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Farshad-Amacker NA, Sutter R. The Great Mimickers of Spinal Pathology. Semin Musculoskelet Radiol 2022; 26:439-452. [PMID: 36103886 DOI: 10.1055/s-0042-1748914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Back pain is one of the leading causes of health costs worldwide, particularly because of the further increased aging population. After clinical examination, spinal imaging is of utmost importance in many patients to reach the correct diagnosis. There are many imaging pitfalls and mimickers of spinal pathology on radiographs, magnetic resonance imaging, and computed tomography. These mimickers may lead to a misdiagnosis or a further imaging work-up if they are not recognized and thus lead to unnecessary examinations and increased health care costs. In this review we present the common mimickers of spinal pathology and describe normal variations when reading imaging studies of the spine.
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Affiliation(s)
- Nadja A Farshad-Amacker
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Reto Sutter
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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2
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Omami G. Foramen transversarium enlargement caused by vertebral artery tortuosity: Diagnosis with cone-beam computed tomography and magnetic resonance angiography. Imaging Sci Dent 2021; 51:329-332. [PMID: 34621661 PMCID: PMC8479427 DOI: 10.5624/isd.20210003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/28/2021] [Accepted: 03/13/2021] [Indexed: 11/18/2022] Open
Abstract
A markedly enlarged foramen transversarium was discovered incidentally on a cone-beam computed tomography scan of a 72-year-old male patient who was referred for dental implant placement. Further evaluation with magnetic resonance angiography revealed that the foramen enlargement was caused by a tortuosity in the course of the vertebral artery. This case report highlights the importance of recognizing significant incidental findings on diagnostic images and the potential need for additional imaging as part of the complete interpretative process.
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Affiliation(s)
- Galal Omami
- Division of Oral Medicine, Diagnosis and Radiology, Department of Oral Health Practice, University of Kentucky College of Dentistry, Lexington, USA
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3
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Tack L, Linden P, Mortelé P, Rosseel F, Floré P. Cervical radiculopathy caused by vertebral artery loop formation: a case report. Radiol Case Rep 2021; 16:1919-1923. [PMID: 34093937 PMCID: PMC8167806 DOI: 10.1016/j.radcr.2021.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/25/2021] [Accepted: 04/25/2021] [Indexed: 12/01/2022] Open
Abstract
Vertebral artery loop formation is a rare cause of cervical radiculopathy. We report a case of a 70-year-old man who was referred because of a chronic cervicobrachialgia. Initial plain cervical x-ray showed widening of the left C3-C4 intervertebral foramen. Additional magnetic resonance angiography revealed the presence of a vertebral artery loop, which had migrated into the left C3-C4 neural foramen and caused compression of the left C4 nerve root. Surgery was considered, but the patient’s symptoms resolved with conservative treatment. The aim of this case report is to raise the knowledge of both clinicians and radiologists about vertebral artery loop formation as a rare but potentially life-threatening cause of cervical radiculopathy. If overlooked, cerebrovascular stroke during transforaminal cervical steroid injections or catastrophic vertebral artery damage during surgery may occur.
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Affiliation(s)
- Laura Tack
- Department of Physical Therapy and Rehabilitation, AZ Delta Hospital, Torhout/Roeselare, Belgium
| | - Patrick Linden
- Department of Physical Therapy and Rehabilitation, AZ Delta Hospital, Torhout/Roeselare, Belgium
| | - Piet Mortelé
- Department of Physical Therapy and Rehabilitation, AZ Delta Hospital, Torhout/Roeselare, Belgium
| | | | - Pierre Floré
- Department of Physical Therapy and Rehabilitation, AZ Delta Hospital, Torhout/Roeselare, Belgium
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4
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Cervical Vertebral Body Erosion Due to Vascular Abnormality: A Case Report. J Chiropr Med 2020; 19:65-69. [PMID: 33192193 DOI: 10.1016/j.jcm.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 10/01/2019] [Accepted: 10/10/2019] [Indexed: 11/20/2022] Open
Abstract
Objective The occurrence of cervical vertebral erosion due to vertebral artery (VA) abnormalities such as tortuosity/loop formation and pseudoaneurysm is rare, but both abnormalities are potentially fatal. There are few reports of cervical vertebral body erosion due to VA abnormality. We report a case of a 92-year-old woman who presented to her primary care physician with neck pain and was referred for chiropractic care. Clinical Features The patient complained of headaches, left-sided neck pain, limited range of motion with radiating pain, and bilateral weakness of the upper extremities. On examination, cervical ranges of motion were decreased with moderate pain, along with sensory, motor, and deep tendon reflex deficits. The initial magnetic resonance imaging report obtained was nonconclusive. Axial T2, sagittal T1, sagittal T2, coronal T2, sagittal STIR, and axial GE sequences of the cervical spine were obtained for a reread. A reread of the magnetic resonance images suggested a diagnosis of a tortuosity of the VA, resulting in a chronic erosion of the C5 vertebral body; however, a pseudoaneurysm of the VA would be considered a possible differential cause for the vertebral body erosion. Intervention and Outcome Management of cervical vertebral body erosion due to VA abnormality is often complicated and must be tailored to each patient's individual clinical presentation and symptoms. The patient in this case was managed with anticoagulant medication, close monitoring, and acupuncture treatment, which resulted in a reduction in pain intensity. Conclusion Vertebral artery abnormality and subsequent erosion of the vertebral body is a rare occurrence and can mimic symptoms of musculoskeletal neck pain and cervical radiculopathy. It is important to recognize features of VA abnormalities on magnetic resonance imaging.
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Naldemir IF, Unlu EN, Onbas O. Tortuous vertebral artery triggering vertebral foramen expansion and radiculopathy in a 19-year-old patient: a case report. J Med Case Rep 2020; 14:170. [PMID: 32981528 PMCID: PMC7520948 DOI: 10.1186/s13256-020-02493-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background Arterial tortuosity is a widespread condition commonly occurring in cerebral arteries and often associated with the elderly. Moderate arterial tortuosity is often not symptomatic, but if there is severe tortuosity, various symptoms may occur, depending on the localization. In the literature, many factors have been reported as causing tortuosity in the vertebral arteries. In this case report, considering the age of our patient, we propose that, in addition to these previously reported reasons, congenital factors may also contribute to this situation. Case presentation We present a case of a 19-year-old Turkish patient with a tortuous vertebral artery causing pain and tingling in the right shoulder and neck. Magnetic resonance imaging revealed vertebral foramen enlargement thought to be secondary to a loop formation in the vertebral artery. The diagnosis was confirmed by magnetic resonance angiography. Conclusions There are many causes of cervical radiculopathy. Arterial tortuosity, a rare cause of radiculopathy, should be considered as a differential diagnosis. Consideration of the existence of this variation is of great importance in preventing possible dangerous complications during surgery.
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Affiliation(s)
- Ibrahim F Naldemir
- Department of Radiology, Duzce University, Konuralp Yerleşkesi Konuralp Merkez, 81620, Düzce, Turkey.
| | - Elif Nisa Unlu
- Department of Radiology, Duzce University, Konuralp Yerleşkesi Konuralp Merkez, 81620, Düzce, Turkey
| | - Omer Onbas
- Department of Radiology, Duzce University, Konuralp Yerleşkesi Konuralp Merkez, 81620, Düzce, Turkey
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Sravani N, Nagarajan K, Venkatesh M, Negi VS, Ramesh AS. Vertebral Artery Loops and Cervicobrachial Pain. INDIAN JOURNAL OF NEUROSURGERY 2020. [DOI: 10.1055/s-0040-1713057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractVertebral 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.
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Affiliation(s)
- Nichanametla Sravani
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Krishnan Nagarajan
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Manchikanti Venkatesh
- Department of Radio-Diagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Veer S. Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
| | - Andi S. Ramesh
- Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry, India
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Croci DM, Koetsier E, Maino P, Reinert M, Robert T, Scarone P. Cervical Radiculopathy Caused by a Vertebral Artery Loop: Is a Focused Fluoroscopic-Guided Cervical Epidural Steroid Injection a Possible Treatment Modality? Pain Pract 2020; 20:787-791. [PMID: 32306517 DOI: 10.1111/papr.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/08/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Eva Koetsier
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
| | - Paolo Maino
- Pain Management Center, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland.,Division of Anaesthesiology, Department of Acute Medicine, Regional Hospital of Lugano, Lugano, Switzerland
| | - Michael Reinert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
| | - Pietro Scarone
- Department of Neurosurgery, Neurocenter of Southern Switzerland, Regional Hospital of Lugano, Lugano, Switzerland
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Kim K, Nariai M, Kawauchi M, Morimoto D, Iwamoto N, Isu T, Morita A. Is the Vertebral Posterior Line a Safety Landmark for Cervical Posterior Screw Insertion? - Radiological Study of the Vertebral Artery in the Cervical Spine. Neurol Med Chir (Tokyo) 2020; 60:223-228. [PMID: 32132344 PMCID: PMC7174243 DOI: 10.2176/nmc.oa.2019-0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
At posterior cervical fixation, iatrogenic injury of the vertebral artery (VA) must be avoided. As the VA is usually located in front of the posterior line of the vertebral body, intraoperative lateral fluoroscopy is used to identify the line. We investigated in how many of 105 patients (210 VAs) this line is a safe marker. We also inspected the original cervical magnetic resonance angiograms (MRA) of 105 consecutive patients who had been treated for other than cervical spine diseases to study some anatomical characteristics of the VA in the cervical spine. The distance from the posterior line of the vertebral body to the posterior VA surface was classified as safe, as requiring attention, and as unsafe. Among the 210 VAs, four hypoplastic vessels were excluded from this study; consequently, 206 VAs were available for assessment. The average distance exceeded 6 mm, it was shorter at the upper cervical level. Although in at least 200 VAs (97.1%) the distance between C4 and C7 was safe, in only 170 VAs (82.5%) was it safe at C3. We observed a total of 31 tortuous loops in 17 VAs; their presence had a significant negative effect on the usefulness of the safety line. Although the posterior line of the vertebral body may be useful for safe screw insertion at the C4-C7 level, it may be less useful at C3. In the presence of tortuous VA loops, close attention must be paid to the reliability of the safety line during cervical spine surgery.
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Affiliation(s)
- Kyongsong Kim
- Department of Neurological Surgery, Chiba Hokuso Hospital, Nippon Medical School.,Department of Neurosurgery, Chiba Shintoshi Rurban Clinic
| | | | | | | | | | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
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Tonsbeek AM, Groen JL, Vleggeert-Lankamp CLAM. Surgical Interventions for Cervical Radiculopathy Caused by a Vertebral Artery Loop: A Case Report and Review of the Literature. World Neurosurg 2019; 135:28-34. [PMID: 31809894 DOI: 10.1016/j.wneu.2019.11.164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 11/26/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Aberrant vertebral artery loops are a rare clinical condition, with sparse data regarding the optimal treatment guidelines for individual patients. The heterogeneity of treatment options in the literature creates a problem when tailoring treatments to individual patients. In this review of the literature, multiple surgical treatments for cervical vertebral artery loops were analyzed and compared. In addition, this article provides a clinical case of a patient with a vertebral artery loop. METHODS A literature review was conducted to identify studies investigating surgical treatments for a vertebral artery loop. Different surgical techniques were examined and the involved techniques and approaches described. The outcomes were assessed for each study and the effectiveness of the treatment determined. RESULTS Twelve articles met the inclusion criteria for this review. Six types of surgical interventions were found in the literature. Each intervention had similar postoperative results, leading to either a significant improvement or a complete resolution of symptoms. CONCLUSIONS Multiple successful surgical interventions have been described in the medical literature. However, because of the lack of evidence-based studies, no surgical intervention protocol could be determined. Treatment should therefore be tailored to individual patients' characteristics. Because not every radiologically detected vertebral artery loop is the main reason for a patient's symptoms, a thorough multidisciplinary approach is justified and advocated in patients with an atypical presentation, before a neurosurgical intervention takes place. More deliberate clinical decisions can be made once the understanding of the pathogenesis of this rare disease entity has been established and treatment protocols formulated.
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Affiliation(s)
- Anthony M Tonsbeek
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Justus L Groen
- Department of Neurosurgery, Leiden University Medical Centre, Leiden, The Netherlands
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Venteicher AS, Quddusi A, Coumans JV. Anterolateral Approach for a Cervical Nerve Root Compression Syndrome Due to an Ectatic Vertebral Artery. Oper Neurosurg (Hagerstown) 2019; 17:E29-E32. [PMID: 30535126 DOI: 10.1093/ons/opy282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew S Venteicher
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ayesha Quddusi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jean V Coumans
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Burulday V, Doğan A, Akgül MH, Alpua M, Çankaya I. Is there a relationship between basilar artery tortuosity and vertigo? Clin Neurol Neurosurg 2019; 178:97-100. [DOI: 10.1016/j.clineuro.2019.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/01/2018] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
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The diagnosis and management of a vertebral artery loop causing cervical radiculopathy. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 30:1-6. [PMID: 28528478 DOI: 10.1007/s00586-017-5123-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/26/2017] [Accepted: 04/30/2017] [Indexed: 10/19/2022]
Abstract
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.
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Wang DD, Burkhardt JK, Magill ST, Lawton MT. Anterior Transposition of Anomalous Tortuous Vertebral Artery Causing Cervical Radiculopathy: A Report of 2 Cases and Review of Literature. World Neurosurg 2017; 101:289-295. [PMID: 28192269 DOI: 10.1016/j.wneu.2017.01.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/27/2017] [Accepted: 01/30/2017] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Doris D Wang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Stephen T Magill
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael T Lawton
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Classification of vertebral artery loop formation and association with cervicogenic dizziness. The Journal of Laryngology & Otology 2016; 130:1115-1119. [PMID: 27786146 DOI: 10.1017/s0022215116009117] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE An examination was conducted of the number, level, clinical association and treatment approaches for vertebral arterial loop formation in patients with this condition with and without concurrent cervicogenic dizziness, and classified them according to the vertebral artery segment in which it was present. METHOD A cross-sectional retrospective study. RESULTS Thirty-seven patients who had undergone double-sided magnetic resonance angiography were examined; vertebral arterial loop formation was observed at only 1 level in 26 patients and at several levels in 9 patients. Segment one (V1) was involved in 78.3 per cent of cases and segment two (V2) was involved in 21.6 per cent. Symptoms in patients with vertebral arterial loop formation included: positional vertigo, in 100 per cent; and pulsatile tinnitus, in 83.7 per cent. CONCLUSION Loop formation at the vertebral artery was observed most often on the proximal side in patients with cervicogenic dizziness (78.3 per cent). The incidence on the left side was twice as high as on the right side.
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Ekşi MŞ, Toktaş ZO, Yılmaz B, Demir MK, Özcan-Ekşi EE, Bayoumi AB, Yener Y, Akakın A, Konya D. Vertebral artery loops in surgical perspective. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:4171-4180. [PMID: 27388018 DOI: 10.1007/s00586-016-4691-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/16/2016] [Accepted: 07/03/2016] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Murat Şakir Ekşi
- Department of Orthopedic Surgery-Spine Center, University of California at San Francisco, Medical Center, 500 Parnassus Avenue MU320 West, San Francisco, CA, 94143-0728, USA.
| | - Zafer Orkun Toktaş
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Baran Yılmaz
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Mustafa Kemal Demir
- Department of Radiology, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Emel Ece Özcan-Ekşi
- Department of Physical Medicine and Rehabilitation, Antalya Ataturk State Hospital, Antalya, Turkey
| | - Ahmed B Bayoumi
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Yasin Yener
- Department of Anesthesiology, Medical Park Göztepe Hospital, Istanbul, Turkey
| | - Akın Akakın
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Deniz Konya
- Department of Neurosurgery, Bahçeşehir University Medical School, Istanbul, Turkey
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Murambi RT, White E, Steel TR. Intraforaminal vertebral artery: a rare and risky anomaly. Spine J 2015; 15:e39. [PMID: 26163774 DOI: 10.1016/j.spinee.2015.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 06/15/2015] [Accepted: 06/29/2015] [Indexed: 02/03/2023]
Affiliation(s)
- Ronald T Murambi
- Department of Neurosurgery, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia
| | - Edward White
- Department of Neurosurgery, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia
| | - Timothy R Steel
- Department of Neurosurgery, St Vincent's Hospital, Sydney, 390 Victoria Street, Darlinghurst, New South Wales 2010, Australia
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Anandkumar S. The effect of sustained natural apophyseal glide (SNAG) combined with neurodynamics in the management of a patient with cervical radiculopathy: a case report. Physiother Theory Pract 2014; 31:140-5. [PMID: 25329587 DOI: 10.3109/09593985.2014.971922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This case report describes a 47-year-old female who presented with complaints of pain in the right elbow radiating down to the thumb. Physical examination revealed symptom reproduction with Spurling A test, upper limb neurodynamic testing-1 and right cervical rotation along with reduced symptoms with neck distraction. Clinical diagnosis of cervical radiculopathy (CR) was made based on a clinical prediction rule. This case report speculates a potentially first-time description of successful conservative management of CR in a patient utilizing simultaneous combination of sustained natural apophyseal glide and neurodynamic mobilization. Immediate improvements were seen in pain, cervical range of motion and functional abilities. The patient was discharged from physical therapy by the second week after four treatment sessions with complete pain resolution maintained at a four-month follow-up period.
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Doweidar A, Al-Sayed S, Al-Kandery S. Symptomatic vertebral artery loop: a case report and review of literature. J Radiol Case Rep 2014; 8:35-41. [PMID: 25426228 DOI: 10.3941/jrcr.v8i5.1407] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Vertebral artery loop formation is a rare anatomical variant capable of causing bony erosion, encroachment on cervical neural foramen, neurovascular compression, or vertebrobasilar insufficiency. Health professionals should keep the diagnosis of vertebral artery loop formation in mind, especially when the plain radiograph of the cervical spine shows enlargement of the intervertebral foramen. If overlooked, serious complications like vertebral artery injury may occur during surgery or vertebrobasilar angiography, as well as cerebrovascular stroke during transforaminal cervical epidural steroid injections. This case report aims at increasing the awareness of both clinicians and radiologists of this entity as a known rare cause of cervical radiculopathy. In suspected cases, Magnetic resonance imaging & Magnetic resonance angiography should always be the first choice in this regard.
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Affiliation(s)
- Ahmed Doweidar
- Department of Clinical Radiology, Al-Razi hospital, Kuwait, Kuwait
| | - Saeed Al-Sayed
- Department of Radio-diagnosis, Zagazig university hospitals, Zagazig, Egypt
| | - Salwa Al-Kandery
- Department of Clinical Radiology, Al-Razi hospital, Kuwait, Kuwait
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Tandon A, Chandela S, Langer D, Sen C. A novel sling technique for microvascular decompression of a rare anomalous vertebral artery causing cervical radiculopathy. Neurosurg Focus 2014; 35:E2. [PMID: 23991815 DOI: 10.3171/2013.6.focus1339] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Adesh Tandon
- Department of Neurosurgery, Albert Einstein College of Medicine, Bronx, New York 10467, USA.
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Park SB, Yang HJ, Lee SH. Medial loop of v2 segment of vertebral artery causing compression of proximal cervical root. J Korean Neurosurg Soc 2012; 52:513-6. [PMID: 23346321 PMCID: PMC3550417 DOI: 10.3340/jkns.2012.52.6.513] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Revised: 09/29/2012] [Accepted: 12/18/2012] [Indexed: 12/01/2022] Open
Abstract
Objective It is rare that the medial loop in the V2 segment of the vertebral artery (VA) causes compression of the proximal cervical root of the spinal cord without leading to bony erosion and an enlarged foramen. We evaluated the clinical significance and incidence of the medial loop in the V2 segment of the VA. Methods We reviewed the records from 1000 consecutive patients who had undergone magnetic resonance imaging evaluation of the cervical spine between January 2005 and January 2008. The inclusion criteria were that over a third of the axial aspect of the VA located in the intervertebral foramen was inside the line between the most ventral points of the bilateral lateral mass, and that the ipsilateral proximal root deviated dorsally because of the medial loop of the VA. We excluded cases of bone erosion, a widened foramen at the medial loop of the VA, any bony abnormalities, tumors displacing VA, or vertebral fractures. The medical records were reviewed retrospectively to search for factors of clinical significance. Results In six patients (0.6%), the VA formed a medial loop that caused compression of the proximal cervical root. One of these patients had the cervical radiculopathy that developed after minor trauma but the others did not present with cervical radiculopathy related to the medial loop of the VA. Conclusion The medial loop of the VA might have a direct effect on cervical radiculopathy. Therefore, this feature should be of critical consideration in preoperative planning and during surgery.
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Affiliation(s)
- Sung Bae Park
- Department of Neurosurgery, Seoul National University Boramae Medical Center, Seoul, Korea
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