UpToDate: Cervical transverse process fracture

Cervical transverse process fracture

Cervical transverse process fractures have a strong association with other cervical spine fractures and blunt cerebrovascular injury 1).

With the advent of whole body computed tomography of trauma patients, the radiologic diagnosis of transverse process fractures (TPF) has increased. Spine service (neurosurgical or orthopedic) consultation is frequently requested for patients with these fractures, stressing constraints on these practices.

When TPF are identified, diligence in searching for a spine injury or abdominal injuries should be exercised, as these associated injuries occur frequently 2).

Isolated cervical transverse process fracture (TPF) of the subaxial cervical spine can be considered as clinically insignificant and do not require treatment 3)

Clinicians should maintain high indices of suspicion for associated injuries in patients with isolated transverse process fractures especially after high-velocity mechanisms 4).

1.- Fracture of the right transverse process of C2 involving the transverse foramen.

2.- Similar fracture passing through right transverse foramen of C3.

Vertebral artery angiography should be considered when patients with transverse process fractures extending into the transverse foramen develop signs and symptoms of vertebrobasilar disease 5).

A case report demonstrates the severity of injury after minor trauma in the context of ankylosing spondylitis, the capacity for full recovery in oesophageal perforations in spinal trauma, and that clinical suspicion of such injuries allows early diagnosistreatment and reduced complications6).

Case series

The Ronald Reagan UCLA Medical Center patient database was queried (years 2005-2016) using International Classification of Diseases, Ninth Revision, code 805: fracture of the vertebral column without mention of spinal cord injury.

A total of 129 patients with isolated transverse process fractures (ITPFs) were identified. Mean age was 38.1 years (range 15-92 years). Women were more likely to present with abdominal pain and associated kidney injury (P = 0.018 and P = 0.012, respectively). Motor vehicle accident (MVA) was the most common mechanism of injury (n = 81, 62.8%) and was associated with thoracic (P = 0.032) and lower extremity pain/injury (P = 0.005). Back pain was the most common presenting symptom (n = 71, 64.6%) and was associated with intraabdominal and lower extremity injuries (P = 0.032 and P = 0.016, respectively). Chest and neck pain were associated with vascular injuries (P < 0.001 and P = 0.001, respectively). Spine consult (neurosurgery or orthopedic surgery) was frequent (n = 94, 72.9%) and was more common after MVA versus fall (P = 0.018).

Several factors were identified as significant markers of associated injuries, including female sex, MVA, and presenting symptoms. Neck and chest pain were significantly associated with vascular injuries. Clinicians should maintain high indices of suspicion for associated injuries in patients with ITPFs, especially after high-velocity mechanisms 7).


21 patients (2.4%) had 25 isolated TPFs of the subaxial cervical spine. The seventh vertebra was involved predominantly (76%). The initial treatment regimen was unrestricted movement in all patients. No associated adverse events were observed. A follow-up of 13 to 39 months was available in 14 patients. Follow-up showed a stable and intact subaxial cervical spine in all patients’ radiographs, a patient satisfaction of 9.3 (SD 1.48), a Cybex measured range of motion in the sagittal plane of 109 degrees (SD 12.5, 95-129), the frontal plane of 70 (SD 17.8, 37-100) and the transverse plane of 144 (SD 12.5, 116-164), and a mean neck disability index score of 3.93 (SD 8.24).

The incidence of isolated TPFs of the subaxial cervical spine was 2.4%. Unrestricted movement resulted in satisfying functional, anatomic, and neurologic outcomes without associated adverse events. This study confirms that isolated TPFs of the subaxial cervical spine can be considered as clinically insignificant and do not require treatment 8).


Patients for a retrospective, institutional review board-approved study were identified by reviewing the daily neurosurgical census from July 2004 to February 2007. Data were collected by chart review on all patients with TPF-grouped into isolated fractures (iTPF) and fractures with other associated spinal injuries (aTPF). Other parameters evaluated included fracture location, other spinal injuries, nonspinal injuries, mechanical stability, neurologic findings, pain, and treatment (surgical stabilization or decompression or bracing or both).

Eighty-four patients with one or more TPF were identified-47 with iTPF and 37 with aTPF. All iTPF and aTPF patients were found to be neurologically intact. No patients with iTPF required surgery or bracing for spinal stability, but 4 aTPF needed surgery and 18 aTPF required bracing with a total of 22 requiring neurosurgical intervention (p < 0.0001). However, none of these patients received treatment for the TPF. Twenty-five patients had associated abdominal injuries (16 of 46 iTPF, 9 of 37 aTPF, p = 0.3335).

iTPF are not associated with neurologic deficit or structural instability requiring spine service intervention. Therefore, conservative management without neurosurgical or orthopedic consultation is appropriate. When TPF are identified, diligence in searching for other spinal injuries or abdominal injuries should be exercised, as these associated injuries occur frequently 9).


In a retrospective study of 216 patients with cervical fractures evaluated by plain films and computed tomography, Woodring et al., found that transverse process fractures were common. Transverse process fractures were present in 24% of patients with cervical fractures and accounted for 13.2% of all cervical fractures. Cervical radiculopathy and brachial plexus palsy were present in 10% of patients with transverse process fractures. In 78% of transverse process fractures, CT scanning showed that the fracture extended into the transverse foramenVertebral artery angiography, performed in eight patients with fractures involving the transverse foramen, showed dissection or occlusion of the vertebral artery in seven (88%) instances. Two of these seven patients had clinical evidence of vertebral-basilar artery stroke. Vertebral angiography should be considered when patients with transverse process fractures extending into the transverse foramen develop signs and symptoms of vertebrobasilar disease 10).


A 66 year old man fell backwards from the first rung of a ladder sustaining a cervical transverse process fracture of C6 vertebral body and a new diagnosis of ankylosing spondylitis. He was taken for surgical fixation, however his oesophagus was discovered entrapped within the fracture at the time of surgery. Despite the severity of the injury, with surgical reduction, fixation and oesophageal exclusion this patient made a full recovery.

This case demonstrates the severity of injury after minor trauma in the context of ankylosing spondylitis, the capacity for full recovery in oesophageal perforations in spinal trauma, and that clinical suspicion of such injuries allows early diagnosistreatment and reduced complications11).


A 40-year-old building and construction male worker who slipped and fell on an iron rod that resulted in penetrating wound on the right side of the anterior neck a week prior to presenting at our facility. He pulled out the iron rod immediately. Computer tomography angiography (CTA) done revealed C2-C4 transverse process fractures on the right side and a fracture at the right lamina of C3 and right common carotid artery dissection with stenosis. He was successfully treated with stenting via endovascular approach.

Richard et al., adopted the view that patient should never pull out objects that result in Penetrating neck injuries (PNI) because of complex neurovascular architecture of the neck. The mortality rate of the patient will have doubled if the iron rode penetrated the common carotid artery. The gold standard treatment option for carotid artery dissection and stenosis is endovascular approaches 12).

References

1)

Green NE, Swiontkowski MF. Skeletal Trauma in Children: Expert Consult – Print and Online, 4e. Saunders. ISBN:1416049002.
2) , 9)

Bradley LH, Paullus WC, Howe J, Litofsky NS. Isolated transverse process fractures: spine service management not needed. J Trauma. 2008 Oct;65(4):832-6; discussion 836. doi: 10.1097/TA.0b013e318184d30e. PubMed PMID: 18849799.
3) , 8)

Schotanus M, van Middendorp JJ, Hosman AJ. Isolated transverse process fractures of the subaxial cervical spine: a clinically insignificant injury or not?: a prospective, longitudinal analysis in a consecutive high-energy blunt trauma population. Spine (Phila Pa 1976). 2010 Sep 1;35(19):E965-70. doi: 10.1097/BRS.0b013e3181c9464e. PubMed PMID: 20479701.
4) , 7)

Bui TT, Nagasawa DT, Lagman C, Jacky Chen CH, Chung LK, Voth BL, Beckett JS, Tucker AM, Niu T, Gaonkar B, Yang I, Macyszyn L. Isolated Transverse Process Fractures and Markers of Associated Injuries: The Experience at University of California, Los Angeles. World Neurosurg. 2017 Aug;104:82-88. doi: 10.1016/j.wneu.2017.04.137. Epub 2017 Apr 28. PubMed PMID: 28461275.
5) , 10)

Woodring JH, Lee C, Duncan V. Transverse process fractures of the cervical vertebrae: are they insignificant? J Trauma. 1993 Jun;34(6):797-802. PubMed PMID: 8315673.
6) , 11)

Vonhoff CR, Scandrett K, Al-Khawaja D. Minor trauma in ankylosing spondylitis causing combined cervical spine fracture and oesophageal injury. World Neurosurg. 2018 Jul 30. pii: S1878-8750(18)31658-9. doi: 10.1016/j.wneu.2018.07.180. [Epub ahead of print] PubMed PMID: 30071342.
12)

Richard SA, Zhang CW, Wu C, Ting W, Xiaodong X. Traumatic Penetrating Neck Injury with Right Common Carotid Artery Dissection and Stenosis Effectively Managed with Stenting: A Case Report and Review of the Literature. Case Rep Vasc Med. 2018 Jun 10;2018:4602743. doi: 10.1155/2018/4602743. eCollection 2018. PubMed PMID: 29984035; PubMed Central PMCID: PMC6015681.

Management of Type II odontoid process fracture in octogenarians

As odontoid process fractures become increasingly common in the aging population, a technical understanding of treatment approaches is critical.
Establishing a clear treatment paradigm for octogenarians with odontoid fracture type II in hampered by a literature replete with level III articles.

Surgical treatment

Anterior approach

Anterior odontoid screw fixation was first reported by Nakanishi 1) and Bohler 2). This procedure provides immediate spinal stability, preserves the normal rotation between C1-2, allows the best anatomical and functional outcome for type II odontoid fracture, and is associated with rapid patient mobilization, minimal postoperative pain and a short hospital stay. Acute odontoid fractures treated by anterior screw fixation have a fusion rate of approximately 90 percent 3).

Posterior approach

Posterior approach for stabilization of odontoid fracture is indicated in the cases of odontoid fracture that are not amenable to anterior screw fixation. Commonly used procedures involve wedging a bone graft between posterior arch of C1 and the C2 lamina with sublaminar wiring. The well-described different methods for this C1- 2 posterior fusion procedure are the Gallie, Brooks, Sonntag techniques. These procedures have a satisfactory fusion rate of about 74 percent. The demerit of this procedure is that it causes elimination of the normal C1-2 rotatory motion ( which accounts for more than 50% of all cervical spine rotatory movements) and reduced cervical spine flexion– extension by 10 percent.
Another excellent alternative technique for odontoid fracture is the posterior C1-2 transarticular screw fixation (Magerl’s procedure) using unilateral or bilateral screws. This provides an excellent spinal rotational spinal stability. This is an indirect method of stabilizing the fracture (in which the normal anatomical configuration is disrupted). Preoperative CT evaluation is mandatory to avoid vertebral artery injury in this procedure. This technique can be supplemented with metal plate for occipito-cervical stabilization. Alternatively, Jain’s technique of occipitocervical fusion, Goel’s plate and screw lateral mass fixation, or a Ransford’s contoured rod technique31 may be utilized.

Case series

2017

In the study by Graffeo et al., the authors evaluated 111 patients over the age of 79 (average age: 87) with type II odontoid fractures undergoing nonoperative (94 patients) vs. operative intervention (17 total; 15 posterior and 2 anterior). They studied multiple variables and utilized several scales [abbreviated injury scale (AIS), injury severity score (ISS), and the Glasgow coma scale (GCS)] to determine the outcomes of nonoperative vs. operative management.
Graffeo et al. concluded that there were no significant differences between nonoperative and operative management for type II odontoid fractures in octogenarians. They found similar frequencies of additional cervical fractures, mechanisms of injury, GCS of 8 or under, AIS/ISS scores, and disposition to “nonhome” facilities. Furthermore, both appeared to have increased mortality rates at 1-year post injury; 13% during hospitalization, 26% within the first post-injury month, and 41% at 1 year.
In the editorial by Falavigna, his major criticism of Graffeo’s article was the marked disparity in the number of patients in the operative (17 patients) vs. the nonoperative group (94 patients), making it difficult to accept any conclusions as “significant”. He further noted that few prior studies provided level I evidence, and that most, like this one, were level III analyses that did not “significantly” advance our knowledge as to whether to treat octogenarians with type II odontoid fractures operatively vs. nonoperatively 4).


Pisapia et al., present in a stepwise fashion the technique of odontoid screw placement using the Medtronic O arm navigation system and describe their initial institutional experience with this surgical approach.
The authors retrospectively reviewed all cases of anterior odontoid screw fixation for Type II fractures at an academic medical center between 2006 and 2015. Patients were identified from a prospectively collected institutional database of patients who had suffered spine trauma. A standardized protocol for navigated odontoid screw placement was generated from the collective experience at the authors’ institution. Secondarily, the authors compared collected variables, including presenting symptoms, injury mechanism, surgical complications, blood loss, operative time, radiographically demonstrated nonunion rate, and clinical outcome at most recent follow-up, between navigated and nonnavigated cases.
Ten patients (three female; mean age 61) underwent odontoid screw placement. Most patients presented with neck pain without a neurological deficit after a fall. O-arm navigation was used in 8 patients. An acute neck hematoma and screw retraction, each requiring surgery, occurred in 2 patients in whom navigation was used. Partial vocal cord paralysis occurred after surgery in one patient in whom no navigation was used. There was no difference in blood loss or operative time with or without navigation. One patient from each group had radiographic nonunion. No patient reported a worsening of symptoms at follow-up (mean duration 9 months).
The authors provide a detailed step-by-step guide to the navigated placement of an odontoid screw. Their surgical experience suggests that O-arm-assisted odontoid screw fixation is a viable approach. Future studies will be needed to rigorously compare the accuracy and efficiency of navigated versus nonnavigated odontoid screw placement 5).

2016

Twenty-one of 22 patients who underwent posterior C1-C2 temporary fixation of an odontoid fracture achieved fracture healing and regained motion of the atlantoaxial joint. The functional outcomes of these 21 patients were compared with that of a control group, which consisted of 21 randomly enrolled cases with posterior C1-C2 fixation and fusion. The differences between the 2 groups in the visual analog scale score for neck pain, neck stiffness, Neck Disability Index, 36-Item Short Form Health Survey, and time to fracture healing were analyzed.
Significantly better outcomes were observed in the temporary-fixation group for visual analog scale score for neck pain, Neck Disability Index, and neck stiffness. The outcomes in the temporary-fixation group was superior to those in the fusion group in all dimensions of the 36-Item Short Form Health Survey. There were no significant differences in fracture healing rate and time to fracture healing between the 2 techniques.
Functional outcomes were significantly better after posterior C1-C2 temporary fixation than after fusion. Temporary fixation can be used as a salvage treatment for an odontoid fracture with an intact transverse ligament in cases of failure of, or contraindication to, anterior screw fixation 6).

2015

Data of twenty patients who underwent posterior temporary-fixation due to Anderson-D’Alonzo type II odontoid fractures with intact transverse ligament were retrospectively reviewed. Another twenty patients undergoing anterior screw fixation were randomly selected as the control group. The range of motion (ROM) in rotation of C1-C2 measured on functional computed tomography (CT) scan and outcomes evaluated by the visual analog scale (VAS) for neck pain, neck stiffness, patient satisfaction, and neck disability index (NDI) were compared between two groups at the final follow-up.
At the final follow-up, 19 cases in each groups achieved facture healing. Total C1-C2 ROM in rotation on both sides in the posterior temporary-fixation group was 32.4 ± 12.5°, smaller than 40.0 ± 13.0 in the anterior fixation group. However, there was no statistical difference between two groups. And there was no significant difference between two groups in functional outcomes evaluated by VAS for neck pain, neck stiffness, patient satisfaction and NDI.
Posterior temporary-fixation can spare the motion of C1-C2 and achieve same good clinical outcomes as anterior screw fixation in the treatment of Anderson-D’Alonzo type II odontoid fractures. It was an ideal alternative strategy to anterior screw fixation 7).


The treatment of type II odontoid fractures in elderly patients is controversial.
Anterior screw fixation is a well-recognized technique that is used to stabilize Type IIB fractures of the odontoid process in the elderly. However, advanced age and osteoporosis are 2 risk factors for pseudarthrosis. Kyphoplasty has been described in the treatment of lytic lesions in C-2. Terraux et al. decided to combine these 2 techniques in the treatment of unstable fractures of the odontoid.
Two approximately 90-year-old patients were treated for this type of fracture. Instability was demonstrated on dynamic radiography in one patient, and the fracture was seen on static radiography in the other.
Clinical parameters, pain, range of motion, 36-Item Short Form Health Survey (SF-36) score (for the first patient), and radiological examinations (CT scans and dynamic radiographs) were studied both before and after surgery. After inflating the balloon both above and below the fracture line, the authors applied a high-viscosity polymethylmethacrylate cement. Some minor leakage of cement was noted in both cases but proved to be harmless. The screws were correctly positioned. The clinical result was excellent, both in terms of pain relief and in the fact that there was no reduction in the SF-36 score. The range of motion remained the same. A follow-up CT scan obtained 1 year later in one of the patients showed no evidence of change in the materials used, and the dynamic radiographs showed no instability. This combination of kyphoplasty and anterior screw fixation of the odontoid seems to be an interesting technique in osteoporotic Type IIB fractures of the odontoid process in the elderly, with good results both clinically and radiologically 8).


1) Nakanishi T. Internal fixation of odontoid fractures. Cent J Orthop Trauma Surg 1980; 23: 399-406.
2) Bohler J. Anterior stabilization for acute fractures and nonunions of the dens.J Bone Joint Surg (Am) 1982; 64: 18-27.
3) Julien TD, Frankel B, Traynelis VC, Ryken TC. Evidence- based analysis of odontoid fracture management. Neurosurg Focus 2000; 8: 1-6.
4) Epstein NE. Commentary on the management of type II odontoid process fractures in octogenarians: Article by Graffeo et al. and Editorial by Falavigna (J Neurosurgery Spine August 19, 2016). Surg Neurol Int. 2016 Nov 21;7(Suppl 38):S901-S904. doi: 10.4103/2152-7806.194515. PubMed PMID: 28028444; PubMed Central PMCID: PMC5159695.
5) Pisapia JM, Nayak NR, Salinas RD, Macyszyn L, Lee JY, Lucas TH, Malhotra NR, Isaac Chen H, Schuster JM. Navigated odontoid screw placement using the O-arm: technical note and case series. J Neurosurg Spine. 2017 Jan;26(1):10-18. doi: 10.3171/2016.5.SPINE151412. PubMed PMID: 27517526.
6) Guo Q, Deng Y, Wang J, Wang L, Lu X, Guo X, Ni B. Comparison of Clinical Outcomes of Posterior C1-C2 Temporary Fixation Without Fusion and C1-C2 Fusion for Fresh Odontoid Fractures. Neurosurgery. 2016 Jan;78(1):77-83. doi: 10.1227/NEU.0000000000001006. PubMed PMID: 26348006.
7) Guo Q, Zhang M, Wang L, Lu X, Guo X, Ni B. Comparison of Atlantoaxial Rotation and Functional Outcomes of two Non-Fusion Techniques in the Treatment of Anderson-D’Alonzo type II Odontoid Fractures. Spine (Phila Pa 1976). 2015 Dec 10. [Epub ahead of print] PubMed PMID: 26656043.
8) Terreaux L, Loubersac T, Hamel O, Bord E, Robert R, Buffenoir K. Odontoid balloon kyphoplasty associated with screw fixation for Type II fracture in 2 elderly patients. J Neurosurg Spine. 2015 Mar;22(3):246-52. doi: 10.3171/2014.11.SPINE131013. Epub 2015 Jan 2. PubMed PMID: 25555053.

Update: Posterior clinoid process meningioma

Posterior clinoid process (PCP) intracranial meningiomas are extremely rare lesions and comprise about 0.7% of central skull base meningiomas
Meningiomas arising from the PCP can compress the pituitary stalk anteriorly, the oculomotor nerve laterally or infero-laterally and encase the C1-C2 segment of the internal carotid artery (ICA) or its perforators and branches 1).

Classification

Clinical and radiological features or characteristics of posterior clinoid process (PCP) meningiomas have rarely been described because of their extreme scarcity and terminological confusion.
These tumors are often referred to as “dorsum sellae” or “upper clivus meningiomas” 2) 3) 4) 5).
Geng et al. subdivided the dorsum sellae meningiomas into two groups
Type 1 (dorsum sellae, inferior third ventricle type)
Type 2 (dorsum sellae, third ventricular type), depending upon the site and direction of growth 6) 7) 8).


Lesions in this region are primarily of two anatomic types:
Centrally placed meningiomas located between the two PCPs and arising from the dorsum sellae or upper clival region – which should be referred to as dorsum sellae meningioma or upper clivus meningiomas.
Eccentrically placed meningiomas centered on the PCP are true PCP meningiomas 9).
Takase et al., suggests that PCP meningioma may be characterized by the anterior displacement of internal carotid artery, and infero-laterally shifted posterior communicating artery, and homonymous hemianopsia, a distinctive clinical feature 10).

Differential diagnosis

Hongo et al., report a case of an osteochondroma in the posterior clinoid process that occurred in a 43-year-old man with trochlear nerve palsy. Although the potential preoperative diagnoses based on computed tomography and magnetic resonance imaging included other intracranial tumors such as calcified meningioma, thallium-201 single-photon emission computed tomography effectively differentiated osteochondroma from those possibilities 11).

Treatment

In close proximity to these lesions are the perforators from the internal carotid artery (ICA) and the oculomotor nerve, which need to be considered while deciding the appropriate surgical approach.
Strategies in the surgical intervention have not been well established. Moreover, the proximity to important neurovascular structures, including optic chiasm, internal carotid artery (ICA), pituitary stalk, and oculomotor nerve, can be difficult to predict preoperatively, making their surgical excision more challenging.
Differentiation between the dorsum sellae/upper clival meningiomas and the PCP meningiomas may have important implications in selecting the surgical approach 12). One of the key issues in PCP meningioma surgery is preservation of the optic nerve. Unlocking the optic nerve by anterior clinoidectomy and dissection, the falciform ligament is the important step to preserve vision for larger tumors 13).

Approaches

Various surgical approaches have been described to approach the PCP to minimize complications, and to improve the extent of resection.
These include the extradural trancavernous-transellar approach described by Dolenc 14).
A frontotemporal or pterional approach, presigmoid transpetrosal approach, and a transzygomatic subtemporal approach 15).
In the frontotemporal and pterional approach, there is direct access to the tumor through the optico-carotid and carotico-oculomotor corridors, but the perforators, which are pushed anteriorly by the tumor, are at risk of injury or vasospasm. A two stage approach, combining retrosigmoid suboccipital corridor to devascularize the tumor, followed by total excision of the tumor by frontotemporal route, has also been described 16) 17).
The transzygomatic subtemporal approach is anatomically a good technique as it allows the dural attachment of the tumor to be coagulated first, followed by piecemeal tumor excision. However, temporal lobe retraction may be hazardous and occasional venous infarcts have been reported 18). The transcavernous approach described by Dolenc is also potentially hazardous for the cranial nerves and the ICA 19).

Complications

Complication with the perforators is also hazardous of these challenging surgeries than anterior clinoid region meningiomas for their specific neuroanatomical structures and might not be feasible to avoid even with additional techniques and critical monitoring. A combination and multi-staged-surgical approach can be options of tailor-made surgical strategy in cases with tumor adhesion to the perforators 20).

Case reports

The tumor described by Nakamura et al. was anteriorly placed, arising from the upper clivus and should be labeled as dorsum sellae or upper clival meningioma 21).
Geng et al. discussed eight cases of dorsum sellae meningiomas (types 1 and 2) but did not mention the exact site of origin 22) 23) 24).

2016

Takase et al., report two surgical cases of PCP meningioma and discuss the appropriate assessment of preoperative features and surgical strategies with review of the literature 25).

2015

Sodhi et al., describe a basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure to resect an eccentrically placed PCP meningioma.
The approach allowed access through the carotico-optic corridor, and between the carotid artery and the oculomotor nerve, as well as the anterior subtemporal approach. This provided an additional surgical trajectory allowing direct access to the PCP posterior to the perforating vessels without temporal lobe retraction.
A basal frontotemporo-orbito-zygomatic approach with splitting of the sylvian fissure is a safe approach to resect an eccentrically placed PCP meningioma 26).

2013

Shukla et al. reported a patient as posterior clinoid meningioma, which was eccentric and centered over the PCP 27).

1) , 5) , 8) , 15) , 17) , 24) , 27) Shukla D, Gangadharan J, Kakati A, Devi BI. Posterior clinoid process meningioma. Clin Neurol Neurosurg. 2013 Aug;115(8):1517-9. doi: 10.1016/j.clineuro.2012.12.007. Epub 2013 Jan 11. PubMed PMID: 23313105.
2) , 14) , 18) , 19) Dolenc VV, Skrap M, Sustersic J, Skrbec M, Morina A. A transcavernous-transsellar approach to the basilar tip aneurysms. Br J Neurosurg. 1987;1:251–9.
3) , 6) , 22) Geng SM, Zhang JT, Zhang LW, Wu Z, Wang ZC. Optimal microsurgical treatment of dorsum sellae meningioma. Chin Med J (Engl) 2009;122:1857–61.
4) , 7) , 16) , 23) Nakamura M, Samii M. Surgical management of a meningioma in the retrosellar region. Acta Neurochir (Wien) 2003;145:215–9.
9) , 12) , 26) Sodhi HB, Singla N, Gupta SK. Posterior clinoid meningioma: A case report with discussion on terminology and surgical approach. Surg Neurol Int. 2015 Feb 11;6:21. doi: 10.4103/2152-7806.151261. eCollection 2015. PubMed PMID: 25722927; PubMed Central PMCID: PMC4338485.
10) , 13) , 20) , 25) Takase H, Kawasaki T, Tateishi K, Yokoyama TA, Murata H, Kawahara N. Characteristics and surgical strategies for posterior clinoid process meningioma: two case reports and review of the literature. Neurosurg Rev. 2016 Aug 24. [Epub ahead of print] PubMed PMID: 27553846.
11) Hongo H, Oya S, Abe A, Matsui T. Solitary Osteochondroma of the Skull Base: A Case Report and Literature Review. J Neurol Surg Rep. 2015 Jul;76(1):e13-7. doi: 10.1055/s-0034-1387189. Epub 2015 Mar 2. PubMed PMID: 26251790; PubMed Central PMCID: PMC4520987.
21) Nakamura M, Samii M. Surgical management of a meningioma in the retrosellar region. Acta Neurochir (Wien) 2003;145:215–9.
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