Neurosurgery

of small occipital condyles, the large surface area of the atlanto-occipital joint and the horizontal orientation of the facet joints. The tectorial membrane, the alar ligaments and the cervical musculature provide the stability for this junction.

Children usually present with signs and symptoms of brainstem and spinal cord injury. Apnea and cardiorespiratory instability can usually be noted at the scene of the accident. Pupillary abnormalities, nystagmus, ocular bobbing, decerebrate posturing, quadriparesis or hemiparesis and cranial nerve palsies have all been described. Injury to the vertebral artery resulting in dissection and thrombosis can also occur, leading to permanent neurological deficits.

Although radiographically gross separation between the occiput and the atlas can be clearly identified, a high index of suspicion needs to be maintained in order for this condition to be identified. Commonly, these patients present with a concomitant head injury which clouds the clinical presentation; hence, aggressive radiographic work-up can lead to early recognition and, potentially, a higher survival rate and eventual functional recovery.

Plain radiography is helpful as an initial screening study, since findings such as a dens-basion interval greater than 14 mm and a Powers ratio greater than 1 are indicative of AOD. A fine-cut CT scan from occiput to C2 with sagittal and coronal reconstruction is helpful, not only in confirming the diagnosis, but also in evaluating the extent of the atlanto-occipital separation.

The preferred treatment is an occiput to C2 fusion. Intraoperative care must be taken to avoid damage to the vertebral artery, which is found 1 cm lateral to the midline. Steinmann pins or Luque rectangles have been advocated to provide immediate internal stability. Postoperatively, a halo is used for at least 12 weeks or until fusion can be confirmed on follow-up radiographs.

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The term vaginitis is one that is applied to any inflammation or infection of the vagina, and there are many different conditions that are categorized together under this ‘broad’ heading, including bacterial vaginosis, trichomoniasis and non-infectious vaginitis.

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