Chiari malformations in children:An overview

Chiari malformations encompass various radiological and clinical entities,sharing the herniation of the rhombencephalic structures through the foramen magnum as a common characteristic.They can be symptomatic or asymptomatic.The therapeutic strategies for these malformations differ on the basis of the diverse pathophysiologic processes that cause them.As Chiari malformations are caused by various pathophysiologic processes,they must be recognized promptly to select the best treatment for each single case.

Cranio-cervical bone hyperpneumatization: An overview and illustrative case

The pneumatization of regions such as the apex of the temporal crag, the mastoid cells and the perilaberytic region is considered physiological in adults. The process of craniocervical pneumatization in unhealthy adults derives from a dysfunction at the level of the eustachian tube, which provides a valve effect causing an increase in pressure at the level of the middle ear, forcing the entry of air into the dome of the skull through the opening of the occipitomastoidal suture. The process of standard pneumatization of the temporal bones, begins in the final weeks preceding birth, characterized by a decrease in the embryonic mesenchyme at the antrum level and progresses through childhood until adolescence, when the stone portion at the level of the rock is pneumatized;Normal variants have been reported, such as pneumatization that extends from the temporal scale to behind the sigmoid sinus. With regard to the process of hyperneumatization, several etiologies have been proposed that a congenital process versus an acquired process to develop this condition should be compared. The present illustrative case is a seventy-three years old male presented to the outpatient clinic with chronic recurrent occipital headache, already investigated by general practitioner for elevated blood pressure which was excluded. We had checked him to exclude the cervical spinal origin of the occipital headache which was then excluded too. This case scenario demonstrates the debate about how to deal with such cases and thus the review will bring the attention of those who take care of such radiological findings to keep in mind the possible causes and complications according to the reported cases till now. We concluded that the hyperpneumatization of the craniocervical junction is an uncommon radiological finding that is usually asymptomatic although it can entail serious complications in some instances, especially when it enlarges progressively, which may be due to an acquired process. Thus, craniocervical hyperpneumatization deserves highlighting for the managing team to gain fluent treatment and better patient outcome.

Atlanto-occipital dislocation

Atlanto-occipital dislocation(AOD) is being increasingly recognized as a potentially survivable injury as a result of improved prehospital management of polytrauma patients and increased awareness of this entity, leading to earlier diagnosis and more aggressive treatment. However, despite overall improved outcomes, AOD is still associated with significant morbidity andmortality. The purpose of this paper is to review the biomechanical aspects, clinical features, radiologic criteria, and treatment strategies of AOD. Given that the diagnosis of AOD can be very challenging, a high degree of clinical suspicion is essential to ensure timely recognition and treatment, thus preventing neurological decline or death.

Os Odontoideum: Report of Eight Cases and Review of the Literature

Background: Os odontoideum is a separate odontoid process from the body of the axis. It is a rare anomaly of the craniovertebral junction with evidence of both congenital and acquired causes but the aetiology still debated in the literature. It can lead to instability of the atlantoaxial joint and places the spinal cord at significant risk. Methods: Eight cases of os odontoideum were symptomatic at time of presentation, submitted for general and neurological examination, and investigated with different radiological modalities and managed with surgical fixation and stabilization. These patients followed for one year postoperatively. Results: The study includes six male patients and two female patients with median age 18.7 years. All patients presented with myelopathy and showed clinical evidence of atlantoaxial instability. They submitted for complete radiological investigations (plain x ray, CT scan and MRI) craniocervical junction. They underwent cervical surgical stabilization, two cases by atlantoaxial arthrodesis with wiring, two atlantoaxial fixation by lateral mass screw one of them with transoral odontoiectomy, two atlantoaxial fixations by a Rosen’s Hooks, and two cases craniocervical fixation by Tie frame. Death postoperatively recorded in two patients. Follow-up one year revealed resolution of symptoms in two patients and four patients remained stationary but without deterioration. Conclusion: Os odontoideum is a rare but sometimes lethal abnormality that requires radiological and clinical judgement to ensure the best choice of management and optimum patient’s care.

New Concept of Whiplash Injuries Rehabilitation

Whiplash injuries are a global health problem and a significant financial burden for both health care systems,and insurance providers.The diverse symptomatology after whiplash injury both in the somatic,emotional and behavioral sphere prompted separation of the Whiplash Associated Disorders(WAD)as a separate category of diseases.The exact mechanism of whiplash injury is still under debate and theories explaining pathogenesis of WAD are very diverse ranging from purely biomechanical to neurophysiological,emphasizing central sensitization but the core disability seems to be strictly connected to somatosensory dysfunction.As a result,the optimal algorithm of rehabilitation has not been established and data published in the current literature on effectiveness of such algorithms are inconsistent.Based on the presented here of Head Neutral Reference Point(HNRP),the objective of central desensitization is to restore valid somatosensory output from Cranio-cervical Junction(CCJ).This new concept of rehabilitation after whiplash presented here is based on clinical observations and is supported by initial results.