title: Investigation of meningomyovertebral structures within the upper cervical epidural space: a sheet plastination study with clinical implications.
abstract: BACKGROUND
  Over the past two decades, soft-tissue structures communicating with the dura mater within the epidural space have become the focus of many anatomical and histopathologic studies. The relationship between these bridging structures has yet to be evaluated in situ.
  
  
  OBJECTIVE
  This is the first study that used E12 sheet plastination to investigate the epidural space of the upper cervical spine in situ and its associated bridging structures. Given the complexity of this space, this study may prove useful to clinical anatomists and surgeons who operate within this region.
  
  
  METHODS
  Anatomical and microscopic analyses of structures that communicate with the dura mater within the upper cervical region were carried out.
  
  
  METHODS
  Gross dissection in conjunction with microscopy was used to evaluate bridging communications of the upper cervical spine in 10 cadavers. To evaluate the in situ arrangement of these structures, E12 sheet plastination was used on 13 cadavers.
  
  
  RESULTS
  In all 23 specimens, suboccipital fascia coalesced with the dorsal meningovertebral ligament of the atlas, and inserted directly into the posterior surface of the dura as a single but separable laminar layer. At the level of the atlantoaxial interspace, suboccipital fasciae combined and coalesced with the dorsal meningovertebral ligament of the atlas and the axis. These structures inserted into the posterior surface of the dura mater as a single but separable layer. Microscopy validated these findings and E12 sheet plastination revealed the in situ organization of these soft-tissue structures. E12 sheet plastination also provided new information on dural arrangement at the craniocervical junction, which was observed to be composed of periosteum from the occiput but consisted mainly of deep fascia from the rectus capitis posterior minor.
  
  
  CONCLUSIONS
  E12 sheet plastination has provided in situ visualization of bridging structures within the cervical epidural space and offers new insight into these structures, as well as the composition and arrangement of the posterior atlantooccipital membrane and cerebrospinal dura at the craniocervical junction. This study aims to expand on the anatomical understanding of the upper cervical region while defining structures that may reduce neurosurgical complications, and aid in the understanding of the pathophysiology of certain neurogenic disorders.
authors.affiliation: American University of the Caribbean School of Medicine, 1 University Drive at Jordan Rd, Cupecoy, St. Maarten. Electronic address: drfrankscali@gmail.com.
authors.forename: Frank
authors.initials: F
authors.lastname: Scali
authors.affiliation: Department of Surgery, Drexel University College of Medicine, 245 N 15th St, Philadelphia, PA, USA.
authors.forename: Matthew E
authors.initials: ME
authors.lastname: Pontell
authors.affiliation: Department of Anatomical Sciences, American University of the Caribbean School of Medicine, 1 University Drive at Jordan Rd, Cupecoy, St. Maarten.
authors.forename: Lance G
authors.initials: LG
authors.lastname: Nash
authors.affiliation: Division of Research, Logan University, 1851 Schoettler Rd, Chesterfield, MO 63017, USA.
authors.forename: Dennis E
authors.initials: DE
authors.lastname: Enix
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002574:Cervical Vertebrae / Q000033:anatomy & histology* / Q000601:surgery; D004210:Dissection / Q000379:methods*; D004388:Dura Mater / Q000033:anatomy & histology* / Q000601:surgery; D004824:Epidural Space / Q000033:anatomy & histology / Q000601:surgery; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009334:Neck Muscles / Q000033:anatomy & histology* / Q000601:surgery; D066231:Surgeons / Q000193:education
keywords: Cervical spine; Dural lacerations; Epidural space; Meningovertebral ligaments; Myodural bridge; PAO membrane; Suboccipital muscles