Numerous conditions affect the occipitocervical junction requiring treatment with occipitocervical fixation. In this paper the authors present their technique of craniocervical fixation achieved with the cephalad extension of posterior C1-3 polyaxial screw and rods to polyaxial screws placed in the occipital condyles. They retrospectively analyzed occipital condyle morphology obtained from CT analyses of 40 patients with normal cervical spines, evaluated occipital condyle screw placement feasibility in 4 cadavers, and provided a case report of a 70-year-old woman with rheumatoid arthritis, basilar invagination, and atlantoaxial instability who was treated with this novel technique. Based on radiographic analysis of occipital condyle anatomy, they concluded that on average a 3.5-mm-diameter x 20- to 30-mm-long screw can be safely placed at an angle of 20-33 degrees from the sagittal plane. Overall, measuring the condylar heights (mean [+/- SD] 10.8 +/- 1.5 mm, range 8.1-15.0 mm), widths (mean 11.1 +/- 1.4 mm, range 8.5-14.2 mm), lengths (20.3 +/- 2.1 mm, range 15.4-24.6 mm), and angles (mean 32.8 +/- 5.2 degrees , range 20.2-45.8 degrees) by using CT studies is an accurate and precise method. This finding correlates with the results of prior anatomical studies of occipital condyles and is important in the planning of craniovertebral junction surgery.

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OBJECT Most cases of traumatic spondylolisthesis of the axis (hangman's fracture) can be treated nonoperatively with reduction and subsequent immobilization in a rigid cervical collar or halo. However, in some instances, operative management is necessary and can be accomplished by using either anterior or posterior fusion techniques. Because open posterior procedures can result in significant blood loss, pain, and limited cervical range of motion, other less invasive options for posterior fixation are needed. The authors describe a minimally invasive, navigation-guided technique for surgical treatment of Levine-Edwards (L-E) Type II hangman's fractures. METHODS For 5 patients with L-E Type II hangman's fracture requiring operative reduction and internal fixation, percutaneous screw fixation directed through the fracture site was performed. This technique was facilitated by use of intraoperative 3D fluoroscopy and neuronavigation. RESULTS Of the 5 patients, 2 were women, 3 were men, and age range was 46–67 years. No intraoperative or postoperative complications occurred. All patients wore a rigid cervical collar, and flexion-extension radiographs were obtained at 6 months. For all patients, dynamic imaging demonstrated a stable construct. CONCLUSIONS L-E type II hangman's fractures can be safely repaired by using percutaneous minimally invasive surgical techniques. This technique may be appropriate, depending on circumstances, for all L-E Type I and II hangman's fractures; however, the degree of associated ligament injury and disc disruption must be accounted for. Percutaneous fixation is not appropriate for L-E Type III fractures because of significant displacement and ligament and disc disruption. This report is meant to serve as a feasibility study and is not meant to show superiority of this procedure over other surgical options.

IntroductionDural sinus venous thrombosis is a rare but potentially devastating disease. Current therapies include intravenous heparin, direct mechanical thrombectomy and local chemical thrombolysis. Despite aggressive management of this disease with these therapeutic interventions there are treatment failures that may be amenable to endovascular intervention. To date there is no endovascular device made specifically for this purpose.MethodsThree patients presented with neurological symptoms related to increased intracranial pressure. Non-invasive imaging demonstrated cerebral sinus occlusion. All patients were initially treated with intravenous heparin. The first patient had bilateral transverse and sigmoid sinus and superior sagittal sinus thrombosis, the second had left transverse and sigmoid sinus thrombosis and the third patient had thrombosis of the left transverse sinus which extended into the sigmoid sinus and internal jugular vein. All patients were neurologically deteriorating at the time of intervention and had developed hemorrhagic strokes despite aggressive heparinization.ResultsAll of the patients were successfully revascularized angiographically with the Penumbra Aspiration System in combination with local chemical thrombolysis. The first patient had end stage renal disease and significant comorbidities and eventually succumbed to multiorgan failure secondary to her pre-existing disease. The second patient developed leg weakness prior to the thrombolysis which progressed to paraplegia post-thrombectomy. Her leg strength was improving at discharge (4/5) and she was able to ambulate with assistive devices. She lives at home 2 months post-thrombectomy and ambulates without assistance. The third patient required hemicraniectomy for left parietal hemorrhage. She was discharged to rehab and returned for follow-up at 6 months with minimal word finding difficulties and otherwise neurologically intact. Both survivors were converted to warfarin therapy on discharge.ConclusionSuccessful revascularization was achieved in all three patients using a combination of thrombectomy with the Penumbra Aspiration System and local thrombolysis. All patients were severely injured secondary to sinus thrombosis related strokes; however, aggressive escalation of therapy along with successful revascularization resulted in very good long term outcomes in two patients. To our knowledge these are the first of such cases reported to use the Penumbra Mechanical thrombectomy device to re-canalize the dural venous sinus system.