Vascular decompression of a vertebral artery loop producing cervical radiculopathy. Case report

Cervical Radiculopathy and Vertebrobasilar Insufficiency Secondary to Intraneural Foramen Vertebral Artery Loop: A Case Report

This case report describes a 40-year-old male who presented with chronic neck pain radiating to the left upper limb, associated with weakness and numbness. He also had symptoms of vertebrobasilar insufficiency. Imaging revealed an intraneural foramen vertebral artery (VA) loop compressing the C3 nerve root. Conservative management was ineffective, prompting surgical decompression via a left C2-C3 facetectomy and foraminotomy. The patient experienced immediate pain relief and gradual improvement in weakness, with complete resolution of symptoms at the six-month follow-up. This case highlights the potential for VA loops to cause radiculopathy and the successful use of surgical decompression for treatment.

Anterior artery release, distraction and fusion (ARDF) for radiculopathy caused by a vertebral artery loop

BACKGROUND

Anomalous vertebral artery (VA) with loop formation is a rare cause of cervical nerve root compression. Various techniques with anterior and posterior approaches have been described for surgical treatment once conservative treatments fail. We herein present a case treated with the new technique of anterior release, distraction and fusion (ARDF) and further provide an updated review of surgically managed VA loops in the subaxial spine.

CASE DESCRIPTION

A 76-year-old female complained of a 6-year history of pulsating, shooting pain in her right arm to the thumb. After obtaining repeated MRI, the VA loop compressing the right-sided C6-nerve root was detected. A neurovascular decompression through ARDF which led to an indirect loop straightening was performed. The patient immediately improved after surgery and remained pain-free 1 year postoperative.

CONCLUSION

Neural irritation due to VA loop formation is a rare cause of cervical radiculopathy. While various surgical strategies have been described, we believe that anterior and anterolateral approaches are the safest to yield neurovascular decompression. We described and documented ARDF (anterior VA release, intervertebral distraction and fusion) on a patient case.

LEVEL OF EVIDENCE

II (Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding).

Vertebral Artery Loops and Cervicobrachial Pain

Vertebral artery loop formation is an uncommon anatomical variation which may be asymptomatic or can cause cervicobrachial pain, radiculopathy, or even bone erosions and enlargement of neural foramina. As this entity is one of the uncommon causes of cervical radiculopathy, this report aims to create awareness among radiologists and clinicians, as vertebral artery loops may be seen incidentally in routine neuroimaging. magnetic resonance imaging (MRI) with magnetic resonance (MR) angiography or multislice computerized tomography (CT) angiography plays an important role in diagnosing as well as creating a roadmap for the surgery.

Vertebral artery loop formation as a cause of radiculopathy is an uncommon condition. An abnormal course of vessel can lead to vascular injury during surgery, hence preoperative evaluation with CT or MRI is essential.1 2 Anomalous looping of vertebral artery can cause neurovascular compression apart from bony erosion, widening of vertebral foramen, and even vertebrobasilar insufficiency. Clinical features of vertebral artery loop formation can be radiculopathy, compression over cervical cord leading to sensory and motor deficit, and vertigo when associated with vertebra–basilar insufficiency, which is known as vascular vertigo. It has also been postulated that loop formation of vertebral artery can also lead to posterior circulation infarcts. Left vertebral artery is more prone for loop formation than the right vertebral artery, probably due to increased caliber in greater proportion of individuals. Multilevel and bilateral tortuosity can occur in younger patients rarely where imaging plays an important role.

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.

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.

Shoulder pain due to cervical radiculopathy: an underestimated long-term complication of herpes zoster virus reactivation?

PURPOSE

To evaluate if herpes zoster virus (HZV) reactivation may be considered in the aetiology of cervical radiculopathy.

METHODS

The study group was composed of 110 patients (52 M-58F;mean age ± SD:46.5 ± 6.12; range:40-73) with a clinical diagnosis of cervical radiculopathy. Patients with signs of chronic damage on neurophysiological studies were submitted to an X-ray and to an MRI of the cervical spine in order to clarify the cause of the cervical radiculopathy and were investigated for a possible reactivation of HZV; HZV reactivation was considered as "recent" or "antique" if it occurs within or after 24 months from the onset of symptoms, respectively. Data were submitted to statistics.

RESULTS

Thirty-eight patients (34,5%,16 M-22F) had a history of HZV reactivation: four (2 M-2F) were "recent" and 34 (14 M-20F) were "antique". In 68 of 110 participants (61,8%,30 M-38F), pathological signs on X-ray and/or MRI of the cervical spine appeared; in the remaining 42 (38,2%,22 M-20F) X-ray and MRI resulted as negative. Among patients with HZV reactivation, seven (18,4%) had a "positive" X-ray-MRI while in 31 (81,6%) the instrumental exams were considered as negative. The prevalence of "antique" HZV reactivations was statistically greater in the group of patients with no pathological signs on X-ray/MRI of the cervical spine with respect to the group with a pathological instrumental exam (p < 0.01).

CONCLUSIONS

It may be useful to investigate the presence of a positive history of HZV reactivation and to consider it as a long-term complication of a cervical root inflammation especially in patients in which X-ray and MRI of the cervical spine did not show pathological findings.

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.

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.

Diagnosis and Treatment of C4 Radiculopathy

STUDY DESIGN

Clinical case series.

OBJECTIVE

This study sought to clarify symptoms, diagnostic criteria, and treatment of C4 radiculopathy, and the role of diagnostic C4 root block in this entity.

SUMMARY OF BACKGROUND DATA

Although well understood cervical dermatomal/myotomal syndromes have been described for symptoms originating from impingement on the C2, C3, C5, C6, C7, and C8 roots, less has been written about the syndrome(s) associated with the C4 root.

METHODS

The senior author reviewed surgical records and describes his personal experience with the diagnosis and treatment of C4 radiculopathy.

RESULTS

A total of 712 procedures for cervical radiculopathy without myelopathy were reviewed. Among that cohort, 13 procedures involved the C4 root only and five procedures involved two level procedures including the C4 root. Patients described pain as involving the axial cervical region, paraspinal muscles, trapezius muscle, and interscapular region. No patient described pain over the anterior chest wall or radiating distal to the shoulder, one described pain over the medial clavicle. All patients who were offered surgery had a positive response to a diagnostic C4 transforaminal single nerve root block. Thirteen patients underwent posterior foraminotomy (five at two levels) and five patients underwent an anterior discectomy and fusion at C3-4. Mean Oswestry Disability Index score significantly declined; preoperative score 24.3 (range 14-29), postoperative score 9.7 (range 2-18; P = 0.003) at ≥3 months. Mean Short Form-36v2 score significantly increased; preoperative score 34.2 (range 20-40.2), postoperative score 73.7 (range 40.5-88.3, P = 0.001) at ≥3 months.

CONCLUSION

C4 root symptoms overlap those of the C3 and C5 roots and are very similar to facet mediated pain. Asymptomatic C4 foraminal stenosis may be a common imaging finding, it can be difficult to diagnose C4 radiculopathy clinically. Diagnostic C4 root block can make an accurate diagnosis and lead to successful surgical outcomes.

LEVEL OF EVIDENCE

4.

Neuroradiology of Pediatric Hemolymphoproliferative Disease

Hemolymphoproliferative diseases (HLD) are among the most common causes of morbidity and mortality in children. In the past few years, the increased effectiveness of treatment modalities has significantly increased overall survival, but has also disclosed new aspects of the natural history of these disorders, among which central nervous system (CNS) involvement. CNS complications of HLD can basically be categorized into direct localization of primary disease, indirect effects of malignancy such as cerebrovascular or infectious complications, and iatrogenic side effects. Magnetic resonance imaging plays an important, often crucial role in the diagnosis of several of these disorders. Close interdisciplinary collaboration between hemato-oncologists and neuroradiologists is of paramount importance to provide affected children with an early diagnosis and proper treatment.

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.

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.

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.

The characteristic clinical symptoms of C-4 radiculopathy caused by ossification of the posterior longitudinal ligament

Cervical radiculopathy of the C2-4 spinal nerves is a rare condition and is poorly documented in terms of clinical symptoms, hindering its detection during initial patient screening based on imaging diagnostics. The authors describe in detail the clinical symptoms and successful surgical treatment of a patient diagnosed with isolated C-4 radiculopathy. This 41-year-old man suffered from sleep disturbance because of pain behind the right ear, along the right clavicle, and at the back of his neck on the right side. The Jackson and Spurling tests were positive, with pain radiating to the area behind the patient's ear. Unlike in cases of radiculopathy involving the C5-8 spinal nerves, no loss of upper-extremity motor function was seen. Magnetic resonance imaging showed foraminal stenosis at the C3-4 level on the right side, and multiplanar reconstruction CT revealed a beak-type ossification of the posterior longitudinal ligament in the foraminal region at the same level. In the absence of intracranial lesions or spinal cord compressive lesions, the positive Jackson and Spurling tests and the C3-4 foraminal stenosis were indicative of isolated C-4 radiculopathy. Microscopic foraminotomy was performed at the C3-4 vertebral level and the ossified lesion was resected. The patient's symptoms completely resolved immediately after surgery. To the authors' knowledge, this report is the first to describe the symptomatic features of isolated C-4 radiculopathy, in a case in which the diagnosis has been confirmed by both radiological findings and surgical outcome. Based on this case study, the authors conclude that the characteristic symptoms of C-4 radiculopathy are the presence of pain behind the ear and in the clavicular region in the absence of upper-limb involvement.

Usefulness of Intraoperative Monitoring during Microsurgical Decompression of Cervicomedullary Compression Caused by an Anomalous Vertebral Artery

We report a case of cervicomedullary compression by an anomalous vertebral artery treated using microsurgical decompression with intraoperative monitoring. A 68-year-old woman presented with posterior neck pain and gait disturbance. MRI revealed multiple abnormalities, including an anomalous vertebral artery that compressed the spinal cord at the cervicomedullary junction. Suboccipital craniectomy with C1 laminectomy was performed. The spinal cord was found to be compressed by the vertebral arteries, which were retracted dorsolaterally. At that time, the somatosensory evoked potential (SSEP) changed. After release of the vertebral artery, the SSEP signal normalized instantly. The vertebral artery was then lifted gently and anchored to the dura. There was no other procedural complication. The patient's symptoms improved. This case demonstrates that intraoperative monitoring may be useful for preventing procedural complications during spinal cord microsurgical decompression.

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.

Anomalous vertebral artery compression of the spinal cord at the cervicomedullary junction

Background:

Myelopathy from ectatic vertebral artery compression of the spinal cord at the cervicomedullary junction is a rare condition.

Case Description:

A 63-year-old female was originally diagnosed with occult hydrocephalus syndrome after presenting with symptoms of ataxia and urinary incontinence. Ventriculoperitoneal shunting induced an acute worsening of the patient′s symptoms as she immediately developed a sensory myelopathy. An MR scan demonstrated multiple congenital abnormalities including cervicomedullary stenosis with anomalous vertebral artery compression of the dorsal spinal cord at the cervicomedullary junction. The patient was taken to surgery for a suboccipital craniectomy, C1-2 laminectomy, vertebral artery decompression, duraplasty, and shunt ligation. Intraoperative findings confirmed preoperative radiography with ectactic vertebral arteries deforming the dorsal aspect of the spinal cord. There were no procedural complications and at a 6-month follow-up appointment, the patient had experienced a marked improvement in her preoperative signs and symptoms.

Conclusion:

Myelopathy from ectatic vertebral artery compression at the cervicomedullary junction is a rare disorder amenable to operative neurovascular decompression.

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.

Multiple symptomatic vertebral artery loops treated with posterior cervical fusion

Multiple symptomatic vertebral artery (VA) loops are rare and their management is challenging. A 55-year-old man presented with a 5-year history of frequent episodes of presyncope and mild left C5 radiculopathy that was exacerbated by flexion or extension of his neck. Examination revealed complex left VA loops at C2/3 and C4. The patient underwent posterior cervical fusion which resolved his presyncope and improved his radiculopathy. Posterior cervical fusion is an option for management of patients suffering from symptoms secondary to multiple VA loops.

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.

Vertebral artery loop causing cervical radiculopathy

We report on a 68-year-old woman with an abnormal loop of the extracranial VA enlarging the intervertebral foramen at C4-5 and compressing the C5 root causing radiculopathy. The diagnosis was confirmed on contrast enhanced CT and MR angiography after initial conservative treatment was unsuccessful. Microvascular decompression using an anterior approach was curative.

Clinical progression and familial occurrence of cerebral cavernous angiomas: the role of angiogenic and growth factors

OBJECT

The authors studied the expression of angiogenic and growth factors and various proliferative indices in cavernous angiomas of the brain. The goal was to define whether the often progressive clinical course of both sporadic and familial forms of the lesion is correlated with different expression of these factors.

METHODS

Forty-three cavernomas of the brain were investigated with immunohistochemical studies and stained for four growth factors (vascular endothelial growth factor [VEGF], tenascin, transforming growth factor-b [TGFb], and platelet-derived growth factor [PDGF]), and for Ki-67 and bcl-2. The intensity of expression was tested in all cases in the walls of cavernoma vessels, in the perivascular tissue, and in the perilesional brain parenchyma. Among the 43 cavernomas, 32 were stable and sporadic single lesions less than 2 cm in size, whereas 11 were cavernomas larger than 2 cm (up to 6 cm). These larger cavernomas had more aggressive behavior (documented growth in five cases, mass effect in eight, significant hemorrhage in four), familial occurrence (six cases), and/or multiple lesions (five cases). The expression of VEGF, tenascin, and PDGF in cavernomas did not significantly differ in the two groups of patients, whereas TGFb expression was higher in the more aggressive forms of cavernomas. The expression of Ki-67 and bcl-2 was always absent in stable lesions, and it was positive in eight (72.7%) of 11 aggressive lesions. The perilesional brain parenchyma showed a significantly higher expression of TGFb, PDGF, and tenascin in more aggressive cavernomas.

CONCLUSIONS

The familial occurrence and more aggressive clinical behavior of cavernous angiomas of the brain are associated with higher expression of Ki-67 and bcl-2 in the cavernoma tissue, as in other proliferative lesions. These features are also associated with higher expression of some growth factors (excluding VEGF) in the perilesional brain parenchyma, suggesting that the neighboring vasculature and glia may be predisposed to and recruited for further growth and progression.

Study of variant anatomical structures (bony canals, fibrous bands, and muscles) in relation to potential supraclavicular nerve entrapment

Since the definition of supraclavicular nerve entrapment syndrome by Gelberman et al. (Gelberman et al. [1975] J. Bone Joint Surg. Am. 57:119) a number of clinical cases of this specific entrapment neuropathy have been reported. In all these cases, the nerve injury has been attributed to the location of the supraclavicular nerve branch in a narrow canal in the clavicle. However, in the anatomical literature, variations in the course of the supraclavicular nerves have not only been ascribed to bony canals but also to abnormal fibrous and muscular structures. Considering the fact that the existence of a narrow site with rigid walls along the course of a nerve is essential for the development of an entrapment neuropathy, our study examines all the variant anatomical structures with a possible role in supraclavicular nerve entrapment. We describe three groups of anatomical structures with close relation to the course of the supraclavicular nerves-transclavicular canals, fibrous bands, and unusual muscular structures. Based on the characteristics of the variations found, for the first time, we suggest that in addition to the bony canals through the clavicle certain fibrous and muscular structures could also be an anatomical basis for supraclavicular nerve entrapment syndrome.

Cavernous malformation after radiation therapy for astrocytoma in adult patients: report of 2 cases

Radiation-induced cavernous malformations are rarely reported, and most cases have been children. We describe two adult patients with cavernous malformation after irradiation for astrocytoma. Magnetic resonance (MR) imaging, at their ages of 53 years, showed a cavernous malformation in the irradiated field 26 and 10 years after resection and irradiation, respectively. Cavernous malformations were confirmed by the histopathological examination in the both cases. Radiation-induced cavernous malformations are rare in adult patients with astrocytoma. One reason why we found two such cases was that these patients had been successfully treated for astrocytoma and had long follow-up periods.

De novo presentation of an arteriovenous malformation. Case report and review of the literature

The authors report the case of a patient with a de novo arteriovenous malformation (AVM), indicating that the origin of these lesions may not always be congenital. A 3-year-old girl who was struck by a car suffered a mild head injury and experienced posttraumatic epilepsy. The initial magnetic resonance (MR) image obtained in this child revealed only a small contusion in the left frontal lobe. Intractable epilepsy subsequently developed. A second MR image obtained almost 4 years after the injury demonstrated an AVM in the right posterior temporal lobe that was verified using angiography. The lesion was classified as a Spetzler-Martin Grade III AVM. The patient underwent embolization of the feeding vessels followed by gamma knife surgery. Fourteen months after treatment she was asymptomatic. Follow-up MR images demonstrate no evidence of an AVM and no changes in the white matter. This case presents a de novo AVM that developed within approximately 4 years. The findings indicate that AVMs may not always be congenital and reinforce the concept that the natural history of AVMs is dynamic. Lesions may appear de novo, grow, and thrombose spontaneously.

Biological activity of adult cavernous malformations: a study of 56 patients

OBJECT

Cerebral cavernous malformations (CCMs) have previously been considered as congenital and biologically static malformations. On the other hand, the potential for growth and de novo generation of CCMs have also been reported. It is therefore important to study the proliferative and neoangiogenetic capacity of these lesions.

METHODS

The authors studied the surgical specimens of 56 CCMs (23 deep and 33 superficial) obtained from adult patients. The proliferative activity of the endothelium and the neoangiogenetic capacity of these lesions were considered through immunohistochemical anaylsis of proliferating cell nuclear antigen (PCNA), MIB-1, Flk-1, vascular endothelial growth factor (VEGF), hypoxia-inducible factor (HIF)-1alpha, and endoglin antibodies. Positive immunostaining of endothelial cells occurred in 86% of patients for PCNA and in 38% of the cases for MIB 1. The expression of Flk-1 was observed in the endothelium of 71% of the cases, for VEGF in 41%, for HIF-1 alpha in 48.1%, and for endoglin in 63.6% of the cases. The correlation of immunohistochemical and clinical data indicated that VEGF was expressed in significantly less deep-seated lesions when compared with superficial CCMs. Neither the expression of the proliferative markers nor the expression of the angiogenetic antibodies correlated with patient age at surgery, sex, or the number of recent prior hemorrhagic episodes in the patients.

CONCLUSIONS

The CCMs from adult patients are active lesions exhibiting endothelial proliferation and neoangiogenesis. According to the data in this study, neoangiogenesis is more prominent in superficial CCMs than in deep-seated CCMs and is not associated with recent prior hemorrhages.

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.

Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy

STUDY DESIGN

A blinded, prospective diagnostic test study was conducted.

OBJECTIVES

To assess the reliability and accuracy of individual clinical examination items and self-report instruments for the diagnosis of cervical radiculopathy, and to identify and assess the accuracy of an optimum test-item cluster for the diagnosis of cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

Although cervical radiculopathy remains largely a clinical diagnosis, the reliability and diagnostic accuracy of clinical examination items, individually or in combination, for cervical radiculopathy is largely unknown.

METHODS

Patients with suspected cervical radiculopathy or carpal tunnel syndrome received standardized electrophysiologic examination of the symptomatic upper quarter followed by a standardized clinical examination by physical therapist examiners blinded to diagnosis. Diagnostic properties were assessed using a neural impairment reference criterion standard.

RESULTS

The study involved 82 patients. More than two thirds of 34 clinical examination items had reliability coefficients rated at least fair or better, and 13 items had likelihood ratio point estimates above 2 or below 0.50. A single diagnostic test item cluster of four variables was identified and produced a positive likelihood ratio point estimate of 30.3. The 95% confidence intervals for all likelihood ratio point estimates in this study were wide.

CONCLUSIONS

Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. Upper limb tension Test A was the most useful test for ruling out cervical radiculopathy. Further investigation is required both to validate the test item cluster and to improve point estimate precision.

Endothelial proliferation, neoangiogenesis, and potential de novo generation of cerebrovascular malformations

OBJECT

To date, both arteriovenous malformations (AVMs) and cavernomas have been considered to be congenital malformations. A recent survey of the literature has shown the potential for de novo generation of both familial and sporadic cavernomas as well as AVMs. Therefore, it was of interest to determine the biological behavior of these lesions in detail.

METHODS

The proliferative and angiogenic capacities of the endothelium of 13 cavernomas and 25 AVMs obtained in patients recently treated (1997-1998) at one institution were studied. Immunohistochemical staining for proliferating cell nuclear antigen (PCNA), MIB-1, and vascular endothelial growth factor (VEGF) and its receptor Flk-1 was performed using standard staining procedures. Positive immunostaining of the nuclei of endothelial cells was observed in specimens of both AVMs and cavernomas for PCNA (80% of AVMs and 85% of cavernomas), and Flk-1 (80% of AVMs and 31% of cavernomas). Endothelial expression of VEGF in the 18 incompletely embolized AVMs was found in 72% of cases but only in 28% of the seven cases in which patients did not undergo endovascular treatment: it was found in 38% of cavernomas. Endothelial expression of MIB-1 was found in 12% of AVMs but in no cavernomas.

CONCLUSIONS

These results indicate that there is endothelial proliferation as well as neoangiogenesis in cerebral cavernomas and AVMs. The increased level of angiogenesis in only partially obliterated AVMs underscores the need for radical and complete occlusion of cerebral AVMs to avoid recurrences and further risks of morbidity.

Vascular reconstruction of a vertebral artery loop causing cervical radiculopathy and vertebrobasilar insufficiency. Case report

The authors present the case of a 62-year-old man with a 4-month history of progressive left-sided C-5 radiculopathy and dizziness. Neuroimaging studies revealed a looped vertebral artery (VA) that had migrated into the widened left C4-5 intervertebral foramen. The patient underwent vascular reconstruction of the VA loop, in which there was minimal manipulation of the C-5 nerve root, via a left-sided anterolateral approach after a balloon occlusion test. Postoperatively the patient's symptoms improved immediately, and there were no signs of recurrence within the 2-year follow-up period. This excellent outcome supports the belief that a proper surgical reconstruction of the compressive, tortuous VA should be the therapeutic option of choice, which carries a lower risk of the nerve root injury and improves the hemodynamics in the posterior circulation.

Diagnosis and nonoperative management of cervical radiculopathy

STUDY DESIGN

Qualitative, comprehensive literature review.

OBJECTIVE

To discuss and summarize the current peer-reviewed literature related to the management of patients with cervical radiculopathy.

BACKGROUND

Cervical radiculopathy is a lesion of the cervical spinal nerve root with a reported prevalence of 3.3 cases per 1000 people; peak annual incidence is 2.1 cases per 1000 and occurs in the fourth and fifth decades of life. Nerve root injury has the potential to produce significant functional limitations and disability.

METHODS AND MEASURES

A search of the MEDLINE, CINAHL, and Web of Science databases for the periods 1966, 1982, and 1996, respectively, to December 1999 was conducted using selected keywords and MeSH headings. The bibliography of all retrieved articles were searched and pertinent articles were obtained. The Cochrane Database of Systematic Reviews was also searched. Literature related to the diagnosis, prognosis, and treatment of cervical radiculopathy were thoroughly reviewed and summarized using a critical appraisal approach.

RESULTS

Although cervical radiculopathy remains largely a clinical diagnosis, the true diagnostic accuracy of the clinical examination for cervical radiculopathy is unknown. Imaging and electrophysiologic tests are capable of detecting clinically significant problems in many patients and each modality has inherent strengths and weaknesses; technical as well as practical factors affect the choice of procedure. The natural course of cervical radiculopathy appears to be generally favorable but no prognostic or risk factors have been firmly established and the efficacy of various nonoperative treatments for the condition is unknown.

CONCLUSION

A clear definition of terms and further research are required to establish definitive diagnostic criteria and effective treatment for the management of patients with cervical radiculopathy.