Skip to main content
SpringerLink
Log in

Evaluation of vertebral artery anomaly in basilar invagination and prevention of vascular injury during surgical intervention: CTA features and analysis

  • Original Article
  • Published:
European Spine Journal Aims and scope Submit manuscript

Abstract

Objective

To evaluate vertebral artery anomaly at the craniovertebral junction (CVJ) in patients with basilar invagination (BI) by computed tomographic angiography (CTA), and to discuss the prevention strategy of vascular injury.

Methods

The primary axial, multiple planar reconstruction and volume-rendering cervicocranial CTA images of 39 BI patients were analysed to evaluate vertebral artery anomaly at the CVJ: persistent first intersegmental artery (PFIA), fenestrated vertebral artery (FEN), and extracranial C1/2 origin of posterior inferior cerebellar artery (PICA), high-riding vertebral artery, side-to-side asymmetry and irregular midline carotid artery loop was determined by subjective vision. 100 patients who underwent CTA for reasons other than CVJ deformity were enrolled as normal controls to evaluate the prevalence of vertebral artery anomaly in a normal population. Chi-square test was utilized for comparing the prevalence of vertebral artery anomaly between these two groups.

Results

The incidence of PFIA was 25.6% (10/39), FEN was 7.7% (3/39), PICA was 5.1% (2/39), and the total incidence of extraosseous anomalous course of vertebral artery was 38.5% (15/39), significantly higher than that of control group, 7.0% (7/100) (P < 0.01). The incidence of high-riding vertebral artery and side-to-side asymmetry were 61.5% (24/39) and 30.8% (12/39), respectively. An irregular midline carotid artery loop was observed in five patients (12.8%).

Conclusion

Vertebral artery anomaly, which can be clearly depicted by CTA, is more frequent in BI patients. Preoperative CTA should be performed for this patient population to prevent vascular injury.

Graphical abstract

These slides can be retrieved under Electronic Supplementary Material.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Chamberlain’s WE (1939) Basilar impression (platybasia): a bizarre developmental anomaly of the occipital bone and upper cervical spine with striking and misleading neurologic manifestations. Yale J Biol Med 11:487–496

    Google Scholar 

  2. Pang D, Thompson DN (2011) Embryology and bony malformations of the craniovertebral junction. Childs Nerv Syst 27(4):523–564

    Article  PubMed  Google Scholar 

  3. Riew KD, Hilibrand AS, Palumbo MA, Sethi N, Bohlman HH (2001) Diagnosing basilar invagination in the rheumatoid patient. J Bone Jt Surg 83:194–200

    Article  Google Scholar 

  4. Chaudhry NS, Ozpinar A, Bi WL (2015) Basilar invagination: case report and literature review. World Neurosurg 83:1187-11

    Article  Google Scholar 

  5. Klekamp J (2014) Treatment of basilar invagination. Eur Spine J 23(8):1656–1665

    Article  PubMed  Google Scholar 

  6. Magerl F, Seemann PS (1987) Stable posterior fusion of the atlas and axis by transarticular screw fixation. In: Kehr P, Weidner A (eds) Cervical spine, vol 1. Springer, New York, pp 322–327

    Chapter  Google Scholar 

  7. Leconte P (1964) Fracture et luxation des deux premieres vertebres cervicales. In: Judet R (ed) Luxation Congenenitale de la Hanche. Fractures du Cou-de-pied Rachis Cervical. Actualites de Chirugie Orthopedique de Hopital Raymond-Poincare 3:147–166

  8. Goel A, Laheri V (1994) Plate and screw fixation for atlanto-axial subluxation. Acta Neurochir 129:47–53

    Article  PubMed  CAS  Google Scholar 

  9. Goel A, Kulkarni AG (2004) Mobile and reducible atlantoaxial dislocation in presence of occipitalized atlas: report on treatment of eight cases by direct lateral mass plate and screw fixation. Spine 29:520–523

    Article  Google Scholar 

  10. Puttlitz CM, Melcher RP, Kleinstueck FS (2004) Stability analysis of craniovertebral junction fixation techniques. J Bone Jt Surg Am 86:561–568

    Article  Google Scholar 

  11. Abumi K, Takada R, Shono Y (1999) Posterior occipitocervical reconstruction using cervical pedicle screws and plate-rod systems. Spine 24:1425–1434

    Article  PubMed  CAS  Google Scholar 

  12. Ondra SL, Marzouk S, Ganju A (2006) Safety and efficacy of C2 pedicle screws placed with anatomic and lateral C-arm guidance. Spine 31:263–267

    Article  Google Scholar 

  13. Ebraheim N, Rollins JR Jr, Xu R (1996) Anatomical consideration of the C2 pedicle screw placement. Spine 21:691–695

    Article  PubMed  CAS  Google Scholar 

  14. Grob D, Jeanneret B, Aebi M (1991) Atlanto-axial fusion with transarticular screw fixation. J Bone Jt Surg Br 73:972–976

    Article  CAS  Google Scholar 

  15. Harms J, Melcher RP (2001) Posterior C1–C2 fusion with polyaxial screw and rod fixation. Spine 26:2467–2471

    Article  PubMed  CAS  Google Scholar 

  16. Jeanneret B, Magerl F (1992) Primary posterior fusion C1/2 in odontoid fractures: indications, technique, and results of transarticular screw fixation. J Spinal Disord 5:464–475

    Article  PubMed  CAS  Google Scholar 

  17. Stillerman CB, Wilson JA (1993) Atlanto-axial stabilization with posterior transarticular screw fixation: technical description and report of 22 cases. Neurosurgery 32:948–955

    Article  PubMed  CAS  Google Scholar 

  18. Aota Y, Honda A, Uesugi M, Yamashita T, Baba N, Niwa T (2006) Vertebral artery injury in C-1 lateral mass screw fixation. Case illustration. J Neurosurg Spine 5:554

    Article  PubMed  Google Scholar 

  19. Rocha R, Safavi-Abbasi S, Reis C, Theodore N, Bambakidis N, de Oliveira E (2007) Working area, safety zones, and angles of approach for posterior C-1 lateral mass screw placement: a quantitative anatomical and morphometric evaluation. J Neurosurg Spine 6:247–254

    Article  PubMed  Google Scholar 

  20. Wright NM, Lauryssen C (2008) Vertebral artery injury in C1–2 transarticular screw fixation: results of a survey of the AANS/CNS section on disorders of the spine and peripheral nerves. J Neurosurg 1998 88:634–640

    Google Scholar 

  21. Neo M, Fujibayashi S, Miyata M, Takemoto M, Nakamura T (2008) Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976) 33(7):779–785

    Article  Google Scholar 

  22. Yoshida M, Neo M, Fujibayashi S (2006) Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine 31:513–517

    Article  Google Scholar 

  23. Jian FZ, Chen Z, Wrede KH (2010) Direct posterior reduction and fixation for the treatment of basilar invagination with atlantoaxial dislocation. Neurosurgery 66:678–687

    Article  PubMed  Google Scholar 

  24. Yeom JS, Buchowski JM, Park KW, Chang BS, Lee CK, Riew KD (2008) Undetected vertebral artery groove and foramen violations during C1 lateral mass and C2 pedicle screw placement. Spine (Phila Pa 1976) 33(25):942–949

    Article  Google Scholar 

  25. Wakao N, Takeuchi M (2014) Vertebral artery variations and osseous anomaly at the C1–2 level diagnosed by 3D CT angiography in normal subjects. Neuroradiology 56:843–849

    Article  PubMed  Google Scholar 

  26. O’Donnell CM, Child ZA (2014) Vertebral artery anomalies at the craniovertebral junction in the US population. Spine 39:1053–1057

    Article  Google Scholar 

  27. Yamazaki M, Okawa A, Furuya T, Sakuma T, Takahashi H, Kato K, Fujiyoshi T, Mannoji C, Takahashi K, Koda M (2012) Anomalous vertebral arteries in the extra- and intraosseous regions of the craniovertebral junction visualized by 3-dimensional computed tomographic angiography: analysis of 100 consecutive surgical cases and review of the literature. Spine 37:1389–1397

    Article  Google Scholar 

  28. Wang S, Wang C, Liu Y, Yan M, Zhou H (2009) Anomalous vertebral artery in craniovertebral junction with occipitalization of the atlas. Spine 34:2838–2842

    Article  PubMed  Google Scholar 

  29. Abtahil AM, Brodke DS (2014) Vertebral artery anomalies at the craniovertebral junction: a case report and review of the literature. Evid Based Spine Care J 5:121–125

    Article  Google Scholar 

  30. Hong JT, Lee SW, Son BC, Sung JH, Yang SH, Kim IS, Park CK (2008) Analysis of anatomical variations of bone and vascular structures around the posterior atlantal arch using three-dimensional computed tomography angiography. J Neurosurg Spine 8:230–236

    Article  PubMed  Google Scholar 

  31. Mazzatenta D, Zoli M, Mascari C, Pasquini E, Frank G (2014) Endoscopic endonasal odontoidectomy: clinical series. Spine 39:846–853

    Article  PubMed  Google Scholar 

  32. Tokuda K, Miyasaka K, Abe H (1985) Anomalous atlantoaxial portions of vertebral and posterior inferior cerebellar arteries. Neuroradiology 27:410–413

    Article  PubMed  CAS  Google Scholar 

  33. Kim JT, Lee HJ, Kim JH (2016) Quantitative analysis of unusual entrance of the vertebral artery into the cervical foramen (V2 segment) and its clinical implications. Eur Spine J 25:4188–4194

    Article  PubMed  Google Scholar 

  34. Eksi MS, Toktas ZO, Yilmaz B (2016) Vertebral artery loops in surgical perspective. Eur Spine J 25:4171–4180

    Article  PubMed  Google Scholar 

  35. Sivaraju L, Mani S, Prabhu K (2017) Three-dimensional computed tomography angiographic study of the vertebral artery in patients with congenital craniovertebral junction anomalies. Eur Spine J 26:1028–1038

    Article  PubMed  Google Scholar 

  36. Madawi AA, Casey ATH, Solanki GA (1997) Radiological and anatomical evaluation of the atlantoaxial transarticular screw fixation technique. J Neurosurg 86:961–968

    Article  PubMed  CAS  Google Scholar 

  37. Mandel IM, Kambach BJ, Petersilge CA (1998) Morphologic considerations of C2 isthmus dimensions for the placement of transarticular screws. Spine 2000 25:1542–1547

    Google Scholar 

  38. Jun BY (1998) Anatomic study for ideal and safe posterior C1–C2 transarticular screw fixation. Spine (Phila Pa 1976) 23(15):1703–1707

    Article  CAS  Google Scholar 

  39. Paramore CG, Dickman CA, Sonntag VK (1996) The anatomical suitability of the C1–2 complex for transarticular screw fixation. J Neurosurg 85:221–224

    Article  PubMed  CAS  Google Scholar 

  40. Igarashi T, Kikuchi S, Sato K (2003) Anatomic study of the axis for surgical planning of transarticular screw fixation. Clin Orthop Relat Res 408:162–166

    Article  Google Scholar 

  41. Neo M (2008) An essential principle for safe C1–C2 transarticular screw insertion. J Spine Disord Tech 21(1):76–77

    Article  Google Scholar 

  42. Lapsiwala SB, Anderson PA, Oza A, Resnick DK (2006) Biomechanical comparison of four C1 to C2 rigid fixative techniques: anterior transarticular, posterior transarticular, C1 to C2 pedicle, and C1 to C2 intralaminar screws. Neurosurgery 58(3):516–521

    Article  PubMed  Google Scholar 

  43. Resnick DK, Lapsiwala S, Trost GR (2002) Anatomic suitability of the C1–C2 complex for pedicle screw fixation. Spine 27:1494–1498

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank the staff members of the institutes.

Author information

Authors and Affiliations

  1. Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

    Shuaishuai Xu & Jianrong Xu

  2. Department of Radiology, Liaocheng People’s Hospital, Liaocheng, Shandong, China

    Shidong Ruan

  3. Shandong Medical Imaging Research Institute, Shandong University, Jinan, Shandong, China

    Xiaoyu Song, Jinyu Yu & Ruozhen Gong

Authors
  1. Shuaishuai Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Shidong Ruan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xiaoyu Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jinyu Yu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jianrong Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ruozhen Gong
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ruozhen Gong.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 6664 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Xu, S., Ruan, S., Song, X. et al. Evaluation of vertebral artery anomaly in basilar invagination and prevention of vascular injury during surgical intervention: CTA features and analysis. Eur Spine J 27, 1286–1294 (2018). https://doi.org/10.1007/s00586-017-5445-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00586-017-5445-4

Keywords

Search

Navigation