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BACKGROUND AND IMPORTANCE: The article identifies the feasibility of transarticular screw fixation after mobilizing the vertebral artery in cases where it is in a “high-riding” location. CLINICAL PRESENTATION: A 42-yr-old male patient had a 4-yr history of progressive quadriparesis. Investigations revealed severe basilar invagination. There was assimilation of atlas and C2-3 fusion. The vertebral artery was “high-riding” into the pedicle-facet of C2 vertebra on both sides. Vertebral artery loop was exposed and mobilized inferiorly on both sides after careful drilling of pedicular bone on the posterior aspect of the dome of the artery. C2 facetal bone on the anterior face of the vertebral artery dome was now available for screw insertion. The C1-2 facets and the articulation were directly in line, making transarticular screw fixation relatively straightforward. The wide bone space available permitted insertion of 2 screws in a transarticular fashion on both sides. The patient had satisfactory clinical improvement. Imaging after 22 mo showed bone fusion across the facets. CONCLUSION: Mobilization of the high-riding vertebral artery loop can help salvage the surgical procedure of lateral mass stabilization.

Objective Four quadrant osteoplastic decompressive craniotomy (FoQOsD) has been described as a novel technique in the management of patients with traumatic brain injury requiring decompressive surgery. There has not been a randomized controlled trial comparing its outcomes with conventional decompressive craniectomy (DECRA) as yet. Methods A randomized controlled trial of 55 patients was conducted, of whom 29 underwent DECRA and 26 patients underwent FoQOsD. The preoperative baseline demographics, clinical conditions, and radiologic features were similar in both the groups. Clinical outcome was decided by the use of Glasgow coma outcome scale extended (GOS-e) at 3 months. Radiographic outcomes were assessed by measurement of the change in midline shift and brain width expansion (ipsilateral and contra-lateral to hematoma) on the postoperative computed tomographic (CT) scan. Results No significant differences were identified in baseline demographics, clinical condition, Rotterdam CT score, and radiographic characteristics between both the groups. At 3-month follow-up, the mean GOS-e score was comparable in both the groups (3.23 in DECRA group and 3.35 in FoQOsD group, p = 0.856). Mortality analysis at 3 months revealed that nine patients died in the DECRA group and eight died in FoQOsD group. Postoperative imaging characteristics, including Rotterdam score, also did not differ significantly. The percentage reduction in midline shift and percentage brain width expansion on the postoperative CT scan was similar in both the groups (p > 0.05). Conclusion FoQOsD appears to be at least as efficacious as DECRA in providing equivalent clinical outcomes with the added benefit of avoiding a second surgery.

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