Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report

Compressive lesions of the head and neck: Common and uncommon must-know entities

There are many lesions that cause compression of nerves and vessels in the head and neck, and they can often be overlooked in the absence of adequate history or if not suspected by the radiologist. Many of these lesions require a high index of suspicion and optimal positioning for imaging. While a multimodality approach is critical in the evaluation of compressive lesions, an MRI utilizing high-resolution (heavily weighted) T2-weighted sequence is extremely useful as a starting point. In this review, we aim to discuss the radiological features of the common and uncommon compressive lesions of the head and neck which are broadly categorized into vascular, osseous, and miscellaneous etiologies.

Neural Basis of Etiopathogenesis and Treatment of Cervicogenic Orofacial Pain

(1) Background and Objectives: The aim of this narrative review was to analyze the neuroanatomical and neurophysiological basis of cervicogenic pain in cervico-cranial pain syndromes, focusing particularly on cervico-orofacial syndromes as a background for the proper diagnosis and non-surgical treatment. Relevant literature on the topic from past 120 years has been surveyed. (2) Material and Methods: We surveyed all original papers, reviews, or short communications published in the English, Spanish, Czech or Slovak languages from 1900 to 2020 in major journals. (3) Results: The cervicogenic headache originates from the spinal trigeminal nucleus where axons from the C₁–C₃ cervical spinal nerves and three branches of the trigeminal nerve converge (trigeminocervical convergence) at the interneurons that mediate cranio-cervical nociceptive interactions. The role of the temporomandibular joint in the broad clinical picture is also important. Despite abundant available experimental and clinical data, cervicogenic orofacial pain may be challenging to diagnose and treat. Crucial non-surgical therapeutic approach is the orthopedic manual therapy focused on correction of body posture, proper alignment of cervical vertebra and restoration of normal function of temporomandibular joint and occlusion. In addition, two novel concepts for the functional synthesis of cervico-cranial interactions are the tricentric concept of mouth sensorimotor control and the concept of a cervicogenic origin of bruxism. (4) Conclusions: Understanding the basis of neuroanatomical and neurophysiological neuromuscular relations enables an effective therapeutic approach based principally on orthopedic manual and dental occlusal treatment.

Cranial Neuralgias in Children and Adolescents A review of the literature

Cranial neuralgias are a well-established cause of headache-related morbidity in the adult population. These disorders are poorly studied in general due to their relative rarity, particularly in children and adolescents, and they are likely underdiagnosed in these populations. Recognizing these disorders and differentiating them from more common headache disorders, such as migraine, is important, as secondary disease is common. This review will cover the basic epidemiology, diagnosis, and treatment of trigeminal, occipital, glossopharyngeal and other, less common, cranial neuralgias. We have reviewed pediatric case reports of these conditions. For trigeminal neuralgia, the most common of these disorders, we have compiled the clinical features and treatment response of previous reports.

Posterolateral epidural supra-C2-root approach (PESCA) for biopsy of lesions of the odontoid process in same sitting after occipitocervical fixation and decompression-perioperative management and how to avoid vertebral artery injury

This study aims to describe the posterolateral epidural supra-C2-root approach (PESCA), which might be a good alternative to the transoral, anterolateral, and other posterolateral approaches for biopsy of lesions of the odontoid process (OP). The preoperative planning of PESCA included computerized tomography (CT), CT-angiography, and three-dimensional reconstruction (if possible, even with three-dimensional print) to analyze the angle of the trajectory and the anatomy of the vertebral artery (VA). For PESCA, the patient is positioned under general anesthesia in prone position. In case of an osteolytic lesion with fracture of the OP, an X-ray is performed after positioning to verify anatomic alignment. In the first step, in case of instability and compression of the spinal cord, a craniocervical fusion and decompression is performed (laminectomy of the middle part of the C1 arc and removal of the lower part of the lateral C1 arc). The trajectory is immediately above the C2 root (and under the upper rest of the lateral part of C1 arc). Even if the trajectory is narrowed, it is possible to perform PESCA without relevant traction of the spinal cord. The vertical segment of V3 of the VA at the level of C2 is protected by the vertebral foramen, and the horizontal part of V3 is protected by the remnant upper lateral part of the C1 arc (in case of normal variants). PESCA might be a good choice for biopsy of selected lesions of the OP in same sitting procedure after craniocervical stabilization and decompression.

Cervical myelopathy due to neurovascular compression syndrome caused by persistent first intersegmental artery: a case report

BACKGROUND

Persistent first intersegmental artery (PFIA) is a rare anatomical variation of vertebral arteries and is an asymptomatic finding in most cases. Here we report a rare case of cervical myelopathy caused by spinal cord compression by the PFIA.

CASE PRESENTATION

The patient was a 52-year-old man who complained of numbness and burning sensation around the neck and left shoulder area, partial weakness in the left deltoid muscle, right side thermal hypoalgesia, and disturbance of deep sensation since the past 1 year, and the symptoms had gradually worsened. Magnetic resonance imaging (MRI) and computed tomography (CT) showed spinal cord compression by the left PFIA at the C1/C2 level. Because conservative treatment was ineffective, microvascular decompression (MVD) of the PFIA was performed. The left PFIA was laterally transposed using polytetrafluoroethylene (PTFE) bands and anchored to the dura mater using three PTFE bands. To achieve adequate transposition, the small blood vessels bridging the spinal cord and PFIA and the dorsal root nerve had to be sacrificed. Postoperative T2-weighted MRI showed a small hyperintense region in the lateral funiculus of the spinal cord, but no new neurological deficits were identified. In the early postoperative stage, the patient's deep sensory impairment and motor dysfunction were improved. His numbness and burning sensation almost disappeared, but slight thermal hypoalgesia remained in the lower limb.

CONCLUSION

MVD is an effective treatment for spinal cord compression caused by the PFIA, but further studies are necessary to help address technical difficulties and avoid complications.

Cervical Radiculopathy Caused by a Vertebral Artery Loop: Is a Focused Fluoroscopic-Guided Cervical Epidural Steroid Injection a Possible Treatment Modality?

We describe a case of a patient suffering with cervical radiculopathy due to vertebral artery loop with nerve root compression, treated with an epidural steroid injection. A 37-year-old man presented with a 2-year history of right-sided radicular pain along the C7 dermatome. Imaging showed a right-sided loop of the vertebral artery at the V1-V2 transition with contact on the C7 nerve root. The pain was resistant to conservative treatment, and the decision was made to perform a focused fluoroscopy-guided translaminar epidural steroid injection near the C7 nerve root. The procedure was uneventful, and the symptoms resolved completely after the procedure. Targeted epidural steroid injection might be a useful and safe diagnostic and therapeutic approach in patients affected by cervical radiculopathy due to a VA loop. To our knowledge, this is the first case of a VA loop associated with cervical radiculopathy treated with this technique.

Occipital neuralgia: A neurosurgical perspective

Occipital neuralgia typically arises in the setting of nerve compression by fibrosis, surrounding anatomic structures, or osseous pathology, such as bone spurs or hypertrophic atlanto-epistropic ligament. It generally presents as paroxysmal bouts of sharp pain in the sensory distribution of the first three occipital nerves. Due to the long course of the greater occipital nerve (GON), and its peculiar anatomy, and location in a mobile region of the neck, it is unsurprising that the GON is at high risk for compression. Little is known how to diagnose or treat this neuropathic pain syndrome. The objective of this paper is to isolate the etiology involved, and treat this condition promptly. After all nonoperative efforts are exhausted, surgical transection of the nerve is the treatment of choice in these cases. An isolated C2 neurectomy or ganglionectomy is performed for an optimal pain relief. C1-2 instrumented fusion can be considered if, extensive facet arthropathy with instability is identified. Authors review the spectrum of treatment options for this debilitating condition, and discuss the case example of a patient who required conversion to a C1-C2 instrumented fusion following C2 ganglionectomy due to an underlying extensive degenerative disease and intraoperative findings suggestive of atlantoaxial instability.

Anterolateral Approach for a Cervical Nerve Root Compression Syndrome Due to an Ectatic Vertebral Artery

BACKGROUND AND IMPORTANCE

Nerve root compression by an ectatic vertebral artery is a known but easily overlooked cause of cervical radiculopathy. Management options include nonoperative conservative therapies or surgical approaches designed to relieve the compression via anterior or posterior cervical approaches.

CLINICAL PRESENTATION

A 72-yr-old female presented with a 6-mo history of sharp, shooting pain in her right arm and shoulder and deltoid weakness. Imaging demonstrated a vertebral artery loop compressing the proximal right C5 nerve root. She previously underwent both nonoperative measures as well as posterior foraminotomy at this level with limited improvement in her pain. Therefore, we performed an anterolateral approach for vascular decompression of the C5 nerve root from the vertebral artery loop. Patient has been pain-free at 1 yr with full recovery of her deltoid weakness.

CONCLUSION

Vertebral artery loop formation is an uncommon cause of cervical radiculopathy, which can be readily treated by vascular decompression of the nerve root-vertebral artery loop complex. Although anomalous vertebral artery compression of a cervical nerve root is rare, it is increasingly being recognized as a readily treatable entity that can lead to lasting and full neurological recovery. We also include an operative video to illustrate the vascular decompression of an ectatic vertebral artery causing severe cervical radiculopathy.

A New Sling Technique in Cervical Radiculopathy Caused by Vertebral Artery Loop Compression

BACKGROUND

A 52-year-old woman had a 20-month history of progressive radiating pain in the left arm and numbness on C7 dermatome.

CASE DESCRIPTION

On physical examination, left head rotation aggravated the radiculopathic pain. For an anatomic diagnosis of the vertebral artery and nerve root, magnetic resonance angiography was performed (computed tomography angiography was not possible because of her dye allergy history). Magnetic resonance angiography showed a left vertebral artery loop entering at the C6-7 intervertebral foramen. Surgical microvascular decompression was performed by an anterior cervical approach and the loop of the artery was fixed using a sling technique. Postoperative computed tomography angiography showed that the left vertebral artery was retracted anteriorly and the C7 nerve root was decompressed in the intervertebral foramen at the left C6-7 level.

CONCLUSIONS

The patient's radiculopathic symptoms were improved and especially the aggravated pain by left head rotation subsided dramatically.

The diagnosis and management of a vertebral artery loop causing cervical radiculopathy

BACKGROUND

Cervical radiculopathies are rarely caused by vertebral artery loop formation, which is estimated to be present in less than 3% of patients. It is uncertain what causes the loop formation: some propose an association with spondylotic changes or trauma, whilst others suggest hypertension and atherosclerosis may be responsible. CASE REPORT 1: A 35-year-old male patient presented with signs and symptoms of cervical radiculopathy that was not improved with anterior cervical discectomy and fusion surgery performed 2 years beforehand. Vertebral artery loop was discovered at the level C5/6 on the MRI. Vertebral artery transposition surgery via a lateral approach was performed at the level of the left C5/6 for symptoms of left C6 radiculopathy. Deroofing of the transverse process was performed with post-surgical complete improvement in weakness and pain. CASE REPORT 2: A 48-year-old female patient presented with a 10-year history of left shoulder pain with occasional radiation into her middle three fingers accompanied by intermittent paraesthesia and weakness. Numerous shoulder surgeries, Botox injections and suprascapular nerve blocks had not provided any significant benefit. A vertebral artery loop was identified at the level of C3/4 and C4/5 on the left with cervical MRI. Transposition surgery of these two levels provided some post-surgical improvement in pain.

CONCLUSION

Vertebral artery loop formations are a rare but potential cause for cervical radiculopathy. In two cases, the loop formations were not radiographically reported on MRI, thus clinicians should be aware of this as a differential diagnosis in the management of cervical radiculopathy. The presented surgical approach may be useful in managing future cases of vertebral artery loop formation causing cervical radiculopathy resistant to conservative measures.

Double crush syndrome caused by cervical spondylosis and vertebral artery loop

PURPOSE

The purpose of this article is to report a successful treatment experience in a rare case of simultaneous cervical nerve root compression by spondylotic cervical foraminal stenosis and a vertebral artery loop.

METHODS

51-year-old man presented with a 4-year history of left-sided cervical pain radiating to the left shoulder with progressive exacerbation of weakness on left shoulder girdle muscles for 7 months. The patient had no history of trauma. The patient's CT and MRI revealed impingement of the left C6 cervical nerve root by a tortuous vertebral artery loop and also by narrowed left C5-6 cervical foramen that had undergone spondylotic changes. The patient underwent left C5-6 hemilaminectomy, facetectomy and C5-6 fusion. The procedures were uneventful, and the patient recovered with complete resolution of symptoms.

RESULTS

The patient continued to be asymptomatic at a 2-year follow-up examination, and the muscle mass of his left girdle returned normal.

CONCLUSIONS

This report illustrates the first phenomenon of a double crush syndrome caused by vertebral artery loop and cervical spondylotic changes. When patients with cervical spondylosis present with unexplainably severe pain and weakness, additional underlying pathologies should be considered when making differential diagnoses. The investigation planning should involve electromyography, computed tomography angiography, and magnetic resonance imaging.

Hemifacial Pain and Hemisensory Disturbance Referred from Occipital Neuralgia Caused by Pathological Vascular Contact of the Greater Occipital Nerve

Here we report a unique case of chronic occipital neuralgia caused by pathological vascular contact of the left greater occipital nerve. After 12 months of left-sided, unremitting occipital neuralgia, a hypesthesia and facial pain developed in the left hemiface. The decompression of the left greater occipital nerve from pathological contacts with the occipital artery resulted in immediate relief for hemifacial sensory change and facial pain, as well as chronic occipital neuralgia. Although referral of pain from the stimulation of occipital and cervical structures innervated by upper cervical nerves to the frontal head of V1 trigeminal distribution has been reported, the development of hemifacial sensory change associated with referred trigeminal pain from chronic occipital neuralgia is extremely rare. Chronic continuous and strong afferent input of occipital neuralgia caused by pathological vascular contact with the greater occipital nerve seemed to be associated with sensitization and hypersensitivity of the second-order neurons in the trigeminocervical complex, a population of neurons in the C2 dorsal horn characterized by receiving convergent input from dural and cervical structures.

Anterior Transposition of Anomalous Tortuous Vertebral Artery Causing Cervical Radiculopathy: A Report of 2 Cases and Review of Literature

OBJECTIVE

Cervical radiculopathy secondary to compression from vertebral artery (VA) tortuosity is a rare entity. We describe successful transposition through an anterolateral approach of tortuous VA loops causing cervical radiculopathy.

METHODS

Two patients with cervical radiculopathy (first case at C5-6 and second case at C3-4) secondary to anomalous VA loop compression underwent anterolateral approaches to the cervical spine for decompression and VA transposition. The anterior transverse foramina were drilled to unroof the VA loop, which was dissected free from the exiting nerve root.

RESULTS

In both cases, the affected cervical nerve root was successfully decompressed with both radiographic and clinical improvements in radiculopathy symptoms. We found 8 other cases of VA transposition via either an anterolateral approach or a posterolateral approach described in the literature. Our second case of anterolateral VA transposition at the C3-4 level is the first case at this level and the highest level reported in the literature.

CONCLUSIONS

Decompression using an anterolateral approach with direct microvascular transposition of the VA is a safe and effective treatment of this pathology and addresses the cause of radiculopathy more directly than the posterolateral approach.

Other facial neuralgias

Premise In this article we review some lesser known cranial neuralgias that are distinct from trigeminal neuralgia, trigeminal autonomic cephalalgias, or trigeminal neuropathies. Included are occipital neuralgia, superior laryngeal neuralgia, auriculotemporal neuralgia, glossopharyngeal and nervus intermedius neuralgia, and pain from acute herpes zoster and postherpetic neuralgia of the trigeminal and intermedius nerves. Problem Facial neuralgias are rare and many physicians do not see such cases in their lifetime, so patients with a suspected diagnosis within this group should be referred to a specialized center where multidisciplinary team diagnosis may be available. Potential solution Each facial neuralgia can be identified on the basis of clinical presentation, allowing for precision diagnosis and planning of treatment. Treatment remains conservative with oral or topical medication recommended for neuropathic pain to be tried before more invasive procedures are undertaken. However, evidence for efficacy of current treatments remains weak.

C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy

PURPOSE

C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF).

METHODS

Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24 months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated.

RESULTS

There were 1 male and 2 females. The age of patients were ranged from 50 to 79 years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1-C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1-C2 joint. After surgery, occipito-cervical pain disappeared.

CONCLUSION

This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.

Vertebral artery loops in surgical perspective

PURPOSE

Vertebral artery loop is a congenital or acquired anomaly. Vertebral artery loops are incidentally diagnosed during evaluation of neck problems and trauma. We aimed to present the incidence of VA loops using magnetic resonance angiography in consecutive patients and discuss epidemiological data including the gender, age, location, signs and symptoms, treatment approaches and outcomes of VA loops via analyzing literature.

METHODS

In the first leg of our two-legged study, consecutive patients were evaluated using magnetic resonance angiography to detect any medial loop of vertebral arteries. The study period was from October 2015 to March 2016. In the second leg, academic databases about medial loop of vertebral artery were screened. Case reports, case series, abstracts and references of relevant literature were searched manually to avoid any missing cases.

RESULTS

We evaluated 239 consecutive patients using magnetic resonance angiography. Twenty-one patients were excluded from the study due to inadequate image acquisition, aplastic vertebral artery and/or concomitant vertebral artery stenosis. Medial loop of V2 vertebral artery was observed in 13 patients (5.9 %): 9 with left, 2 with right and 2 with bilateral medial V2 loop. Patients with medial V2 loop were significantly older than patients with straight vertebral arteries (70.30 vs. 62.36, p = 0.028). In the literature analysis, VA loops were more commonly observed at V2 segment (90.5 %). Vertebral artery loops were mostly diagnosed at the 5th and 6th decades of life predominantly in females. The most common signs and symptoms were radiculopathy and/or neck pain, and signs and symptoms of vertebrobasilar insufficiency.

CONCLUSIONS

Concise pre-operative evaluation of the vertebral arteries is essential to avoid the injury of undiagnosed VA loops during surgery, which might result in catastrophic circumstances. Further evaluation of the vertebral arteries using MR angiography is required, especially in elder age, before cervical spine surgeries.

Neuralgias of the Head: Occipital Neuralgia

Occipital neuralgia is defined by the International Headache Society as paroxysmal shooting or stabbing pain in the dermatomes of the greater or lesser occipital nerve. Various treatment methods exist, from medical treatment to open surgical procedures. Local injection with corticosteroid can improve symptoms, though generally only temporarily. More invasive procedures can be considered for cases that do not respond adequately to medical therapies or repeated injections. Radiofrequency lesioning of the greater occipital nerve can relieve symptoms, but there is a tendency for the pain to recur during follow-up. There also remains a substantial group of intractable patients that do not benefit from local injections and conventional procedures. Moreover, treatment of occipital neuralgia is sometimes challenging. More invasive procedures, such as C2 gangliotomy, C2 ganglionectomy, C2 to C3 rhizotomy, C2 to C3 root decompression, neurectomy, and neurolysis with or without sectioning of the inferior oblique muscle, are now rarely performed for medically refractory patients. Recently, a few reports have described positive results following peripheral nerve stimulation of the greater or lesser occipital nerve. Although this procedure is less invasive, the significance of the results is hampered by the small sample size and the lack of long-term data. Clinicians should always remember that destructive procedures carry grave risks: once an anatomic structure is destroyed, it cannot be easily recovered, if at all, and with any destructive procedure there is always the risk of the development of painful neuroma or causalgia, conditions that may be even harder to control than the original complaint.

Occipital neuralgia secondary to unilateral atlantoaxial osteoarthritis: Case report and review of the literature

Background:

Atlantoaxial osteoarthritis (AAOA), either in isolation or in the context of generalized peripheral or spinal arthritis, presents most commonly with neck pain and limitation of cervical rotational range of motion. Occipital neuralgia (ON) is only rarely attributed to AAOA, as fewer than 30 cases are described in the literature.

Case Description:

A 64-year-old female presented with progressive incapacitating cervicalgia and occipital headaches, refractory to medications, and local anesthetic blocks. Computed tomography and magnetic resonance imaging studies documented advanced unilateral atlantoaxial arthrosis with osteophytic compression that dorsally displaced the associated C2 nerve root. Surgical decompression and atlantoaxial fusion achieved rapid and complete relief of neuralgia. Ultimately, postoperative spinal imaging revealed osseous union.

Conclusions:

Atlantoaxial arthrosis must be considered in the differential diagnosis of ON. Surgical treatment is effective for managing refractory cases. Intraoperative neuronavigation is also a useful adjunct to guide instrumentation and the intraoperative extent of bony decompression.

Aberrant posterior inferior cerebellar artery injury with C1 lateral mass screw placement: a case report and review of the literature

BACKGROUND CONTEXT

Complications associated with C1 lateral mass screw placement are relatively infrequent. The most commonly feared complications include neural or vascular injury. Although both vertebral artery and internal carotid artery injuries have been discussed in the literature, there have been no reports of posterior inferior cerebellar artery (PICA) injury from C1 lateral mass screw placement. We report a case of patient who had a cerebellar stroke after C1 lateral mass screw placement, secondary to injury of an aberrant PICA.

PURPOSE

To describe the normal anatomy of the PICA, the anatomic variations previously reported in the literature, the sequela and symptoms of a patient with PICA injury, and the relevance to C1 lateral mass screw placement. No previous reports of PICA injury with a cerebellar stroke have been reported with C1 lateral mass screw instrumentation.

STUDY DESIGN

Case report and literature review.

METHODS

The patient underwent an Occiput-C6 posterior instrumentation for a pathologic fracture, secondary to multiple myeloma. In the postoperative period, the patient was found to have dysarthria, imbalance, and dysdiadochokinesia. Urgent computed tomography confirmed well placed C1 lateral mass screws. Magnetic resonance imaging/Magnetic Resonance Angiography showed an infarct in the PICA distribution with an abnormal variant of the PICA coursing extracranially around C1. Neurologic monitoring did not detect the injury intraoperatively.

RESULTS

The patient was treated with anticoagulation and he made a reasonable recovery from his stroke.

CONCLUSIONS

We report the first case of an aberrant PICA injured during a C1 lateral mass screw placement, resulting in a cerebellar stroke. Consideration should be given to abnormal PICA variation when placing C1 lateral mass screws.

Microvascular decompression of a C-2 segmental-type vertebral artery producing trigeminal hypesthesia

The authors report a case of trigeminal hypesthesia caused by compression of the spinal cord by a C-2 segmental-type vertebral artery (VA) that was successfully treated with microvascular decompression. Aberrant intradural VA loops have been reported as causes of cervical myelopathy, some of which improved with microvascular decompression. A 52-year-old man presented with progressive complaints of headache, dizziness, left facial numbness, and left upper-extremity paresthesia that worsened when turning his head to the right. Magnetic resonance imaging of the cervical spine showed the left VA passing intradurally between the axis and atlas, foregoing the C-1 foramen transversarium, and impinging on the spinal cord. The patient underwent left C-1 and C-2 hemilaminectomies followed by microvascular decompression of an aberrant VA loop compressing the spinal cord. The patient subsequently reported complete resolution of symptoms.

[Scalp neuralgia and headache elicited by cranial superficial anatomical causes: supraorbital neuralgia, occipital neuralgia, and post-craniotomy headache]

Most scalp neuralgias are supraorbital or occipital. Although they have been considered idiopathic, recent studies revealed that some were attributable to mechanical irritation with the peripheral nerve of the scalp by superficial anatomical cranial structures. Supraorbital neuralgia involves entrapment of the supraorbital nerve by the facial muscle, and occipital neuralgia involves entrapment of occipital nerves, mainly the greater occipital nerve, by the semispinalis capitis muscle. Contact between the occipital artery and the greater occipital nerve in the scalp may also be causative. Decompression surgery to address these neuralgias has been reported. As headache after craniotomy is the result of iatrogenic injury to the peripheral nerve of the scalp, post-craniotomy headache should be considered as a differential diagnosis.

A novel sling technique for microvascular decompression of a rare anomalous vertebral artery causing cervical radiculopathy

Cervical radiculopathy secondary to compression from congenital anomalous vertebral arteries (VAs) is a known entity. Patients present with a variety of symptoms ranging from upper-extremity numbness to true occipital neuralgia. Treatment options for extracranial tortuous VAs include conservative management or some form of surgical microvascular decompression (MVD). The authors report on a patient with a congenital anomalous VA loop causing cervical nerve root compression. Successful MVD was conducted with relief of the patient's symptoms. A novel sling technique was used for mobilization of the VA. To the authors' knowledge, this is the first MVD described utilizing this technique.

Surgical management of cervical radiculopathy caused by redundant vertebral artery loop

In this article, the authors describe the case of a 27-year-old female presenting with a 2-year history of neck pain and radiculopathy attributable to compression of the right C-7 nerve root by tortuosity of the vertebral artery at the level of the C6-7 cervical foramina. An anterolateral approach to the transverse foramen was used to perform a vascular decompression to decompress the nerve root. The procedure was uneventful, and the patient woke up with almost all of her symptoms resolved. The authors also include a literature review of techniques performed in this setting, showing that multiple surgical approaches can be used and should be tailored to the patient symptoms and lesion characteristics.

Vertebral artery loop--a cause of cervical radiculopathy

OBJECTIVE

To report a case of cervical radiculopathy caused by an anomalous vertebral artery (VA) and illustrate the efficacy of microvascular decompression by the anterolateral approach.

METHODS

A 50-year-old woman was referred because of an 8-year history of progressive left C6 radiculopathy refractory to other forms of treatment, including C5-6 anterior cervical discectomy. Clinical and radiologic evaluation showed an abnormally tortuous loop of V2 causing direct neurovascular compression.

RESULTS

A left cervical anterolateral approach was used to expose the anomalous loop. After a generous bony decompression, the loop was identified, and the artery was mobilized and ultimately separated from the C6 nerve root removing the direct pulsatile compression.

CONCLUSIONS

Cervical root compression by an aberrant or anomalous extracranial VA is a rare cause of radiculopathy. The best management of such lesions is the anterolateral approach with bony and direct microvascular decompression.

Infiltrative cervical lesions causing symptomatic occipital neuralgia

Background: Occipital neuralgia is a well-recognized cause of posterior head and neck pain that may associate mild sensory changes in the cutaneous distribution of the occipital nerves, lacking a recognizable local structural aetiology in most cases. Atypical clinical features or an abnormal neurological examination are alerts for a potential underlying cause of pain, although cases of clinically typical occipital neuralgia as isolated manifestation of lesions of the cervical spinal cord, cervical roots, or occipital nerves have been increasingly reported.

Case reports: We describe two cases (one with typical and another one with atypical clinical features) of occipital neuralgia secondary to paravertebral pyomyositis and vertebral relapse of multiple myeloma in patients with relevant medical history that aroused the possibility of an underlying structural lesion.

Discussion: We discuss the need for cranio-cervical magnetic resonance imaging in all patients with occipital neuralgia, even when typical clinical features are present and neurological examination is completely normal.

Vertebral artery anomaly causing C2 suboccipital neuralgia, relieved by neurovascular decompression

We report imaging and surgical findings of a symptomatic 40-year-old male with an anomalous left vertebral artery. MR, CT myelography, angiography, and intraoperative photos demonstrate the vertebral artery entering the thecal sac at the C1-C2 intervertebral foramen and compressing the dorsal C2 nerve rootlets against the cord. Open microvascular decompression alleviated the patient's long-standing suboccipital and posterior cervical neck pain. An embryologic review of the vertebral and lateral spinal artery systems reveals possible developmental explanations for this variant. Intradural course of the vertebral artery at C2 is one of the few symptomatic developmental vertebral artery anomalies. Recognition of this condition is important because surgical intervention can alleviate associated neck pain.

Transarticular screw fixation of C1-2 for the treatment of arthropathy-associated occipital neuralgia

Two patients with occipital neuralgia due to severe arthropathy of the C1-2 facet joint were treated using atlantoaxial fusion with transarticular screws without decompression of the C-2 nerve root. Both patients experienced immediate postoperative relief of occipital neuralgia. The resultant motion elimination at C1-2 eradicated not only the movement-evoked pain, but also the paroxysms of true occipital neuralgia occurring at rest. A possible pathophysiological explanation for this improvement is presented in the context of the ignition theory of neuralgic pain. This represents the first report of C1-2 transarticular screw fixation for the treatment of arthropathy-associated occipital neuralgia.

Cervical radiculopathy caused by vertebral artery loop formation : a case report and review of the literature

Vertebral artery loop formation causing encroachment on cervical neural foramen and canal is a rare cause of cervical radiculopathy. We report a case of 61-year-old woman with vertebral artery loop formation who presented with right shoulder pain radiating to her arm for 2 years. Plain radiograph and computed tomography scan revealed widening of the right intervertebral foramen at the C5-6 level. Magnetic resonance imaging and angiogram confirmed the vertebral artery loop formation compressing the right C6 nerve root. We had considered microdecompressive surgery, but the patient's symptoms resolved after conservative management. Clinician should keep in mind that vertebral artery loop formation is one of important causes of cervical radiculopathy. Vertebral artery should be visualized using magnetic resonance angiography in suspected case.

Posterior atlantoaxial screw-rod fixation in a case of aberrant vertebral artery course combined with bilateral high-riding vertebral artery

We present a case of posterior atlantoaxial screw-rod fixation in a patient with an aberrant vertebral artery (VA) course combined with bilateral high-riding VA. An aberrant VA which courses below the posterior arch of the atlas (C1) that does not pass through the C1 transverse foramen and without an osseous anomaly is rare. However, it is important to consider an abnormal course of the VA both preoperatively and intraoperatively in order to avoid critical vascular injuries in procedures which require exposure or control of the VA, such as the far-lateral approach and spinal operations.

8. Occipital neuralgia

Occipital neuralgia is defined as a paroxysmal shooting or stabbing pain in the dermatomes of the nervus occipitalis major and/or nervus occipitalis minor. The pain originates in the suboccipital region and radiates over the vertex. A suggestive history and clinical examination with short-term pain relief after infiltration with local anesthetic confirm the diagnosis. No data are available about the prevalence or incidence of this condition. Most often, trauma or irritation of the nervi occipitales causes the neuralgia. Imaging studies are necessary to exclude underlying pathological conditions. Initial therapy consists of a single infiltration of the culprit nervi occipitales with local anesthetic and corticosteroids (2 C+). The reported effects of botulinum toxin A injections are contradictory (2 C+/-). Should injection of local anesthetic and corticosteroids fail to provide lasting relief, pulsed radio-frequency treatment of the nervi occipitales can be considered (2 C+). There is no evidence to support pulsed radio-frequency treatment of the ganglion spinale C2 (dorsal root ganglion). As such, this should only be done in a clinical trial setting. Subcutaneous occipital nerve stimulation can be considered if prior therapy with corticosteroid infiltration or pulsed radio-frequency treatment failed or provided only short-term relief (2 C+).

Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment

Cervicogenic headache is characterised by pain referred to the head from the cervical spine. Although the International Headache Society recognises this type of headache as a distinct disorder, some clinicians remain sceptical. Laboratory and clinical studies have shown that pain from upper cervical joints and muscles can be referred to the head. Clinical diagnostic criteria have not proved valid, but a cervical source of pain can be established by use of fluoroscopically guided, controlled, diagnostic nerve blocks. In this Review, we outline the basic science and clinical evidence for cervicogenic headache and indicate how opposing approaches to its definition and diagnosis affect the evidence for its clinical management. We provide recommendations that enable a pragmatic approach to the diagnosis and management of probable cervicogenic headache, as well as a rigorous approach to the diagnosis and management of definite cervical headache.

Vascular Compression as a Potential Cause of Occipital Neuralgia: A Case Report

Vascular compression is a well-established cause of cranial nerve neuralgic syndromes. A unique case is presented that demonstrates that vascular compression may be a possible cause of occipital neuralgia. A 48-year-old woman with refractory left occipital neuralgia revealed on magnetic resonance imaging and computed tomographic imaging of the upper cervical spine an atypically low loop of the left posterior inferior cerebellar artery (PICA), clearly indenting the dorsal upper cervical roots. During surgery, the PICA loop was interdigitated with the C1 and C2 dorsal roots. Microvascular decompression alone has never been described for occipital neuralgia, despite the strong clinical correlation in this case. Therefore, both sectioning the dorsal roots of C2 and microvascular decompression of the PICA loop were performed. Postoperatively, the patient experienced complete cure of her neuralgia. Vascular compression as a cause of refractory occipital neuralgia should be considered when assessing surgical options.

Can proximity of the occipital artery to the greater occipital nerve act as a cause of idiopathic greater occipital neuralgia? An anatomical and histological evaluation of the artery-nerve relationship

BACKGROUND

The purpose of this study was to clarify whether proximity of the occipital artery to the greater occipital nerve can act as a cause of occipital neuralgia, analogous to the contribution of intracranial vessels due to compression in cranial nerve neuralgias, represented by trigeminal neuralgias due to compression of the trigeminal nerve root by adjacent arterial loops.

METHODS

Twenty-four suboccipital areas in cadaver heads were studied for anatomical relationships between the occipital artery and the greater occipital nerve, with histopathological assessment of the greater occipital nerve for signs of mechanical damage.

RESULTS

The occipital artery and greater occipital nerve were found to cross each other in the nuchal subcutaneous layer, and the latter was constantly situated superficial to the former at the cross point. An indentation of the greater occipital nerve due to the occipital artery was observed at the cross point in all specimens. However, histopathological examination did not reveal any findings of damage to nerves, even in specimens with atherosclerosis of the occipital artery.

CONCLUSIONS

Although the present study did not provide direct evidence that the occipital artery contributes to occipital neuralgia at the point of contact with the greater occipital nerve, the possibility still cannot be precluded, because the occipital artery may be palpable in areas corresponding to tenderness of the greater occipital nerve. Further studies, including clinical cases, are needed to clarify this issue.

Congestion of epidural venous plexus secondary to vertebral artery occlusion mimicking a herniated cervical disc

Vascular abnormalities or dissection of the vertebral artery are rare causes for cervical monoradiculopathy. We present the case of a 44-year-old female patient with a short history of radiculopathy of the right C5 root with radicular pain and a severe motor deficit. CT-imaging showed a hyperdense structure at the C4/C5 level suggesting a herniated disc. Because of the neurological deficit the patient was operated by a dorsal approach. Intraoperatively no herniated disc but only a congested epidural venous plexus was found. Postoperative MRI and angiography showed occlusion of the vertebral artery from C3 to C6 level probably due to dissection. The present case shows that a CT-study suggestive for a herniated disc can be misleading. Enlargement of the vertebral artery secondary to dissection or occlusion may lead to compression of the venous plexus which resembles disc material on CT-scan.

Subarachnoid hemorrhage caused by posterior inferior cerebellar artery aneurysm with an anomalous course of the atlantoaxial segment of the vertebral artery

✓ Various anatomical courses of the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) have been described. The authors present a unique case of a subarachnoid hemorrhage resulting from an aneurysm in a patient with an anatomical variation of the extracranial portion of the VA and cervical origin of the PICA. The surgical implications of this variant are discussed, and the pertinent literature reviewed. Subarachnoid hemorrhage caused by rupture of a PICA aneurysm is reported for the first time in association with a rare variation of the course of the VA.

Biomechanical comparison of C1–2 posterior fixation techniques

Object. In a nondestructive, repeated-measures in vitro flexibility experiment, the authors compared the acute stability of C1–2 after placement of C-1 lateral mass and C-2 pars interarticularis (LC1—PC2) instrumentation with that of C1–2 transarticular screw fixation.

Methods. The effect of C-1 laminectomy and C1–2 interspinous cable/graft fixation on LC1—PC2 stability was studied. Screw pullout strengths were also compared. Seven human cadaveric occiput—C3 specimens were loaded nondestructively with pure moments while measuring nonconstrained atlantoaxial motion. Specimens were tested with graft alone, LC1—PC2 alone, LC1—PC2 combined with C-1 laminectomy, and graft-augmented LC1—PC2. Interspinous cable/graft fixation significantly enhanced LC1—PC2 stability during extension. After C-1 laminectomy, the LC1—PC2 construct allowed increased motion during flexion and extension. There was no significant difference in lax zone or range of motion between LC1—PC2 fixation and transarticular screw fixation, but graft-assisted transarticular screws yielded a significantly smaller stiff zone during extension. The difference in pullout resistance between C-1 lateral mass screws and C-2 pars interarticularis screws was insignificant. The LC1—PC2 region restricted motion to within the normal range during all loading modes. Atlantal laminectomy reduced LC1—PC2 stability during flexion and extension.

Conclusions. The instrumentation-augmented LC1—PC2 construct performed biomechanically similarly to the C1–2 transarticular screw fixation. The LC1—PC2 construct resisted flexion, lateral bending, and axial rotation well. The weakness of the LC1—PC2 fixation in resisting extension can be overcome by adding an interspinous graft to the construct.

Cervical Radiculopathy Caused by Vertebral Artery Loop Formation

Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The criterion standard for the detection of vertebral artery loop formation is digital subtraction angiography. Computed tomography (CT) and magnetic resonance imaging provide good accuracy in the evaluation of vertebral arteries. A case of vertebral artery loop formation is reported. The diagnosis was confirmed by 16-row multisection CT angiography findings of vertebral artery loop formation.

The neck and headaches

Referred pain from disorders of the cervical spine can be perceived as headache. The mechanism is convergence between trigeminal afferents and afferents of the upper three cervical nerves in the trigeminocervical nucleus. Cervicogenic headache cannot be diagnosed on clinical grounds alone. The definitive criterion is complete relief of pain after controlled diagnostic blocks of cervical structures or their nerve supply. The most rigorously studied example of cervicogenic headache is third occipital headache.

Cervical cord compression with myelopathy caused by bilateral persistence of the first intersegmental arteries: case report

OBJECTIVE AND IMPORTANCE

Cervical myelopathy induced by vascular compression is rare. We report a case caused by bilateral persistence of the first intersegmental arteries (a vertebral artery anomaly). Myelopathy was successfully treated with vascular decompression.

CLINICAL PRESENTATION

A 66-year-old woman presented with gradually worsening paroxysmal neck and arm pain. Magnetic resonance imaging and angiography demonstrated anomalous intradural courses of both vertebral arteries, compressing the dorsal aspect of the cervical spinal cord.

INTERVENTION

Microvascular decompression was performed with transposition of the arteries, followed by anchoring of the arteries to the dorsolateral dura mater with Gore-Tex bands (W.L. Gore & Associates, Inc., Flagstaff, AZ).

CONCLUSION

The pain disappeared promptly after surgery. Surgical decompression, with anchoring of an anomalous vertebral artery to the dura, can relieve pain and other symptoms resulting from vascular cord compression.

Vertebral artery loop formation: a frequent cause of cervicobrachial pain

STUDY DESIGN

Patients with cervicobrachial pain were examined in detail with special attention to vertebral artery loop formation.

OBJECTIVES

To determine the incidence, short-time natural course and response to a conservative approach to vertebral artery loop formation in a group of patients with cervicobrachial pain.

SUMMARY OF THE BACKGROUND DATA

Vertebral artery loop formation is reported to be a rare cause of cervicobrachial neuralgia, discovered incidentally during the search for its cause. It can be congenital or acquired, occurring equally in both sexes. Surgical decompression has been the preferred method in the majority of reported cases, with favorable results.

METHODS

One hundred seventy-three patients with cervicobrachial pain were examined in a period of 7 months using physical examination, radiography, and magnetic resonance imaging with or without angiography.

RESULTS

Thirteen patients with a mean age of 43.9 +/- 13.5 years were diagnosed with vertebral artery loop formation. The most common level was C6-C7. Four patients presented with loop formation at two levels. None of the patients had symptoms attributable to intervertebral disc pathology. The complaints were in accordance with the level of the vascular pathology. Complete relief or decrease in pain was observed in all patients with the conservative approach.

CONCLUSIONS

In patients with cervicobrachialgic symptoms and without established discopathy, during the examination of sagittal magnetic resonance images, vertebral artery loop formation should be kept in mind, and in suspected cases, the vertebral artery should be visualized using three-dimensional time of flight magnetic resonance angiography. Vertebral artery-nerve root relation should also be demonstrated using the multiplanar reformatting method from time of flight images. A conservative course of treatment has a favorable outcome.

Ganglionectomy of C-2 for the treatment of medically refractory occipital neuralgia

Occipital neuralgia is a result of neuropathic pain transmission in the distribution of the greater occipital nerve. Because it is well anatomically localized, occipital neuralgia has been the focus of various surgical treatments. Ablation, decompression, and modulation of the C-2 nerve have all been described as effective treatments. The C-2 dorsal root ganglionectomy provides effective treatment for this disorder with a low incidence of unpleasant side effects. In this review the authors summarize the current treatment of occipital neuralgia.