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Klepinowski T, Żyłka N, Pettersson SD, Hanaya J, Pala B, Łątka K, Taterra D, Poncyljusz W, Ogilvy CS, Sagan L. Types of high-riding vertebral artery: a classification system for preoperative planning of C2 instrumentation based on 908 potential screw insertion sites. Spine J 2024:S1529-9430(24)00993-8. [PMID: 39255917 DOI: 10.1016/j.spinee.2024.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 08/05/2024] [Accepted: 08/24/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND CONTEXT Our recent studies indicated that a high-riding vertebral artery (HRVA) is a common variant posing a risk of injuring the vessel during C2 instrumentation. However, several different types fit in the current definition of HRVA, which may require a different strategy for C2 screw placement. PURPOSE To classify HRVA and provide a clinical aid for preoperative planning of C2 instrumentation. A secondary goal was to estimate coexistence of each HRVA type with the ipsilateral narrow C2 pedicle (NP). STUDY DESIGN A retrospective observational study involving radiologic measurements of the estimated number of anonymized cervical computed tomography (CT) scans. STROBE checklist was applied. PATIENT SAMPLE A total of 908 potential screw insertion sites (PSIS) of 454 consecutive cervical CT scans were analyzed. The sample size was estimated using ScalaR SP function in RStudio. OUTCOME MEASURES Three types of HRVA based on a series of C2 vertebral morphological parameters including the C2 isthmus height (C2IsH) and C2 internal height (C2InH). Also, the prevalences of each HRVA type and coexisting NP based on the C2 pedicle width (C2PW). METHODS HRVA was defined as C2IsH of ≤5 mm and/or C2InH of ≤2 mm measured 3 mm lateral to the lateral border of the spinal canal. A narrow pedicle was defined as C2PW of ≤4 mm. Measurements were done using Syn.govia software. Interobserver, intraobserver, and inter-software agreement coefficients for C2IsH, C2InH, and C2PW parameters were adopted from our previous study. K-means cluster analysis was applied. RESULTS Prevalence of at least 1 HRVA was 24.9% (n=113 subjects) and 16.2% of PSIS (n=147 sites). Based on the measurements and K-means clustering, the following 3 types of HRVA have been distinguished: type 1-isthmic with only C2IsH being reduced and normal C2InH; type 2-internal with only C2InH being reduced and C2IsH within normal limits; type 3-isthmo-internal with both C2IsH and C2InH being reduced. Kruskal-Wallis test followed by unadjusted and Bonferroni-adjusted post-hoc multiple comparison analysis detected significant differences across the types. The prevalences of the newly identified types were as follows: 78.2%, 8.8%, and 12.9% for type 1, type 2, and type 3, respectively. 73.9% of type 1 HRVA, 53.8% of type 2 HRVA, and 100% of type 3 HRVA had a concomitant ipsilateral NP. Prediction of the HRVA types by the K-means clustering has been evaluated. Screw placement techniques for each type are proposed and discussed. CONCLUSION We present the first classification system for the high-riding vertebral artery distinguishing 3 types based on the large homogenous cohort, which may serve as an adjunct to preoperative planning of C2 instrumentation. External validation of this classification scheme shall determine its further clinical utility.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland; Department of Neurosurgery, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK.
| | - Natalia Żyłka
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Samuel D Pettersson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jagoda Hanaya
- Faculty of Medicine, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Bartłomiej Pala
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Kajetan Łątka
- Department of Neurology, St Hedwig's Regional Specialist Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland
| | - Dominik Taterra
- Department of Orthopedics and Rehabilitation, Jagiellonian University Medical College, Zakopane, Poland
| | - Wojciech Poncyljusz
- Department of Diagnostic Imaging and Interventional Radiology, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Akbulut F, Pınar E, Çekiç E, Akdeniz E, Harman F. Radiologic Examination of High Riding Vertebral Artery and Analysis of Secure Areas. World Neurosurg 2024; 183:e772-e780. [PMID: 38211814 DOI: 10.1016/j.wneu.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To radiologically examine the pedicle, lamina, and vertebral artery foraminal anatomies at the C2 vertebra for pedicular and laminar screw instrumentation at the axis in a Turkish population. METHODS From 2018 to 2019, we evaluated 100 patients who underwent cervical computed tomography (CT) for various reasons (excluding cervical pathologies) at Marmara University Hospital. The C2 pedicles were measured on CT images using measurement tools. In addition, axial computed tomography was performed at 0.1 mm intervals. Bilateral measurements were performed for each case. RESULTS The median right and left pedicle axial diameters were 5.01 and 5.09 mm, respectively for the male patients and 4.31 and 4.38 mm for the female patients, showing a statistically significant difference between the sexes (P < 0.01). Of the patients, 15% had narrow pedicles. The pedicle sagittal diameters were smaller than 5 mm in 30% of the computed tomographic series. The internal height was <2 mm in 4% of the cases. CONCLUSIONS Our findings suggest significant individual and sex-related differences. Vertebral artery groove anomalies are commonly observed. Before performing a posterior craniocervical instrumentation surgery, a computed tomography (CT) examination is beneficial because high-riding vertebral arteries must be kept in mind in determining the appropriate screw diameter and screw trajectory.
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Affiliation(s)
- Fatih Akbulut
- Department of Neurosurgery, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey.
| | - Ertuğrul Pınar
- Department of Neurosurgery, Private Pendik Yuzyil Hospital, İstanbul, Turkey
| | - Efecan Çekiç
- Department of Neurosurgery, Polatlı State Hospital, Ankara, Turkey
| | - Esra Akdeniz
- Department of Medical Education, Marmara University, İstanbul, Turkey
| | - Ferhat Harman
- Department of Neurosurgery, Marmara University Hospital, İstanbul, Turkey
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Lin MS, Huang CW, Tsou HK, Tzeng CY, Kao TH, Lin RH, Chen TY, Li CR, Lee CY. Advances in surgical treatment for atlantoaxial instability focusing on rheumatoid arthritis: Analysis of a series of 67 patients. Int J Rheum Dis 2023; 26:1996-2006. [PMID: 37565304 DOI: 10.1111/1756-185x.14855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023]
Abstract
AIM An estimated 88% of rheumatoid arthritis (RA) patients experience various degrees of cervical spine involvement. The excessive movement of the atlantoaxial joint, which connects the occiput to the upper cervical spine, results in atlantoaxial instability (AAI). AAI stabilization is usually achieved by C1 lateral mass-to-C2 pedicle screw-rod fixation (LC1-PC2 fixation), which is technically challenging in RA patients who often show destructive changes in anatomical structures. This study aimed to analyze the clinical results and operative experiences of C1-C2 surgery, with emphasis on the advancement of image-guided surgery and augmented reality (AR) assisted navigation. METHODS We presented our two decades of experience in the surgical management of AAI from April 2004 to November 2022. RESULTS We have performed surgery on 67 patients with AAI, including 21 traumatic odontoid fractures, 20 degenerative osteoarthritis, 11 inflammatory diseases of RA, 5 congenital anomalies of the os odontoideum, 2 unknown etiologies, 2 movement disorders, 2 previous implant failures, 2 osteomyelitis, 1 ankylosing spondylitis, and 1 tumor. Beginning in 2007, we performed LC1-PC2 fixation under C-arm fluoroscopy. As part of the progress in spinal surgery, since 2011 we used surgical navigation from presurgical planning to intraoperative navigation, using the preoperative computed tomography (CT) -based image-guided BrainLab navigation system. In 2021, we began using intraoperative CT scan and microscope-based AR navigation. CONCLUSION The technical complexities of C1-C2 surgery can be mitigated by CT-based image-guided surgery and microscope-based AR navigation, to improve accuracy in screw placement and overall clinical outcomes, particularly in RA patients with AAI.
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Affiliation(s)
- Mao-Shih Lin
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chih-Wei Huang
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Hsi-Kai Tsou
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Houlong, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
- College of Health, National Taichung University of Science and Technology, Taichung, Taiwan, ROC
| | - Chung-Yuh Tzeng
- Department of Rehabilitation, Jen-Teh Junior College of Medicine, Nursing and Management, Houlong, Taiwan, ROC
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Medicinal Botanicals and Foods on Health Applications, Da-Yeh University, Changhua, Taiwan, ROC
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Ting-Hsien Kao
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Ruei-Hong Lin
- Functional Neurosurgery Division, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Tse-Yu Chen
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Chi-Ruei Li
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Cheng-Ying Lee
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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Klepinowski T, Sagan L. EuroQol-5 dimensions health-related quality of life questionnaire in craniovertebral instability treated with posterior fixation with or without occipital plating: A comparative study with matched datasets. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:72-79. [PMID: 35386241 PMCID: PMC8978853 DOI: 10.4103/jcvjs.jcvjs_125_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/28/2021] [Indexed: 11/04/2022] Open
Abstract
Objective: Methods: Results: Conclusions:
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Shimizu T, Koda M, Abe T, Shibao Y, Kono M, Eto F, Miura K, Mataki K, Noguchi H, Takahashi H, Funayama T, Yamazaki M. Correlation between osteoarthritis of the atlantoaxial facet joint and a high-riding vertebral artery. BMC Musculoskelet Disord 2021; 22:406. [PMID: 33941142 PMCID: PMC8091766 DOI: 10.1186/s12891-021-04275-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A high-riding vertebral artery (HRVA) is an intraosseous anomaly that narrows the trajectory for C2 pedicle screws. The prevalence of a HRVA is high in patients who need surgery at the craniovertebral junction, but reports about HRVAs in subaxial cervical spine disorders are limited. We sought to determine the prevalence of HRVAs among patients with subaxial cervical spine disorders to elucidate the potential risk for VA injury in subaxial cervical spine surgery. METHODS We included 215 patients, 94 were with a main lesion from C3 to C7 (subaxial group) and 121 were with a main lesion from T1 to L5 (thoracolumbar group). A HRVA was defined as a maximum C2 pedicle diameter of < 3.5 mm on axial CT. The sex, age of patients, body mass index (BMI), osteoarthritis of the atlantoaxial (C1-2) facet joints, and prevalence of a HRVA in the 2 groups were compared and logistic regression was used to identify the factors correlated with a HRVA. RESULTS The patients in the subaxial group were younger than those in the thoracolumbar group, but their sex and BMI did not differ significantly between the 2 groups. The mean osteoarthritis grade of the C1-2 facet joints of patients in the subaxial group was significantly higher than that in those in the thoracolumbar group. A HRVA was found in 26 patients of 94 (27.7 %) in the subaxial group and in 19 of 121 (15.7 %) in the thoracolumbar group. The prevalence of a HRVA in the subaxial group was significantly higher and osteoarthritis of C1-2 facet joints correlated significantly with a HRVA. CONCLUSIONS The prevalence of a HRVA in patients with subaxial cervical spine disorders is higher than in those without and osteoarthritis of the C1-2 facet joints is correlated with a HRVA.
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Affiliation(s)
- Tomoaki Shimizu
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan.
| | - Masao Koda
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Tetsuya Abe
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Yosuke Shibao
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Mamoru Kono
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Fumihiko Eto
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kousei Miura
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Kentaro Mataki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Hiroshi Noguchi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Toru Funayama
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, 305-8575, Tsukuba, Ibaraki, Japan
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Prevalence of high-riding vertebral arteries and narrow C2 pedicles among Central-European population: a computed tomography-based study. Neurosurg Rev 2021; 44:3277-3282. [PMID: 33559797 PMCID: PMC8592946 DOI: 10.1007/s10143-021-01493-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/12/2021] [Accepted: 02/01/2021] [Indexed: 11/26/2022]
Abstract
High-riding vertebral artery (HRVA) and narrow C2 pedicles (C2P) pose a great risk of injuring the vessel during C2 pedicle or transarticular screw placement. Recent meta-analysis revealed a paucity of European studies regarding measurements and prevalence of these anatomical variants. Three hundred eighty-three consecutive cervical spine CT scans with 766 potential screw insertion sites were analyzed independently by two trained observers. C2 internal height (C2InH), C2 isthmus height (C2IsH), and C2P width were measured. Kappa statistics for inter- and intraobserver reliability as well as for inter-software agreement were calculated. HRVA was defined as C2IsH of ≤ 5 mm and/or C2InH of ≤ 2 mm. Narrow C2P was defined as C2P width ≤ 4 mm. STROBE checklist was followed. At least 1 HRVA was found in 25,3% (95% CI 21,1–29,8) of patients (16,7% of potential sites). At least 1 narrow C2P was seen in 36,8% (95% CI 32,1–41,7) of patients (23,8% of potential sites). Among those with HRVA, unilateral HRVA was present in 68,0% (95% CI 58,4–77,0), whereas bilateral HRVA in 32,0% (95% CI 23,0–41,6). No difference in terms of laterality (right or left) was seen neither for HRVA nor narrow C2P. Significant differences were found between females and males for all measurements. Each parameter showed either good or excellent inter- or intraobserver, and inter-software agreement coefficients. HRVA and narrow C2P are common findings in Central-European population and should be appreciated at the planning stage before craniocervical instrumentation. Measurements can be consistently reproduced by various observers at varying intervals using different software.
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