a unique pathophysiology related to an interaction between T-DMI and radiation therapy. CONCLUSIONS: A progressively enlarging intraparenchymal hematoma can be seen just a few months after delivery of radiation therapy for a metastatic brain lesion in HER2-positive breast cancer patients who are receiving T-DM1. In such patients, even a small focus of hemorrhage on magnetic resonance images should prompt close follow-up with serial imaging.

Matriderm for Management of Scalp Necrosis Following Surgical Treatment of Giant Parietal Encephalocele.

BACKGROUND: Management of encephaloceles is challenging when massive brain herniation is present. In such instances, an expansile cranioplasty may be attempted so as to preserve some herniated brain tissue. Complications such as wound dehiscence, cerebrospinal fluid leak, and scalp necrosis are postoperative concerns. The treatment of scalp necrosis with dural and brain exposure is certainly a challenge due to the complexity of flap techniques in such a young age. Herein we describe the use of a novel technique for the management of a scalp necrosis and dehiscence in an infant. CASE DESCRIPTION: A patient with a giant parietal encephalocele and massive brain herniation underwent an expansile cranioplasty. A large scalp necrosis ensued as a complication and later progressed to a suture dehiscence despite a new surgical intervention, with resultant brain exposure. A scalp reconstruction was subsequently performed using an artificial dermal substitute, laid directly onto the brain, followed by a split-thickness skin graft. We observed a rapid engraftment, without any further complications, with an acceptable cosmetic result in the long-term follow-up. CONCLUSION: A simple technique, such as the use of an artificial dermal matrix with simultaneous split-thickness skin graft, may be an effective treatment for the repair of scalp defects, even when coverage of exposed brain tissue is necessary, when no other techniques are found to be suitable.

Cerebellar cortical vein thrombosis mimicking a vermian tumor: case report.

Cortical vein thrombosis is an uncommon cause of stroke and generally occurs in the supratentorial compartment. Spontaneous venous thrombosis with infarction in the posterior fossa usually occurs in association with either dural sinus thrombosis and/or thrombosis of the petrosal vein, usually with venous infarction of the cerebellar hemisphere. Our goal is to present the case of a patient with thrombosis of cerebellar cortical veins, without sinus involvement, which mimicked a vermian cerebellar tumor.

A Hemorrhagic Clival Chordoma with a Long Progression-Free Survival.

BACKGROUND: Chordomas and ecchordosis physaliphora may on rare occasions present with intracranial hemorrhage. Their distinction usually relies on the results of the Ki-67 proliferative index, with a result lower than 1% favoring ecchordosis physaliphora. Intracranial hemorrhagic chordomas have been linked to unfavorable prognosis, due to acute neurologic deterioration and death, or progression after treatment. To the best of our knowledge, this is the first report of a patient with an intracranial hemorrhagic chordoma who had a long progression-free survival. CASE DESCRIPTION: A 67-year-old woman presented with a large hemorrhagic clival tumor that was resected through an endonasal endoscopic approach. Physallipharous cells interspersed in a myxoid matrix, positivity for S-100, cytokeratin, and epithelial membrane antigen were found, along with an extremely low Ki-67 index. Imaging findings of bone erosion, a large size, and enhancement favored the diagnosis of chordoma. The patient received adjuvant stereotactic radiotherapy and has remained disease free after 4 years. CONCLUSIONS: Although hemorrhagic intracranial chordomas have been linked to unfavorable outcomes, our case demonstrates that they may have a low proliferative index, and a long progression-free survival may be seen.

Long iliac screw fixation in a case of isthmic spondyloptosis.

BACKGROUND: We report the case of a patient with a spondyloptosis who presented with progressive deformity and worsening neurological deficits. The patient had two previous lumbosacral instrumented fusions. CASE DESCRIPTION: A salvage revision surgery was performed, in which long iliac screws along with anterior column support at L5-S1 were used to immobilize the lumbosacral junction. Two years after the procedure a solid fusion is seen along with marked neurological improvement. CONCLUSIONS: Pelvic fixation using long iliac screws is a very useful technique that can be employed when revision surgery for high-grade spondylolisthesis is needed.

Paradoxical herniation after decompressive craniectomy provoked by lumbar puncture or ventriculoperitoneal shunting.

OBJECT: Two patients who underwent decompressive craniectomy after head trauma deteriorated secondary to paradoxical herniation, one after lumbar puncture and the other after ventriculoperitoneal shunting. They motivated the authors to investigate further provoked paradoxical herniation. METHODS: The authors reviewed the records of 205 patients who were treated at a single hospital with decompressive craniectomy for head trauma to identify those who had had lumbar puncture performed or a ventriculoperitoneal shunt placed after craniectomy but before cranioplasty. Among the patients who met these criteria, those with provoked paradoxical herniation were identified. The authors also sought to identify similar cases from the literature. Exact binomials were used to calculate 95% CIs. RESULTS: None of 26 patients who underwent a lumbar puncture within 1 month of craniectomy deteriorated, whereas 2 of 10 who underwent a lumbar puncture 1 month afterward did so (20% [95% CI 2.4%-55.6%]). Similarly, after ventriculoperitoneal shunting, 3 of 10 patients deteriorated (30% [95% CI 6.7%-65.2%]). Timing of the procedure and the appearance of the skin flap were important factors in deterioration after lumbar puncture but not after ventriculoperitoneal shunting. A review of the literature identified 15 additional patients with paradoxical herniation provoked by lumbar puncture and 7 by ventriculoperitoneal shunting. CONCLUSIONS: Lumbar puncture and ventriculoperitoneal shunting carry substantial risk when performed in a patient after decompressive craniectomy and before cranioplasty. When the condition that prompts decompression (such as brain swelling associated with stroke or trauma) requires time to resolve, risk is associated with lumbar puncture performed ≥ 1 month after decompressive craniectomy.

Blunt cerebrovascular injuries in association with craniocervical distraction injuries: a retrospective review of consecutive cases.

BACKGROUND CONTEXT: Blunt cerebrovascular injuries (BCVIs) have the potential to cause brain, cerebellar, and/or spinal cord ischemia. Certain subtypes of spine fractures, such as vertebral subluxation, fractures through the foramen transversarium, and C1-C3 fractures have been linked to a higher incidence of BCVI. On the other hand, BCVI in association with craniocervical distraction injuries (CCDs) have been only anecdotally reported. PURPOSE: We hypothesized that because CCD is also caused by a high-energy hyperflexion/hyperextension distraction mechanism, it could also be associated with a high incidence of BCVI. STUDY DESIGN/SETTING: Retrospective chart review. PATIENT SAMPLE: Of 46 consecutive patients with unstable craniocervical dissociations treated operatively at a single Level I trauma center from January 1996 to December 2009, 29 of the 46 had vascular studies that comprised the study sample. OUTCOME MEASURES: Primary outcomes assessed were BCVI subdivided into blunt carotid artery injuries and/or blunt vertebral artery injuries and classified according to the Biffl criteria. Secondary measures included associated strokes and evidence of emboli on transcranial Doppler. METHODS: All consecutive patients diagnosed with unstable CCD injuries that were surgically treated at a single Level I trauma center during the period of 1996 to 2009 were identified. Those who were adequately screened with a catheter angiogram and/or computed tomography angiogram of the neck so as to rule out BCVI were included in this study. Electronic medical records were used to determine mechanism, demographics, clinical findings, and transcranial Doppler reports. Angiography and computed tomography angiograms were analyzed to assess for BCVI. If a BCVI was identified, these were classified using the Biffl criteria. RESULTS: Among the 29 screened patients, 30 BCVIs were identified in 15 patients. According to the Biffl criteria, there were 13 Grade I, eight Grade II, five Grade III, three Grade IV, and one Grade V injuries. Three major strokes were diagnosed in those 15 patients with BCVI, as opposed to none among the other 14 patients without BCVI. CONCLUSIONS: Blunt cerebrovascular injuries were seen in more than 50% of the patients screened, with major strokes occurring in 20% of the patients. We suggest screening for BCVI in all patients presenting with C0-C1 and/or C1-C2 distraction injuries.

Blunt traumatic occlusion of the internal carotid and vertebral arteries.

OBJECT: The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. METHODS: A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. RESULTS: Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. CONCLUSIONS: At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.

Horizontal C-1 fractures in association with unstable distraction injuries of the craniocervical junction.

OBJECT: Horizontal fractures of the anterior arch of the atlas not associated with odontoid fractures have been regarded as stable fractures that can be simply treated with a cervical collar. The authors report that C-1 horizontal fractures also occur in association with severe distraction injuries of the craniocervical junction. METHODS: The authors retrospectively reviewed imaging studies obtained in all surviving patients in whom unstable distraction injuries of the craniocervical junction were diagnosed and in whom surgery was performed at their institution between 1995 and 2009. All patients who also had a C-1 horizontal fracture as a component of their spinal injury were included in the study. RESULTS: Of 47 patients with unstable craniocervical distraction injuries, 5 patients had a horizontal fracture through the anterior ring of C-1: 1 patient had a primarily C1-2 distractive injury whereas 4 others had a grossly unstable injury across the occipitoatlantal junction (occipitoatlantal dissociation). CONCLUSIONS: The finding of a C-1 horizontal fracture does not always reflect a benign injury and its presence should heighten the concern of a more severe and unstable injury at the craniocervical junction.

Reliability of classification systems for subaxial cervical injuries.

STUDY DESIGN: Interobserver and intraobserver reliabilityObjective: To measure and compare the interobserver and intraobserver reliability of the cervical spine injury severity score (CSISS), the subaxial injury classification (SLIC) and severity scale, and the Allen-Ferguson system in patients with subaxial cervical spine injuries presenting to the emergency department. METHODS: Five examiners independently reviewed c-spine x-rays (CT/MRI) of 50 consecutive patients with subaxial cervical-spine injuries. They classified each case using CSISS, SLIC, and the Allen-Ferguson system. Examiners also documented if they believed the case required surgical management. At least 6 weeks later, the above steps were repeated for ten randomly chosen cases. RESULTS: The interobserver and intraobserver reliability for the total CSISS and total SLIC score are excellent. There is poor interobserver reliability and excellent intraobserver reliability when a total kappa score is calculated using all 21 groups for the Allen-Ferguson system. With respect to surgical management decisions, the interobserver agreement is moderate and the intraobserver agreement is excellent. CONCLUSIONS: There is no universally accepted classification scheme for subaxial cervical-spine injuries. A useful classification system must have excellent reliability to consistently and accurately describe injury patterns between different observers and allow for comparison across systems or cohorts. Both the CSISS and the SLIC and severity scale are promising classification systems with excellent interobserver and intraobserver reliability. Future studies will need to determine if their quantitative scores correlate with management and clinical outcomes.

Atlantal fracture with transverse ligament disruption in a child. Case report.

Even though fractures in children with immature spines occur predominantly in the upper cervical spine, isolated C-1 fractures are relatively rare. The fractures in almost all cases reported to date were considered stable due to the presence of the intact transverse ligament. The authors report the case of a young child who sustained a Jefferson fracture and in whom MR imaging revealed disruption of the transverse ligament. Although surgical treatment has been suggested as the treatment of choice for children with unstable atlantoaxial injuries, external immobilization alone allowed a full recovery in the patient with no evidence of instability at follow-up.

Useful C8 and T1 function seen immediately after a complete cervical spinal cord injury: report of 2 cases.

BACKGROUND: Because of the rarity of cervicothoracic spine injuries, detailed reports on the neurologic examination after complete cord injuries are scarce. A few retrospective case series scantily documented the intrinsic hand function after C7-T1 complete cord injuries. A complete cervical cord injury with useful C8 and T1 motor function present immediately after the injury has not been reported to date. CASE DESCRIPTION: Functional C8 and T1 motor strength at the time of the initial neurologic examination was seen in 2 cases in which a complete C7-T1 injury resulted in paraplegia. Serial neurologic examinations were performed to document useful C8 and T1 motor function and maintenance of the neurologic status after surgical treatment. CONCLUSIONS: Patients can present with useful lower cervical root function (C8 and T1) when first seen at admission after a complete cervical cord injury. Careful neurologic examination must be performed at admission in patients with lower cervical spine injuries because useful intrinsic hand function can be present and must not be overlooked.

U-shaped sacral fracture and lumbosacral dislocation as a result of a shotgun injury: case report.

OBJECTIVE: Gunshot wounds to the spine and/or sacrum rarely cause spinal instability. Our goal is to report the first case of a U-shaped sacral fracture and lumbosacral dislocation caused by a gunshot injury to the spine. CLINICAL PRESENTATION: A 37-year-old man sustained a close-range shotgun wound to the abdomen. The blast partially destroyed the L4 and L5 vertebral bodies and fractured the S1 and S2 segments of the spine, resulting in severe neurological deficits with lumbosacral and spinopelvic instability. INTERVENTION: Debridement of devitalized tissues, proper antibiotic coverage, decompression of the cauda equina, and lumbopelvic fixation. CONCLUSION: Close-range shotgun injuries result in massive destruction of tissues. As opposed to civilian injuries, a different approach must be taken to prevent infectious complications. A bilateral lumbopelvic fixation using long iliac screws effectively restored lumbosacral pelvic stability.

Superficial temporal artery to middle cerebral artery bypass: past, present, and future.

OBJECT: The aim of this study was to review the historical developments and current status of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. METHOD: A literature review was performed to review the origins and current uses of the STA bypass procedure in neurosurgery. RESULTS: The idea of providing additional blood supply to the brain to prevent stroke and maintain neurological function has been present in the mind of neurosurgeons for many decades. In 1967 the first STA-MCA bypass was done by M. G. Yasargil, and an enormous step was made into the field of microneurosurgery and cerebral revascularization. During the decades that followed, this technique was used as an adjuvant or a definitive surgical treatment for occlusive disease of the extracranial and intracranial cerebral vessels, skull base tumors, aneurysms, carotid-cavernous fistulas, cerebral vasospasm, acute cerebral ischemia, and moyamoya disease. With the results of the first randomized extracranial-intracranial (EC-IC) bypass trial and the development of endovascular techniques such as angioplasty for intracranial atherosclerotic disease and cerebral vasospasm, the indications for STA-MCA bypass became limited. Neurosurgeons continued to perform EC-IC bypasses as an adjuvant to clipping of aneurysms and in the treatment of skull base tumors and moyamoya disease; the procedure is less commonly used for atherosclerotic carotid artery occlusion (CAO) with definite evidence of hemodynamic insufficiency. The evidence that patients with symptomatic CAO and "misery perfusion" have an increased stroke risk has prompted a second trial for evaluating EC-IC bypass for stroke prevention. The Carotid Occlusion Surgery Study is a new trial designed to determine whether STA-MCA bypass can reduce the incidence of stroke in these patients. New trials will also reveal the role of the STA-MCA bypass in the prevention of hemorrhages in moyamoya disease. CONCLUSIONS: The role of STA-MCA bypass in the management of cerebrovascular disease continues to be refined and evaluated using advanced imaging techniques and by performing randomized trials for specific purposes, including symptomatic CAO.

Lumbopelvic fixation and sacral decompression for a U-shaped sacral fracture: case report.

BACKGROUND: U-shaped sacral fractures are highly unstable, can cause significant neurological deficits, lead to progressive deformity and chronic pain if not treated appropriately. OBJECTIVE: To report a case of a U-shaped sacral fracture treated with lumbopelvic fixation and decompression of sacral roots in a 23-year-old man. METHOD: Decompression of the sacral roots combined with internal reduction and lumbopelvic fixation using iliac screws. RESULTS: Restitution of lumbosacropelvic stability and recovery of sphincter function. CONCLUSION: Lumbopelvic fixation is effective in restoring lumbosacralpelvic stability and allows full mobilization in the postoperative period. Good neurological recovery can be expected in the absence of discontinuity of the sacral roots.

Lumbopelvic fixation and sacral decompression for a U-shaped sacral fracture: case report

BACKGROUND: U-shaped sacral fractures are highly unstable, can cause significant neurological deficits, lead to progressive deformity and chronic pain if not treated appropriately. OBJECTIVE: To report a case of a U-shaped sacral fracture treated with lumbopelvic fixation and decompression of sacral roots in a 23-years-old man. METHOD: Decompression of the sacral roots combined with internal reduction and lumbopelvic fixation using iliac screws. RESULTS: Restitution of lumbosacropelvic stability and recovery of sphincter function. CONCLUSION: Lumbopelvic fixation is effective in restoring lumbosacralpelvic stability and allows full mobilization in the postoperative period. Good neurological recovery can be expected in the absence of discontinuity of the sacral roots.

INTRODUÇÃO: As fraturas sacrais em U são instáveis e podem causar significativa lesão neurológica, deformidade progressiva e dor crônica se não tratadas apropriadamente. OBJETIVO: Relatar caso de um homem de 23 anos com fratura em U do sacro tratada com fixação lombopélvica e descompressão das raízes sacrais. MÉTODO: Descompressão da cauda equina associada a redução interna e fixação lombopélvica usando parafusos ilíacos. RESULTADOS: Reconstituição da estabilidade lombosacropélvica e recuperação da continência esfincteriana CONCLUSÃO: A fixação lombopélvica é eficaz em restaurar a estabilidade lombo-sacro-pélvica e permite mobilização imediata no pós-operatório. Recuperação neurológica pode ser esperada na ausência de neurotmese das raízes sacrais.

C1 lateral mass screws for posterior segmental stabilization of the upper cervical spine and a new method of three-point rigid fixation of the C1-C2 complex.

OBJECTIVE: To describe our experience with C1 lateral mass screws as part of a construct for C1-2 stabilization and report an alternate method of C1-C2 complex three-point fixation. METHOD: All patients that had at least one screw placed in the lateral mass of C1 as part of a construct for stabilization of the C1-C2 complex entered this study. In selected patients who had a higher chance of nonunion an alternate construct was used: transarticular C1-C2 screws combined with C1 lateral mass screws. RESULTS: Twenty-one C1 lateral mass screws were placed in 11 patients. In three patients the alternate construct was used. All patients had a demonstrable solid and stable fusion on follow-up. CONCLUSION: C1 lateral mass screws are safe and provide immediate stability. The use of C1-C2 transarticular screws combined with C1 lateral mass screws is a feasible and also an excellent alternative for a three-point fixation of the C1-C2 complex.