scholarly journals Sectioning of C2 nerve roots during C1–2 fusion: report of aberrant vertebral artery during C2 nerve root sectioning. Illustrative case

2021 ◽  
Vol 2 (18) ◽  
Author(s):  
Max Kahn ◽  
Paul MacMahon ◽  
Thomas Russell ◽  
Jeffrey D. Klopfenstein ◽  
Daniel R. Fassett
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Vascular Anatomy ◽  
Preoperative Assessment ◽  
Illustrative Case ◽  
Vascular Control ◽  
Instrumented Fusion ◽  
Arterial Bleeding ◽  
C2 Nerve Root ◽  
The Right

BACKGROUND Sectioning the C2 nerve root is increasingly utilized during posterior C1–2 fusion, as the nerve overlies the entry point for C1 lateral mass screws and the C1–2 joint. Nerve sectioning improves visualization for screw placement and enables joint decortication for arthrodesis. While rare, vascular injury is a devastating complication of atlantoaxial fusion. Anomalous vascular anatomy at C1–2 greatly increases risk of iatrogenic injury. OBSERVATIONS A 78-year-old female with rheumatoid arthritis and prior C2–7 fusion presented with myelopathy from a compressive pannus at C1–2. She underwent C1 laminectomy and C1–2 posterior instrumented fusion. Intraoperatively, arterial bleeding occurred as the right C2 nerve root was sectioned. Vertebral artery injury was suspected, and tamponade was performed while vascular control was established. The artery passed aberrantly beneath the nerve root in the C1–2 foramen. It was repaired microsurgically, and patency was confirmed using indocyanine green. The remainder of the fusion was aborted. The patient wore a cervical collar and was treated with aspirin for 6 weeks before undergoing instrumented fusion. The patient suffered no deficits. LESSONS Although rare, anomalous vertebral artery anatomy increases risk of injury at time of C2 nerve root sectioning. Preoperative assessment of the vasculature is vital.

Bow Hunter's Syndrome: Complete Microsurgical Decompression of Vertebral Artery by Far Lateral Retrocondylar Approach: 3-Dimensional Operative Video

2019 ◽  
Author(s):  
Qazi Zeeshan ◽  
Juan P Carrasco Hernandez ◽  
Laligam N Sekhar
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Dynamic Compression ◽  
Skin Incision ◽  
Left Vertebral Artery ◽  
Occipital Condyle ◽  
Cerebral Angiogram ◽  
Microsurgical Decompression ◽  
C2 Nerve Root ◽  
The Right

Abstract This 50-yr-old man had a 15-yr history of presyncopal episodes that were precipitated by turning his head to the right, and had worsened recently. Cerebral angiogram demonstrated complete cessation of anterograde flow in left vertebral artery (VA) at the level of the C1 sulcus arteriosus while turning head to right, indicating dynamic compression at the C1 level.  Patient underwent left extreme lateral retrocondylar approach, partial C1 laminectomy and opening of the C1 foramen with complete microsurgical decompression of the VA. After skin incision, meticulous muscle dissection was performed and superior and inferior oblique muscles were disconnected from the tubercle of C1. The VA was exposed, and three areas of constriction were visible, first at the atlanto-occipital membrane laterally; second, located more medially as the artery curved around the occipital condyle to enter the posterior fossa; and third, located anterior to C2 nerve root. The artery was dissected from all the surrounding tissues, preserving the C2 nerve root, and the Cl foramen was opened completely. The Cl lamina was also partially resected and grooved to allow free placement of the VA. The VA was also decompressed near the C2 foramen. Postoperative computed tomography angiogram of the head and neck showed complete decompression of VA. The patient had no episodes of presyncope or dizziness while turning head to right and his mRs was 0 at 8 mo follow up.  This 3D video shows the technical nuances of decompression of V3 segment of VA in bow hunters's syndrome.  Informed consent was obtained from the patient prior to the surgery that included videotaping of the procedure and its distribution for educational purposes. All relevant patient identifiers have also been removed from the video and accompanying radiology slides.

scholarly journals Digital intravascular pressure wave recording during endovascular treatment reveals abnormal shunting flow in vertebral venous fistula of the vertebral artery: illustrative case

2021 ◽  
Vol 2 (2) ◽  
Author(s):  
Yoshiteru Shimoda ◽  
Shinya Sonobe ◽  
Kuniyasu Niizuma ◽  
Toshiki Endo ◽  
Hidenori Endo ◽  
...  
Keyword(s):  
Blood Flow ◽  
Endovascular Treatment ◽  
Vertebral Artery ◽  
Resistance Index ◽  
Illustrative Case ◽  
Limb Weakness ◽  
Dicrotic Notch ◽  
The Central Nervous System ◽  
Venous Fistula ◽  
The Right

BACKGROUND An arteriovenous fistula is an abnormal arteriovenous shunt between an artery and a vein, which often leads to venous congestion in the central nervous system. The blood flow near the fistula is different from normal artery flow. A novel method to detect the abnormal shunting flow or pressure near the fistula is needed. OBSERVATIONS A 76-year-old woman presented to the authors’ institute with progressive right upper limb weakness. Right vertebral angiography showed a fistula between the right extracranial vertebral artery (VA) and the right vertebral venous plexus at the C7 level. The patient underwent endovascular treatment for shunt flow reduction. Before the procedure, blood pressures were measured at the proximal VA, distal VA near the fistula, and just at the fistula and drainer using a microcatheter. The blood pressure waveforms were characteristically different in terms of resistance index, half-decay time, and appearance of dicrotic notch. The fistula was embolized with coils and N-butyl cyanoacrylate solution. LESSONS During endovascular treatment, the authors were able to digitally record the vascular pressure waveform from the tip of the microcatheter and succeeded in calculating several parameters that characterize the shunting flow. Furthermore, these parameters could help recognize the abnormal blood flow, allowing a safer endovascular surgery.

Vascular decompression of a vertebral artery loop producing cervical radiculopathy

1998 ◽  
Vol 89 (3) ◽  
pp. 485-488 ◽  
Author(s):  
Paul W. Detwiler ◽  
Randall W. Porter ◽  
Timothy R. Harrington ◽  
Volker K. H. Sonntag ◽  
Robert F. Spetzler
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Cervical Radiculopathy ◽  
Vascular Structure ◽  
Loop Formation ◽  
Content Type ◽  
History Of ◽  
Radicular Symptoms ◽  
The Right ◽  
Vascular Decompression

✓ Vertebral artery tortuosity and loop formation are rare causes of cervical radiculopathy. The authors present the case of a 70-year-old man with 9 years of progressive right-sided cervical and scapular pain but no history of trauma. Computerized tomography myelography and magnetic resonance imaging revealed an ovoid mass in the right C3–4 intervertebral foramen. The patient underwent a right C-3 and C-4 hemilaminectomy and a complete C3–4 facetectomy. A pulsatile vascular structure was found compressing the right C-4 nerve root. The bone overlying the vascular structure was removed, producing decompression of the nerve root. Immediate postoperative angiography showed that this lesion was a focal vertebral artery loop. The patient's symptoms resolved after surgery, supporting the use of vascular decompression of a cervical nerve root compressed by a vertebral artery loop for the relief of radicular symptoms.

Cervical Dumbbell Intra-extradural Hemangioblastoma: Total Removal through the Lateral Approach: Technical Case Report

Neurosurgery ◽  
2005 ◽  
Vol 56 (3) ◽  
pp. E625-E625 ◽  
Author(s):  
Cédric Barrey ◽  
Michel Kalamarides ◽  
Marc Polivka ◽  
Bernard George
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Histopathological Examination ◽  
Lateral Approach ◽  
Primary Control ◽  
Cervical Nerve Root ◽  
Cervical Nerve ◽  
Dumbbell Tumor ◽  
Computed Tomographic ◽  
The Right

Abstract OBJECTIVE AND IMPORTANCE: Extradural hemangioblastomas account for 8 to 12% of all spinal hemangioblastomas. Among them, intra-extradural forms with a dumbbell extension are extremely rare. We report a case of intra-extradural hemangioblastoma involving the C6 cervical nerve root. CLINICAL PRESENTATION: The patient was a 31-year-old woman presenting with signs of myelopathy and C6 radiculopathy on the right side. A computed tomographic scan and magnetic resonance imaging demonstrated a dumbbell tumor that had developed through the C5–C6 intervertebral foramen. Angiography revealed a well-circumscribed mass with feeders from the vertebral artery and the deep cervical artery. INTERVENTION: The tumor was totally removed through the lateral approach, with control of the vertebral artery and sacrifice of the C6 cervical nerve root. Limited bone drilling to enlarge the foramen permitted us to reach and resect the intradural component. Histopathological examination confirmed the diagnosis of hemangioblastoma. Follow-up was uneventful. CONCLUSION: This is the sixth reported case of a cervical dumbbell hemangioblastoma investigated by computed tomographic scanning and MRI but the first one resected via the lateral approach. The lateral approach seems appropriate for surgical resection because it provides primary control of the vascular feeders and access to the extradural and intradural components.

Atlantoaxial Fusion Using C1 Sublaminar Cables and C2 Translaminar Screws

2017 ◽  
Vol 14 (6) ◽  
pp. 647-653 ◽  
Author(s):  
Alexandra M Giantini Larsen ◽  
Benjamin L Grannan ◽  
Robert M Koffie ◽  
Jean-Valéry Coumans
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Limited Range ◽  
Atlantoaxial Instability ◽  
Posterior Arch ◽  
Hardware Failure ◽  
Risk Of Injury ◽  
Limited Range Of Motion ◽  
C2 Nerve Root ◽  
Translaminar Screws

Abstract BACKGROUND Atlantoaxial instability, which can arise in the setting of trauma, degenerative diseases, and neoplasm, is often managed surgically with C1–C2 arthrodesis. Classical C1–C2 fusion techniques require placement of instrumentation in close proximity to the vertebral artery and C2 nerve root. OBJECTIVE To report a novel C1–C2 fusion technique that utilizes C2 translaminar screws and C1 sublaminar cables to decrease the risk of injury to the vertebral artery and C2 nerve root. METHODS To facilitate fixation to the atlas, while minimizing the risk of injury to the vertebral artery and to the C2 nerve root, we sought to determine the feasibility of using a soft cable around the C1 arch and affixing it to a rod connected to C2 laminar screws. We reviewed our experience in 3 patients. RESULTS We used this technique in patients in whom we anticipated difficult C1 screw placement. Three patients were identified through a review of the senior author's cases. Atlantoaxial instability was associated with trauma in 2 patients and chronic degenerative changes in 1 patient. Common symptoms on presentation included pain and limited range of motion. All patients underwent C1–C2 fusion with C2 translaminar screws with sublaminar cable harnessing of the posterior arch of C1. There were no reports of postoperative complications or hardware failure. CONCLUSION We demonstrate a novel, technically straightforward approach for C1–C2 fusion that minimizes risk to the vertebral artery and to the C2 nerve root, while still allowing for semirigid fixation in instances of both traumatic and chronic degenerative atlantoaxial instability.

scholarly journals Atypical presentation of rotational vertebral artery insufficiency: illustrative case

2021 ◽  
Vol 1 (9) ◽  
Author(s):  
Pranish A. Kantak ◽  
Sarv Priya ◽  
Girish Bathla ◽  
Mario Zanaty ◽  
Patrick W. Hitchon
Keyword(s):  
Vertebral Artery ◽  
Facet Joint ◽  
Head Rotation ◽  
Rotational Instability ◽  
Anatomical Location ◽  
Illustrative Case ◽  
Vertebrobasilar Insufficiency ◽  
Course Of Action ◽  
Heterogeneous Nature ◽  
The Right

BACKGROUNDRotational vertebral artery insufficiency (RVAI), also known as bow hunter’s syndrome, is an uncommon cause of vertebrobasilar insufficiency that leads to signs of posterior circulation ischemia during head rotation. RVAI can be subdivided on the basis of the anatomical location of vertebral artery compression into atlantoaxial RVAI (pathology at C1-C2) or subaxial RVAI (pathology below C2). Typically, RVAI is only seen with contralateral vertebral artery pathologies, such as atherosclerosis, hypoplasia, or morphological atypia.OBSERVATIONSThe authors present a unique case of atlantoaxial RVAI due to rotational instability, causing marked subluxation of the C1-C2 facet joints. This case is unique in both the mechanism of compression and the lack of contralateral vertebral artery pathology. The patient was successfully treated with posterior C1-C2 instrumentation and fusion.LESSONSWhen evaluating patients for RVAI, neurosurgeons should be aware of the variety of pathological causes, including rotational instability from facet joint subluxation. Due to the heterogeneous nature of the pathologies causing RVAI, care must be taken to decide if conservative management or surgical correction is the right course of action. Because of this heterogeneous nature, there is no set guideline for the treatment or management of RVAI.

scholarly journals Arteriovenous malformation of the trigeminal nerve root presented with venous congestive edema of the medulla oblongata and upper cervical cord: illustrative case

2021 ◽  
Vol 2 (9) ◽  
Author(s):  
Arata Nagai ◽  
Hidenori Endo ◽  
Kenichi Sato ◽  
Tomohiro Kawaguchi ◽  
Hiroki Uchida ◽  
...  
Keyword(s):  
Arteriovenous Malformation ◽  
Medulla Oblongata ◽  
Trigeminal Nerve ◽  
Nerve Root ◽  
Venous Hypertension ◽  
Cervical Cord ◽  
Illustrative Case ◽  
Trigeminal Nerve Root ◽  
Upper Cervical ◽  
The Right

BACKGROUND Arteriovenous malformation (AVM) of the trigeminal nerve root (TNR) is a rare subtype of the lateral pontine AVM. Most of them are diagnosed when they bleed or exert trigeminal neuralgia. Venous congestive edema is a rare phenomenon caused by TNR AVMs. OBSERVATIONS An 82-year-old man was admitted with progressive limb weakness and dysphasia. Magnetic resonance imaging (MRI) revealed extensive edema of the medulla oblongata and the upper cervical cord with signal flow void at the C3 anterior spinal cord. Vertebral angiography revealed a small nidus fed mainly by the pontine perforating arteries (PPAs). The anterior pontomesencephalic vein (AMPV) was dilated, functioning as the main drainage route. This suggests that venous hypertension triggered the brainstem and upper cervical cord edema. MRI with gadolinium enhancement showed that the nidus was located around the right TNR. Because the nidus sat extrinsically on the pial surface of the right TNR’s base, microsurgical obliteration with minimum parenchymal injury was achieved. Postoperative MRI showed disappearance of the brainstem and cervical cord edema with improved clinical symptoms. LESSONS TNR AVM is rarely associated with brainstem and upper cervical cord edema caused by venous hypertension of the congestive drainage system.

scholarly journals Posterior arch C-1 screw technique: a cadaveric comparison study

2017 ◽  
Vol 26 (6) ◽  
pp. 679-683 ◽  
Author(s):  
Marc Moisi ◽  
Christian Fisahn ◽  
Lara Tkachenko ◽  
Shiveindra Jeyamohan ◽  
Stephen Reintjes ◽  
...  
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Access Point ◽  
Screw Placement ◽  
Posterior Arch ◽  
Lateral Mass ◽  
Entry Site ◽  
Starting Point ◽  
The Right

OBJECTIVEPosterior atlantoaxial stabilization and fusion using C-1 lateral mass screw fixation has become commonly used in the treatment of instability and for reconstructive indications since its introduction by Goel and Laheri in 1994 and modification by Harms in 2001. Placement of such lateral mass screws can be challenging because of the proximity to the spinal cord, vertebral artery, an extensive venous plexus, and the C-2 nerve root, which overlies the designated starting point on the posterior center of the lateral mass. An alternative posterior access point starting on the posterior arch of C-1 could provide a C-2 nerve root–sparing starting point for screw placement, with the potential benefit of greater directional control and simpler trajectory. The authors present a cadaveric study comparing an alternative strategy (i.e., a C-1 screw with a posterior arch starting point) to the conventional strategy (i.e., using the lower lateral mass entry site), specifically assessing the safety of screw placement to preserve the C-2 nerve root.METHODSFive US-trained spine fellows instrumented 17 fresh human cadaveric heads using the Goel/Harms C-1 lateral mass (GHLM) technique on the left and the posterior arch lateral mass (PALM) technique on the right, under fluoroscopic guidance. After screw placement, a CT scan was obtained on each specimen to assess for radiographic screw placement accuracy. Four faculty spine surgeons, blinded to the surgeon who instrumented the cadaver, independently graded the quality of screw placement using a modified Upendra classification.RESULTSOf the 17 specimens, the C-2 nerve root was anatomically impinged in 13 (76.5%) of the specimens. The GHLM technique was graded Type 1 or 2, which is considered “acceptable,” in 12 specimens (70.6%), and graded Type 3 or 4 (“unacceptable”) in 5 specimens (29.4%). In contrast, the PALM technique had 17 (100%) of 17 graded Type 1 or 2 (p = 0.015). There were no vertebral artery injuries found in either technique. All screw violations occurred in the medial direction.CONCLUSIONSThe PALM technique showed statistically fewer medial penetrations than the GHLM technique in this study. The reason for this is not clear, but may stem from a more angulated ”up-and-in” screw direction necessary with a lower starting point.

Surgical management of cervical radiculopathy caused by redundant vertebral artery loop

2012 ◽  
Vol 17 (4) ◽  
pp. 337-341 ◽  
Author(s):  
Ziad A. Hage ◽  
Sepideh Amin-Hanjani ◽  
Dennis Wen ◽  
Fady T. Charbel
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Cervical Radiculopathy ◽  
Surgical Approaches ◽  
Anterolateral Approach ◽  
Transverse Foramen ◽  
History Of ◽  
The Right ◽  
Almost All ◽  
Vascular Decompression

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.

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

2021 ◽  
Author(s):  
Mazda Farshad ◽  
José Miguel Spirig ◽  
Marco D. Burkhard
Keyword(s):  
Vertebral Artery ◽  
Nerve Root ◽  
Cervical Radiculopathy ◽  
Loop Formation ◽  
Level Of Evidence ◽  
Cross Sectional ◽  
Surgical Strategies ◽  
History Of ◽  
The Right ◽  
Neurovascular Decompression

Abstract 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).

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