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Microcrystalline arthritis sometimes have atypical localizations and presentations. The crowned dens syndrome, due to hydroxyapatite or calcium pyrophosphate deposits in peri-odontoid ligaments of the atlas, can provoke acute or chronic cervicalgia or misleading presentations such as meningitidis or fever of unknown origin. We present a particularly severe new case requesting urgent surgery, and a literature review to alert clinicians and prevent misdiagnosing this syndrome. Indeed, calcifications may be very discrete or just incidental and prevent a complete diagnostic approach.

Seven cases of atlantoaxial rotatory dislocation in children are reported. The CT scan permitted differentiation of the lesions in all the cases. Analysis of the results has led us to introduce two modifications for Fielding's classification: a distance between the atlas and odontoid of less than 5 mm is normal. sagittal dislocation must be included in the same classification. We propose the following therapeutic protocol: rotatory luxation without tears of the transverse ligament should receive orthopedic treatment, rotatory luxation with tears of the transverse ligament should have surgical treatment if orthopaedic treatment fails. sagittal luxation with or without rotatory fixation needs surgical treatment.

The trans-oral approach is a well codified and classical technique in neurosurgery. When correctly performed, this procedure gives excellent results in selected indications, such as: mechanical decompression of ondotoïdal vicious callus and more particularly, malformations of the craniovertebral function. This approach is also used for extirpation of C1, C2 and inferior clivus tumors. The complications of this technique are mainly septic, and must be prevented by appropriate pre and post-operative nursing.

A posterior screw fixation technique for C1-C2 is described which respects strict anatomical relations and allows associated posterior arthrodesis limited to C1-C2, using a single approach route. This method of posterior fixation can be used even when anomalies of the posterior arch of C1 or C2 exist, of whatever origin, as well as in the presence of a laminectomy. Four patients were operated upon using this method without any postoperative complications.

The authors describe the surgical technique of atlanto-axial fixation using a bilateral lateral approach. The cartilage of the articular processes of C1 and C2 are excised and the joints grafted. A screw fixation of the articular processes is performed. 8 cases are reported.

The author has approached 18 atlanto-axial joints in 15 years by a transoral approach. Fourteen of the lesions were post traumatic, two congenital, one rheumatoid and one a tumour. It is concluded that the approach is a valuable one provided that there is adequate surgical technique, good antiseptic preparation, antibiotic therapy, provisional peroperative tracheostomy and special retractors. Use of adequate suture is also important. In some cases, magnification was needed. Medullary monitoring may also be helpful. The author estimates that the approach is more effective than extrabuccal techniques since it allows a direct exposure of the lesion. Large excisions are possible followed by reconstruction and grafting. It also allows screw fixation of the odontoid process. Two patients among earlier cases became infected but without serious long-term complications. Remaining cases have uncomplicated follow-up.

Following an anatomical study of the lateral suboccipital region, the authors have devised an approach to the third segment of the vertebral artery, from C2 to the foramen magnum, which enabled them to treat an arteriovenous fistula in C1 while preserving the vertebral artery. The different operative stages and anatomical features are described. The simplicity and safety of this approach should encourage surgeons to use it.