Abstract
Purpose
To elucidate the anatomic relationship between the internal carotid artery (ICA) and the bony structures of the craniovertebral junction among “sandwich” atlantoaxial dislocation (AAD) patients, and to analyze the risks of injury during surgical procedures.
Methods
The distance from the medial wall of ICA to the midsagittal plane (D1), the shortest distance between the ICA wall and the anterior cortex of the lateral mass of atlas (LMA) (D2) on the most caudal and cranial levels of LMA and the angle (A) between the sagittal plane passing through the screw entry point of C1 lateral mass(C1LM) screw and the medial tangent line of the vessel passing through the entry point were measured. Besides, the location of ICA in front of the atlantoaxial vertebra was divided into 4 categories (Z1–Z4).
Results
There was a statistically difference between the male and female patients regarding D1, and the difference between D2 at level a and level b as well as angle A between the left and right sides were statistically different (p < 0.05). Ninety-two ICAs (57.5%) were anteriorly located in Z3, 50 (31.3%) were located in Z4, 17 were located in Z2, and only one ICA was located in Z1 in all 80 patients.
Conclusions
In “sandwich” AAD patients, particular attention should be paid to excessively medialized ICA to avoid ICA injury during trans-oral procedures, and the risk of injuring the ICA with more cranially and medially angulated C1LM screw placement was relatively less during posterior fixation procedures. A novel classification of ICA location was used to describe the relationship between ICA and LMA.
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Data availability
This study is based on confidential patient data which are available upon request from the author SLW.
Code availability
Not applicable.
References
Blagg SE, Don AS, Robertson PA (2009) Anatomic determination of optimal entry point and direction for C1 lateral mass screw placement. Clin Spine Surg 22(4):233–239
Bogaerde MV, Viaene P, Thijs V (2007) Iatrogenic perforation of the internal carotid artery by a transarticular screw: an unusual case of repetitive ischemic stroke. Clin Neurol Neurosurg 109(5):466–469
Chan WP, Chou BT, Bendo JA, Spivak JM (2008) Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures. Spine J: Off J North Am Spine Soc 9(1):70–76
Christensen DM, Eastlack RK, Lynch JJ, Yaszemski MJ, Currier BL (2007) C1 anatomy and dimensions relative to lateral mass screw placement. Spine 32(8):844–848
Cirpan S, Sayhan S, Yonguc GN, Eyuboglu C, Naderi S (2017) Surgical anatomy of neurovascular structures related to ventral C1–2 complex: an anatomical study. Surg Radiol Anat 40(3):1–6
Currier BL, Todd LT, Maus TP, Fisher DR, Yaszemski MJ (2003) Anatomic relationship of the internal carotid artery to the C1 vertebra: a case report of cervical reconstruction for chordoma and pilot study to assess the risk of screw fixation of the atlas. Spine 28(22):461–467
Currier BL, Maus TP, Eck JC, Larson DR, Yaszemski MJ (2008) Relationship of the internal carotid artery to the anterior aspect of the C1 vertebra: implications for C1–C2 transarticular and C1 lateral mass fixation. Spine 33(6):635–639
Jorn VDV, Mary S, J MM, Catherine W, Marguerite H, Vera VV (2021) The surgical management of intraoperative intracranial internal carotid artery injury in open skull base surgery-a systematic review. Neurosur Rev 45(2):1263–1273
Tian Y, Fan D, Xu N, Wang S (2018) "Sandwich Deformity" in Klippel-Feil syndrome: A "Full-Spectrum" presentation of associated craniovertebral junction abnormalities. J Clin Neurosci 53:247–249
Tian Y, Xu N, Yan M, Passias PG, Wang S (2020) Atlantoaxial dislocation with congenital "sandwich fusion" in the craniovertebral junction: a retrospective case series of 70 patients. BMC Musculoskelet Disord 21(1):821
Tian Y, Xu N, Leng H, Wang S (2021) Spinous Process Screw Fixation: A Salvage Technique in Subaxial Cervical Spinal Instrumentation. World Neurosurg 154:e458–e464
Wang S, Leng H, Tian Y, Xu N, Liu Z (2021) A novel 3D-printed locking cage for anterior atlantoaxial fixation and fusion: case report and in vitro biomechanical evaluation. BMC Musculoskelet Disord 22(1):121
Yi-Heng Y, Huai-Yu T, Guang-Yu Q, Xin-Guang Y (2016) Posterior Reduction of Fixed Atlantoaxial Dislocation and Basilar Invagination by Atlantoaxial Facet Joint Release and Fixation: A Modified Technique With 174 Cases. Neurosurg 78(3):391–400
Lunardini DJ, Eskander MS, Even JL, Dunlap (2014) Vertebral artery injuries in cervical spine surgery. SPINE J 14(8):1520–1525
Makoto Y, Masashi N, Shunsuke F, Takashi N (2006) Comparison of the anatomical risk for vertebral artery injury associated with the C2-pedicle screw and atlantoaxial transarticular screw. Spine 31(15):E513-517
Murakami S, Mizutani J, Fukuoka M, Kato K, Sekiya I, Okamoto H, Abumi K, Otsuka T (2008) Relationship between screw trajectory of C1 lateral mass screw and internal carotid artery. Spine 33(24):2581–2585
Rusconi A, Peron S, Roccucci P, Stefini R (2021) The internal carotid artery and the atlas: anatomical relationship and implications for C1 lateral mass fixation. Surg Radiol Anat 43(1 Suppl)
Salunke P, Sahoo S, Khandelwal NK, Ghuman MS (2015) Technique for direct posterior reduction in irreducible atlantoaxial dislocation: multi-planar realignment of C1–2. Clin Neurol Neurosurg 131:47–53
Srivastava AK, Behari S, Sardhara J, Das KK (2017) Simultaneous odontoid excision with bilateral posterior C1–2 distraction and stabilization utilizing bilateral posterolateral corridors and a single posterior midline incision. Neurol India 65(5):1068
Tian Y, Xu N, Yan M, Passias PG, Wang S (2020) Atlantoaxial dislocation with congenital "sandwich fusion" in the craniovertebral junction: a retrospective case series of 70 patients. Bmc Musculoskelet Disord 21(1)
Tian Y, Fan D, Xu N, Wang S (2018) "Sandwich deformity" in Klippel-Feil syndrome: a "full-spectrum" presentation of associated craniovertebral junction abnormalities. J Clin Neurosci. S0967586818303631
Tian Y, Xu N, Leng H, Wang S (2021) Spinous process screw fixation: a salvage technique in subaxial cervical spinal instrumentation. World Neurosurg
Rusconi A, Peron S, Roccucci P, Stefini R (2021) The internal carotid artery and the atlas: anatomical relationship and implications for C1 lateral mass fixation. Surg Radiol Anat 43(1):87–92
Wang H-W, Li X-P, Yin Y-H, Li T, Yu X-G (2019) Change of anatomical location of the internal carotid artery relative to the atlas with congenital occipitalization and the relevant clinical implications. World Neurosurg 130:e505–e512
Wang HW, Li XP, Yin YH, Li T, Yu XG (2019) Change of Anatomical Location of the Internal Carotid Artery Relative to the Atlas with Congenital Occipitalization and the Relevant Clinical Implications. World Neurosurg 130:e505–e512
Yin YH, Yu XG, Qiao GY, Guo SL, Zhang JN (2014) C1 lateral mass screw placement in occipitalization with atlantoaxial dislocation and basilar invagination: a report of 146 cases. Spine 39(24):2013–2018
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This was a retrospective study and the formal ethics approval has been required as ruled by the ethics committee of Peking University Third Hospital.
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Tian, Y., Xu, N., Yan, M. et al. Strategies to avoid internal carotid artery injury in “sandwich” atlantoaxial dislocation patients during surgery. Acta Neurochir 165, 1155–1160 (2023). https://doi.org/10.1007/s00701-022-05449-7
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DOI: https://doi.org/10.1007/s00701-022-05449-7