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The INYBI is an instrument used to release the suboccipital myofascial area. There is scarce evidence of its efficacy. A randomized controlled, double-blinded, longitudinal and prospective trial was performed. Ninety-six subjects (aged 29.47 ± 5.16 years) (70 women) with chronic neck pain were randomly assigned to the manual suboccipital inhibition technique (MSIT), instrumental suboccipital inhibition (INYBI) or the INYBI plus upper cervical manipulation technique (INYBI + UCMT) groups and received two sessions with a week interval between them. The Neck Disability Index was used before the first intervention and two weeks after the second intervention. Pre- and post-measurements were taken on both intervention days for pressure pain threshold of the upper trapezius and suboccipital muscles, self-perceived pain and cervical range of motion. In spite of a significant general improvement in time that was found for the three groups for all of the outcome measurements (p &lt, 0.05 in all cases), no between-groups differences were found (p &gt, 0.05 in all cases), with the exception of self-perceived pain for left rotation (p = 0.024), with the MSIT group showing the lower improvement. However, the higher degree of within-group improvements was found for the INYBI + UCMT group. It was concluded that the myofascial release therapy in the suboccipital area is effective in patients with chronic neck pain, either through a manual application or by means of the INYBI tool. Moreover, the addition of craniocervical manipulation achieved the higher within-group improvements, but with no statistical significance.

Tenosynovial giant cell tumors (TGCTs) are benign neoplasms that arise from the synovium of tendon sheaths, bursae, and joints. We report a rare presentation of TGCT involving the suboccipital spine.

Synovial sarcoma (SS) most commonly affects the lower limbs of males in the third to fifth decades of life, with masses of the head and neck accounting for 3–10% of all cases, mainly as a metastatic lesion. The lack of specific symptoms and radiological features in addition to the diversity of their microscopic aspects may cause confusion in the diagnosis; hence, knowledge of the unusual locations of SSs is very important. The immunohistochemistry, and more recently the cytogenetic studies, contribute to the differential diagnosis. We report the case of a 12-year-old girl with a rare primary SS in the suboccipital region, which underwent complete surgical resection.

The coexistence of venous anomalies, such as vertical embryonic positioning of the straight sinus (VEP of SS), has been reported in patients with atretic cephalocele (AC). VEP of SS has been exclusively encountered when the AC is found above the torcular. We report a patient with suboccipital AC associated with venous anomalies analogous to VEP of SS, consisted of the Galenic venous system which did not drain into the straight sinus in the tentorium, but into the falcine sinus instead. Differences with VEP of SS in our case had no anatomical relationship between the falcine sinus and the suboccipital AC and no large cerebrospinal fluid space around the falcine sinus. A detailed neuroradiological examination was helpful for detecting these minute anomalies.

Herein we report a rare case of a giant suboccipital osteoma in a 55-year-old woman presenting primarily due to cosmetic issue. We discuss the management algorithm taken in the patient, highlighting excision of a potentially curable bony tumor only after ruling out its extension to the ear cavity, mastoid ear cells, transverse sinus, and the intracranial compartment.

[Purpose] The purpose of this study was to research the effect of performing the suboccipital muscle inhibition (SMI) and self-myofascial release (SMFR) techniques in the suboccipital area on the flexibility of the hamstring. [Subjects] Fifty persons with short hamstrings participated in this research. According to the results of the finger-floor distance (FFD) test, the subjects were allocated to SMI and SMFR groups of 25 subjects each. [Methods] The SMI and SMFR techniques were applied to the groups. For the analysis, we used the FFD test and the straight leg raise (SLR) test for the flexibility of hamstring. The evaluator was blindfolded. [Results] In the SMI group, FFD, SLR, and PA were significantly changed after the intervention, and in the SMFR group, there was a significant change in SLR after the intervention. In a comparison between the groups, FED was found to be significantly increased in the SMI group. [Conclusion] Application of the SMI and SMFR to persons with short hamstrings resulted in immediate increases in flexibility of the hamstring. However, we could see that the SMI technique was more effective.

The mastoid emissary vein (MEV) is a small venous channel connecting the intracranial and extracranial venous systems. Most current knowledge about the MEV has been obtained through cadaver studies. This study aimed to explore the MEV in vivo, using magnetic resonance imaging (MRI). Ninety-six patients were enrolled in this study. The initial examinations used the conventional MRI sequences; contrast examinations were performed using thin-sliced sections. The MEVs were identified bilaterally in 59.3 % of the 96 patients and unilaterally in 29.2 %. The original site, size, and intraosseous course of the MEVs were highly variable. On coronal images, the MEVs originated from a variable height on the posterior wall of the sigmoid sinus, most frequently from the lower third of the wall. Intraosseous MEV courses were classified as straight, curved, or tortuous, with the straight type occurring most frequently. The MEVs were dominant on the right side in 51.8 % of cases and on the left side in 24.7 % of cases. Two patients had two MEVs on the same side. Furthermore, on eight sides (5.6 %), the diploic venous channel was found to communicate with the MEV. The MEV is a structure with diverse morphologies and right-sided dominancy. MEVs should be evaluated before performing surgical and endovascular procedures around the suboccipital region.

Because of the potentially dangerous structures in the suboccipital region (such as the foramen magnum and vertebral artery), clinicians have tended to avoid this area, despite the pathology often seen there. This chapter discusses the regional pathology, the alternative techniques, and a novel interventional approach, the “Stealth” approach, for occipital decompression.

The anatomy of the muscular branches of the vertebral arteries has clinical relevance during surgical procedures, suboccipital injections, and manual therapies. Each vertebral artery is divided into four segments. Segment V3, found in the suboccipital triangle, courses posteromedially around the lateral mass to lie in a groove on the posterior arch of the atlas, ultimately coursing beneath the posterior atlanto-occipital membrane to enter the skull. Although not always present, any muscular branch that emanates from this segment to supply the suboccipital muscles is called the suboccipital artery of Salmon. There is a paucity of literature on this artery despite its clinical relevancy. We found the suboccipital artery of Salmon in 10 (67%) of 15 embalmed adult cadavers. This frequency is considerably higher than that in previous reports. Two (20%) of the 10 cadavers demonstrated bilateral and symmetrical suboccipital arteries of Salmon (one artery on each side). Four (40%) of the 10 cadavers had an arrangement of two parallel suboccipital arteries of Salmon on one side, and one on the contralateral side. Three (30%) of the 10 cadavers displayed an asymmetrical unilateral arrangement (only one artery). One (10%) of the 10 cadavers displayed the unique arrangement of three arteries of Salmon on one side and one artery on the contralateral side. This study adds to a limited, but growing, body of knowledge by providing photographic evidence of the course and arrangement of these arteries and, therefore, can be of value to surgeons and other clinicians whose procedures focus on the suboccipital region.

Haemangiomas are most commonly found in skin and subcutaneous tissue and are very rare in intramuscular region. Paraspinal musculature has been barely reported as location of intramuscular haemangioma while we could not find any literature reporting haemangioma in cervical paraspinal previously. We report a case of middle aged woman with a large intamuscular haemangioma involving left cervical paraspinal musculature extending from suboccipital region to C5 vertebra and reaching upto left parotid gland along with C6 vertebral body haemangioma.

This report describes a case of bilateral greater occipital neuralgia treated with cooled radiofrequency ablation. The case is considered in relation to a review of greater occipital neuralgia, continuous thermal and pulsed radiofrequency ablation, and current medical literature on cooled radiofrequency ablation. In this case, a 35-year-old female with a 2.5-year history of chronic suboccipital bilateral headaches, described as constant, burning, and pulsating pain that started at the suboccipital region and radiated into her vertex. She was diagnosed with bilateral greater occipital neuralgia. She underwent cooled radiofrequency ablation of bilateral greater occipital nerves with minimal side effects and 75% pain reduction. Cooled radiofrequency ablation of the greater occipital nerve in challenging cases is an alternative to pulsed and continuous RFA to alleviate pain with less side effects and potential for long-term efficacy.

Schwannomas are benign tumors that originate from the Schwann cells of the nerve sheath. They can arise from any myelinated nerve. The pre-operative diagnosis of schwannoma is difficult and should be suggested by clinical features and supported by investigations based on techniques such as ultrasonography, computed tomography (CT), magnetic resonance imaging, and fine-needle aspiration cytology. Schawannomas can present with very subtle symptoms or morbid sequel. A 19-year-old male patient presented with 6 months history of swelling in the upper left side part of the neck. Local examination showed a 5 cm and times; 3 cm single globular mass in the left suboccipital region. The contrast enhanced CT scan showed a 44 mm and times; 46 mm and times; 39 mm well defined heterogeneous mildly enhancing mass on the left side of the upper three cervical vertebras abutting them. The mass was excised under general anesthesia by transcervical approach. After extensive search of English literature we came across only three case reports where schwannoma of greater occipital nerve presented with neuralgia. [Arch Clin Exp Surg 2016; 5(1.000): 59-62]

Klippel-Feil syndrome in its most basic definition includes several anomalous conditions of the cervicomedullary junction and suboccipital region. Pediatric neurosurgeons are often involved in surgical palliation of this syndrome, without realizing how the accompanying anomalies may obfuscate management in the older child. A brief review of the embryology of the rhombencephalon helps to clarify the etiology of some of these symptoms which may cause confusion and, occasionally, inappropriate treatment. Illustrative cases will demonstrate some of these pitfalls. Appropriate early intervention, such as posterior fossa decompression, ventricular shunting, and fundal plication, may help to avoid needless morbidity. The advent of magnetic resonance scanning has helped to clarify the diagnosis and resulted in more appropriate treatment in these cases.

Cervical orthoses is important for the postopereative treatment of the cervical disorder. A Newly designed cervical orthoses, N-type cervical orthoses, has been developed for 5 years. It is characteristic of the N-type cervical orthoses that it is supported by frontal, suboccipital region, mastoid process and thorax without supporting mandibula.The availability of the N-type cervical orthoses is as follows;1) Alignment can be changed at will by posterior adjustable dual hinge.2) It can be easily taken off because frontal solid cuff is inlaid design and truncal jacket is fixed by magic tape.3) It allows the patient to eat and talk easily because no mandibular support is necessary.4) It is lighter than other orthoses (700gr).As a result of measurement of stability with the N-type cervical orthoses by radiography and photography, range of motion was 13.2° in flexion and extension, 7.6°, in bending, 8.3° in rotation, and rate of control was, 77.4% in flexion, and extension 74.8% in bending and 87.1% in rotation.

Referred pain evoked by suboccipital muscle trigger points (TrPs) spreads to the side of the head over the occipital and temporal bones and is usually perceived as bilateral headache. This paper describes the presence of referred pain from suboccipital muscle TrPs in subjects with episodic tension-type headache (ETTH) and in healthy controls. Ten patients presenting with ETTH and 10 matched controls without headache were examined by a blinded assessor for the presence of suboccipital muscle TrPs. Diagnostic criteria described by Simons and Gerwin were adapted to diagnose TrPs, i.e. presence of tenderness in the suboccipital region, referred pain evoked by maintained pressure for 10 s, and increased referred pain on muscle contraction. Six ETTH patients (60%) had active TrPs and 4 had latent TrPs (40%). On the other hand, 2 control subjects also had latent TrPs. Differences in the presence of suboccipital muscle TrPs between both groups were significant for active TrPs (P

A 20-year-old male patient was involved in a violent conflict and a wound was inflicted upon his suboccipital region by a wooden chopstick. He was sent to our emergency room about 1 h later. He was irritable with fluent and clear speech and complaining of neck pain. On examination, he was conscious and alert. No peripheral neurological abnormalities or weakness of the extremities were noted. Lateral cervical spine and skull X-rays were unremarkable. Emergent nonenhanced computed tomography (CT) of the head and craniocervical junction was performed. The patient had no intracranial lesion. Axial CT at the level of craniocervical junction showed a linear low-density signal represented by a low Hounsfield unit (Hu) number of −68, traversing the spinal canal of the craniocervical junction, which coincided with the location of the chopstick (Fig. 1). A wooden chopstick retained in the foramen magnum was diagnosed. Prophylactic antibiotics and tetanus toxoid were administered. The patient underwent an emergency operation to remove the foreign body. A splinter of wooden chopstick in the foramen magnum was removed. A small dural penetration wound that was found intra-operatively was repaired after debridement. He was well, without neurological deficit or cerebrospinal fluid leakage 1 year after discharge.

The aim of this study was to investigate vegetative reactions in infants after mechanical irritation of the suboccipital region. The investigation is based on 199 infants who were observed while being treated with a suboccipital impulse (manual therapy). The results revealed vegetative reactions in more than half of all cases (52.8%, n = 105). The frequency of such vegetative reactions observed was at follows: flush 48.7% (n = 97), apnoea 22.1% (n = 44), hyperextension 13% (n = 26), and sweating 7.5% (n = 15). It is pointed out that approximately 25% of all the infants examined reacted by apnoea due to a mechanical irritation of the suboccipital region. This symptom was part of an extensive vegetative reaction. This method of inducing an apnoea has not yet been described; from this it follows that there are close relations to sudden infant death.

In suboccipital craniectomy where the bone is not repositioned, there may be a significant cosmetic defect due to lack of skull bone in the suboccipital region. It may accompanied by sensory symptoms, including pain. To prevent any cosmetic defect and sensory symptoms we repositioned the bone chips at the craniectomy site in 42 suboccipital craniectomies before the closure of the scalp. At a mean follow-up of 22 months (range: 5-44 months), two patients complained of mild discomfort in the healed wound or of occasional local pain. One patient complained of mild itching at the site. In two patients, bone chips were accumulated at the lower part of the suboccipital craniectomy and failed to form a uniform bone cover at the operated site. In one patient, all bone chips were reabsorbed and there was no bone at the operated site. There was pseudomeningocele formation in one patient. In the rest of the cases there was satisfactory bone coverage at the operated site, both clinically and radiologically. The wound sites were aesthetically acceptable in 40 cases. Our study suggests that in the majority of cases where suboccipital craniotomy is not possible or not done, repositioning of the bone chips at the craniectomy site is associated with satisfactory aesthetic and functional outcome and formation of bone coverage at the operated site.

Anatomic study of the suboccipital region, specifically the deep muscles of the suboccipital triangle, was performed in cadaveric specimens.To observe and describe the relationship between the deep suboccipital musculature and the spinal dura.A review of the literature revealed no reports describing a physical connection between suboccipital musculature and the spinal dura.Dissections of the suboccipital region were performed in 10 embalmed and one fresh sagittally hemisected head and neck specimens.A connective tissue bridge between the rectus capitis posterior minor muscle and the dorsal spinal dura at the atlanto-occipital junction was observed in every specimen. The fibers of the connective tissue bridge were oriented primarily perpendicular to the dura. This arrangement of fibers appears to resist movement of the dura toward the spinal cord.Awareness of the physical relation between the rectus capitis posterior minor muscle and spinal dura via this connective tissue bridge should lessen the potential risk of dural damage during surgery. This connective tissue bridge may help resist dural infolding during head and neck extension.

We report a supine lateral retromastoid approach for computed tomography-guided stereotactic aspiration of hematomas of the posterior fossa. The method involves horizontal insertion of the aspiration needle at the suboccipital region with the patient in a supine position with the head turned 30 to 40° away from the lesion and with slight forward flexion of the neck. Eleven hematomas have been removed through this approach thus far, nine cerebellar and two pontine. With this technique, general anesthesia is not needed and operative invasion is minimal, allowing hematoma aspiration in patients in whom operation would previously not have been indicated. An additional merit is the suitability of this method for elderly patients.

✓ A case of ectopic extraspinal meningioma is reported which presented as a tumor at the back of the neck of a 51-year-old woman. This neoplasm was of considerable size and arose extradurally in the region of the C-2 nerve root, with its main bulk lying almost totally outside the spinal canal in the right suboccipital region. Total resection was accomplished in two stages, with no evidence of recurrence after 1 year. The rarity of such cases prompted this report.

✓ The authors describe the occurrence of proatlantal artery as an incidental angiographic observation in a young Indian soldier. This primitive anastomotic channel is seen extending from near the origin of the external carotid artery to the suboccipital region, traversing the foramen magnum and coursing beyond like a vertebral artery. The developmental and roentgenological aspects of carotid-basilar and carotid-vertebral anastomosis are discussed, along with a review of four similar cases reported previously.

Between 1966 and 1976, postmortem examinations revealed significant intracranial birth trauma in 17 infants delivered breech first and in ten infants delivered head first; separation of the squamous and lateral parts of the occipital bone (occipital osteodiastasis) was found in five of the infants who died after breech delivery. The finding of the lesions in these infants is attributed to the adoption, since 1971, of a postmortem technique involving dissection of the suboccipital region before opening the skull. Review of earlier necropsy reports suggests that the lesion was sometimes missed. Analysis of the fresh stillbirths and neonatal deaths occurring in the 477 vaginal breech deliveries at the Hammersmith Hospital (1966 to 1976) showed that all neonatal deaths in infants weighing more than 3000 g at birth associated with intracranial birth trauma: 2 out of 3 had occipital osteodiastasis which seems to be more common than is generally recognized and is only found with careful autopsy technique.

Currently osteoarticular tuberculosis [5, 8, 10] remains the most frequently observed extrapulmonary form of tuberculosis [10]. The spine is involved in 50 to 60% of the cases of osteoarticular tuberculosis, most commonly of the dorsolumbar level [2, 3]. Cervical Pott’s disease is an uncommon localization (1–10% of the cases with spinal involvement) and its appearance in the suboccipital region is even rarer (0–4.8%), although its consequences are much more serious [1, 4, 6, 12].

The theoretical risk of injuring the vertebral artery or anomalous vessels at lateral cervical puncture is assessed. In just less than 30% of vertebral arteries the vessel overlies the lateral aspect of the spinal canal between the first and second cervical vertebrae, usually the antero-inferior quadrant. Directing the spinal needle to the posterior third of the canal virtually eliminates the possibility of injuring this and most anomalous arteries traversing the region. The likelihood of inducing subarachnoid haemorrhage by injuring these vessels would appear to be considerably less in lateral cervical than in cisternal puncture.

To the Editor.— This case report describes the possible association of positional nystagmus of the benign paroxysmal type (PN-BPT) with posterior fossa medulloblastoma. Report of a Case.— A 35-year-old man complained of an eight-month, nonprogressive history of headache and dizziness. The headache occurred almost daily and began immediately when he sat up in bed in the morning and lasted about an hour. Sometimes it would occur later in the day with a sudden change in head position, but it would be milder and shorter in duration. The morning head pain occurred in the left occipital region, was severe, and was aggravated by straining at stool, bending over, or turning the head from side to side. It was accompanied by dizziness that lasted from seconds to a minute or two without nausea. Physical examination showed a good range of neck movement but severe muscular tenderness in the suboccipital region. A striking

The authors have designed various implants made of alumina ceramic for neurosurgical use. They were used for reconstruction of the sellar floor and orbital wall and for cranioplasty to repair bone defects in both the convexity and the suboccipital region. Burr hole and sphenoid buttons were made to prevent postoperative dents in the skin. A ceramic-silicon sponge was developed as a marker prosthesis for neurovascular decompression. There were no untoward side effects such as infection or rejection by recipient tissue in humans or dogs. The advantages and disadvantages of the material are discussed.

This case is reported because of its rarity and because of the fact that a cure of the patient was effected. A white baby, aged 5 months, was brought to the office by its mother, March 17, 1932, who gave the following clinical history: She had noticed a lump in the suboccipital region of the infant when it was only a few days old. This lump had gradually increased in size until it had become as large as the child's head. During the preceding two weeks the child had vomited after each feeding, and it had lost weight. She had taken the child to several doctors, who had given her no hopes for cure. The baby was poorly nourished and markedly dehydrated. It weighed 9 pounds (4 Kg.). There was a huge suboccipital meningocele about the size of the child's head. The coverings of the meningocele were sufficiently thin to

Flexion of the head with obliteration of the folds usually found in the occipital and cervical regions is essential in order to obtain the best exposure in either suboccipital craniotomy or cervical laminectomy. We have sometimes found that sufficient flexion is not produced by the head rest, and traction by an assistant has been necessary. If a retractor is used it is usually applied in the region of the external occipital protuberance where only a scant purchase is possible, and if the retractor slips the tissues are likely to be stripped from the cranium or torn. Such traumatism where the corners of the incision come together is unfortunate, since it is the weakest part of the wound and, unless the tissues at this point are brought together accurately, leakage of cerebrospinal fluid may be favored. In order to obtain flexion and better exposure of the suboccipital region without additional traction

To the Editor:— I am offering a suggestion for fastening the Levin nasal tube in place, which I consider simple and practical. After the tube is passed the desired distance and wiped free of lubricant, a 2 foot length of 1 or 2 inch gauze roller bandage is placed parallel to the tube, with its midpoint just beneath the nostril. The bandage is fastened to this point on the tube by a few turns of 1/2 inch adhesive tape. The bandage is then knotted over the tape, and the free ends are brought across the face over the ears and tied in the suboccipital region, as in tying the strings of a surgical mask. This method is comfortable and avoids slipping of adhesive tape which has been loosened by perspiration.