1
|
Goyal K, Sunny JT, Gillespie CS, Wilby M, Clark SR, Kaiser R, Fehlings MG, Srikandarajah N. A Systematic Review and Meta-Analysis of Vertebral Artery Injury After Cervical Spine Trauma. Global Spine J 2024; 14:1356-1368. [PMID: 37924280 DOI: 10.1177/21925682231209631] [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] [Indexed: 11/06/2023] Open
Abstract
STUDY DESIGN Systematic Review and Meta-Analysis. OBJECTIVE Identify the incidence, mechanism of injury, investigations, management, and outcomes of Vertebral Artery Injury (VAI) after cervical spine trauma. METHODS A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines (PROSPERO-ID CRD42021295265). Three databases were searched (PubMed, SCOPUS, Google Scholar, CINAHL PLUS). Incidence of VAI, investigations to diagnose (Computed Tomography Angiography, Digital Subtraction Angiography, Magnetic Resonance Angiography), stroke incidence, and management paradigms (conservative, antiplatelets, anticoagulants, surgical, endovascular treatment) were delineated. Incidence was calculated using pooled proportions random effects meta-analysis. RESULTS A total of 44 studies were included (1777 patients). 20-studies (n = 503) included data on trauma type; 75.5% (n = 380) suffered blunt trauma and 24.5% (n = 123) penetrating. The overall incidence of VAI was .95% (95% CI 0.65-1.29). From the 16 studies which reported data on outcomes, 8.87% (95% CI 5.34- 12.99) of patients with VAI had a posterior stroke. Of the 33 studies with investigation data, 91.7% (2929/3629) underwent diagnostic CTA; 7.5% (242/3629) underwent MRA and 3.0% (98/3629) underwent DSA. Management data from 20 papers (n = 475) showed 17.9% (n = 85) undergoing conservative therapy, anticoagulation in 14.1% (n = 67), antiplatelets in 16.4% (n = 78), combined therapy in 25.5% (n = 121) and the rest (n = 124) managed using surgical and endovascular treatments. CONCLUSION VAI in cervical spine trauma has an approximate posterior circulation stroke risk of 9%. Optimal management paradigms for the prevention and management of VAI are yet to be standardized and require further research.
Collapse
Affiliation(s)
- Kartik Goyal
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Northern General Hospital, Sheffield Teaching Hospital Trusts, Sheffield, UK
| | - Jesvin T Sunny
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Cambridge University Hospital NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Conor S Gillespie
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Martin Wilby
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Simon R Clark
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Nisaharan Srikandarajah
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
- Institute of Systems, Molecular and Integrative Biology, Liverpool, UK
| |
Collapse
|
2
|
Bilateral persistent intersegmental artery in a patient with posterior atlantoaxial subluxation after subaxial cervical laminoplasty. Int J Surg Case Rep 2022; 102:107796. [PMID: 36481588 PMCID: PMC9731870 DOI: 10.1016/j.ijscr.2022.107796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE To summarize the clinical manifestations and treatment of bilateral persistent first intersegmental artery (PFIA) in a patient with posterior subluxation of atlantoaxial joint. CASE PRESENTATION A-85-year-old woman with a two-months history of aggravating of gait disturbance and finger clumsiness was referred to our hospital. Magnetic resonance imaging revealed posterior subluxation of the atlantoaxial joint and spinal cord compression at C1 level. Three-dimensional computed tomography angiography (CTA) of cervical spine showed bilateral PFIA and left side high-riding VA. Because of the high risk of vertebral artery injury with posterior arch resection and lateral mass screw insertion due to the presence of PFIA, as well as the bony fragility of the cervical spine and the fact that the posterior atlantoaxial subluxation was reduced in the flexed position, the posterior occipito-thoracic fixation without posterior arch resection in the mildly flexed cervical position was underwent. The postoperative course was uneventful and her neurological symptoms improved gradually after surgery. CLINICAL DISCUSSION PFIA is a very rare condition representing between 0.01 % and 1.8 %. Most patients with this condition have a unilateral persistent segmental artery, but in a small minority of cases it occurs bilaterally. It may be more difficult to resect of posterior arch or insert the C1 lateral mass screw in cases of PFIA. CONCLUSION The best way to avoid IVAI may be careful examining the abnormal running of VA preoperatively especially on 3D-CT of cervical spine with arteriography and not to choose a technique with a high risk of VA injury.
Collapse
|
3
|
Balik V, Takizawa K. Safe and bloodless exposure of the third segment of the vertebral artery: a step-by-step overview based on over 50 personal cases. Neurosurg Rev 2019; 42:991-997. [PMID: 31410682 DOI: 10.1007/s10143-019-01158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/23/2019] [Accepted: 08/05/2019] [Indexed: 11/29/2022]
Abstract
Craniovertebral junction surgery usually requires the exposure of the third segment of the vertebral artery (V3). However, the complexity of musculature, a relatively high incidence of anomalies in the course of the vertebral artery (VA), and the presence of a rich venous plexus in this region make the V3 exposure challenging with a high risk of serious complications while taking down the suboccipital muscles in a single layer. A muscle dissection in interfascial layers, however, overcomes the drawbacks inherent in a blind dissection of the V3 as each of the muscles represents substantial landmark aiding subsequent step of the procedure and thus helping identify underlying anatomical structure early and safely. Moreover, along with a bloodless VA dissection off its surrounding venous plexus, it permits a safe and comfortable V3 exposure during the surgically demanding procedures.
Collapse
Affiliation(s)
- Vladimir Balik
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, 1-1-1-1, Akebono, Asahikawa, Hokkaido, 070-8530, Japan. .,Institute of Molecular and Translational Medicine, Faculty of Medicine and Dentistry, Palacky University and Faculty Hospital Olomouc, Hněvotínská 1333/5, 779 00, Olomouc, Czech Republic.
| | - Katsumi Takizawa
- Department of Neurosurgery, Japanese Red Cross Asahikawa Hospital, 1-1-1-1, Akebono, Asahikawa, Hokkaido, 070-8530, Japan
| |
Collapse
|
4
|
Prehospital care of spinal injuries: a historical quest for reasoning and evidence. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:2999-3006. [PMID: 30220041 DOI: 10.1007/s00586-018-5762-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 09/08/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE The practice of prehospital immobilization is coming under increasing scrutiny. Unravelling the historical sequence of prehospital immobilization might shed more light on this matter and help resolve the situation. Main purpose of this review is to provide an overview of the development and reasoning behind the implementation of prehospital spine immobilization. METHODS An extensive search throughout historical literature and recent evidence based studies was conducted. RESULTS The history of treating spinal injuries dates back to prehistoric times. Descriptions of prehospital spinal immobilization are more recent and span two distinct periods. First documentation of its use comes from the early 19th century, when prehospital trauma care was introduced on the battlefields of the Napoleonic wars. The advent of radiology gradually helped to clarify the underlying pathology. In recent decades, adoption of advanced trauma life support has elevated in-hospital trauma-care to an high standard. Practice of in-hospital spine immobilization in case of suspected injury has also been implemented as standard-care in prehospital setting. Evidence for and against prehospital immobilization is equally divided in recent evidence-based studies. In addition, recent studies have shown negative side-effects of immobilisation in penetrating injuries. CONCLUSION Although widely implementation of spinal immobilization to prevent spinal cord injury in both penetrating and blunt injury, it cannot be explained historically. Furthermore, there is no high-level scientific evidence to support or reject immobilisation in blunt injury. Since evidence in favour and against prehospital immobilization is equally divided, the present situation appears to have reached something of a deadlock. These slides can be retrieved under Electronic Supplementary Material.
Collapse
|
5
|
3D Printing Applications in Minimally Invasive Spine Surgery. Minim Invasive Surg 2018; 2018:4760769. [PMID: 29805806 PMCID: PMC5899854 DOI: 10.1155/2018/4760769] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/26/2018] [Indexed: 11/18/2022] Open
Abstract
3D printing (3DP) technology continues to gain popularity among medical specialties as a useful tool to improve patient care. The field of spine surgery is one discipline that has utilized this; however, information regarding the use of 3DP in minimally invasive spine surgery (MISS) is limited. 3D printing is currently being utilized in spine surgery to create biomodels, hardware templates and guides, and implants. Minimally invasive spine surgeons have begun to adopt 3DP technology, specifically with the use of biomodeling to optimize preoperative planning. Factors limiting widespread adoption of 3DP include increased time, cost, and the limited range of diagnoses in which 3DP has thus far been utilized. 3DP technology has become a valuable tool utilized by spine surgeons, and there are limitless directions in which this technology can be applied to minimally invasive spine surgery.
Collapse
|
6
|
Zibis A, Mitrousias V, Galanakis N, Chalampalaki N, Arvanitis D, Karantanas A. Variations of transverse foramina in cervical vertebrae: what happens to the vertebral artery? EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 27:1278-1285. [PMID: 29455293 DOI: 10.1007/s00586-018-5523-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study is to examine variations of the foramen transversarium and the vertebral artery in computed tomography angiographies (CTa) of the cervical spine, investigate their coexistence, and present possible considerations regarding such variations in spine surgical procedures. METHODS Fifty CTa of the neck were retrospectively reviewed. Transverse and anteroposterior diameter of the foramen and diameter of the vertebral artery were measured. Variations of the foramen and the vertebral artery were detected. RESULTS Cervical CTa of 32 males and 18 females (mean age 66.4 ± 10.78 years), all belonging to the Indo-European race, were reviewed. Variations of the foramen transversarium were found in 17 vertebrae (4.85%) of 15 patients (30%). Duplication of the foramen was the most frequent variation, followed by the open foramen, the absence of the foramen, the triple foramen, and the hypoplastic foramen. Variations of the vertebral artery were found in 7 patients (14%) and asymmetry was found in 12 (24%) patients. Moreover, six patients presented with hypoplastic vertebral arteries (12%). When examining coexistence, 60% of patients exhibiting variations in the transverse foramen were also exhibiting variations or asymmetry in the vertebral artery, compared to 25.7% of patients with no foramen variations (p = 0.02). CONCLUSIONS Vertebral artery injury is not common but may be a disastrous complication during cervical spine surgery. Proper preoperative planning is essential for any surgeon and exact knowledge of the anatomy in each patient is essential. This study strongly recommends the preoperative use of a CTa when suspicion of a variation is present and implied by a foramen variation. These slides can be retrieved under Electronic Supplementary Material.
Collapse
Affiliation(s)
- Aristeidis Zibis
- Department of Anatomy, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Vasileios Mitrousias
- Department of Anatomy, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Nikolaos Galanakis
- Department of Medical Imaging, University Hospital, 71003, Heraklion, Crete, Greece
| | | | - Dimitrios Arvanitis
- Department of Anatomy, School of Health Sciences, University of Thessaly, 41110, Larissa, Greece
| | - Apostolos Karantanas
- Department of Medical Imaging, University Hospital, 71003, Heraklion, Crete, Greece. .,Department of Radiology, Medical School-University of Crete, 71003, Heraklion, Crete, Greece.
| |
Collapse
|
7
|
Diao Y, Sun Y, Wang S, Zhang F, Pan S, Liu Z. Delayed epidural pseudoaneurysm following cervical laminectomy and instrumentation in a patient with canal stenosis secondary to skeletal fluorosis: A case report. Medicine (Baltimore) 2018; 97:e9883. [PMID: 29465576 PMCID: PMC5842004 DOI: 10.1097/md.0000000000009883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE The typical intraoperative presentation of vertebral artery injury (VAI) usually involves profuse bleeding and requires immediate treatment. However, an occult VAI may occur intraoperatively and result in delayed life-threatening epidural pseudoaneurysm several days postoperatively. PATIENT CONCERNS A 21-year-old man with compressive cervical myelopathy resulting from canal stenosis of skeletal fluorosis underwent decompression of C1 to C7 and instrumentation from C2 to C7. No impressive bleeding event occurred during the operation. On postoperative day 40, progressive quadriplegia developed. DIAGNOSES Pseudoaneurysm of the VA was established by angiography. INTERVENTIONS After occlusion of the right VA, the patient underwent hematoma clearing. OUTCOMES Fortunately, the patient experienced significant recovery of neurologic function after the second surgery. LESSONS From this case, we realize even in the absence of obvious signs of VAI during a cervical operation, postoperative evaluation should be mandatory for suspected bleeding events occurring at VAI-prone sites during surgery. Moreover, the bone morphological abnormality of skeletal fluorosis was determined to be the most important risk contributing to VAI in this case. The safety limits of bone removal should be determined preoperatively to avoid the effects of bone morphological abnormalities.
Collapse
|
8
|
Theodore N. In Reply: Occipitocervical fixation: A single surgeon's experience with 120 patients. Neurosurgery 2017; 80:E265. [PMID: 28402569 DOI: 10.1093/neuros/nyx037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
9
|
Martinez-del-Campo E, Turner JD, Kalb S, Rangel-Castilla L, Perez-Orribo L, Soriano-Baron H, Theodore N. Occipitocervical Fixation. Neurosurgery 2016; 79:549-60. [DOI: 10.1227/neu.0000000000001340] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Occipitocervical junction instability can lead to serious neurological injury or death. Open surgical fixation is often necessary to provide definitive stabilization. However, long-term results are limited to small case series.
OBJECTIVE
To review the causes of occipitocervical instability, discuss the indications for surgical intervention, and evaluate long-term surgical outcomes after occipitocervical fixation.
METHODS
The charts of all patients undergoing posterior surgical fixation of the occipitocervical junction by the senior author were retrospectively reviewed. A total of 120 consecutive patients were identified for analysis. Patient demographic characteristics, occipitocervical junction pathology, surgical indications, and clinical and radiographic outcomes are reported.
RESULTS
The study population consisted of 64 male and 56 female patients with a mean age of 39.9 years (range, 7 months to 88 years). Trauma was the most common cause of instability, occurring in 56 patients (47%). Ninety patients (75%) were treated with screw/rod constructs; wiring was used in 30 patients (25%). The median number of fixated segments was 5 (O-C4). Structural bone grafts were implanted in all patients (100%). Preoperative neurological deficits were present in 83 patients (69%); 91% of those patients improved with surgery. Mean follow-up was 35.1 ± 27.4 months (range, 0-123 months). Two patients died, and 10 were lost to follow-up before the end of the 6-month follow-up period. Fusion was confirmed in 107 patients (89.1%). The overall complication rate was 10%, including 3 patients with vertebral artery injuries and 2 patients who required revision surgery.
CONCLUSION
Occipitocervical fixation is a durable treatment option with acceptable morbidity for patients with occipitocervical instability.
Collapse
Affiliation(s)
- Eduardo Martinez-del-Campo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Jay D. Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Samuel Kalb
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Luis Perez-Orribo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hector Soriano-Baron
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas Theodore
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| |
Collapse
|