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Peeters JB, Idriceanu T, El Hage G, Martin T, Salaud C, Champagne PO, Bojanowski MW. A comprehensive review of the vertebral artery anatomy. Neurochirurgie 2024; 70:101518. [PMID: 38277859 DOI: 10.1016/j.neuchi.2023.101518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/21/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND The vertebral arteries (VA) play a critical role by supplying nearly one-third of the brain's blood flow, predominantly contributing to the posterior circulation. These arteries may need to be exposed in a various cranial and cervical procedures and offers access to investigate or treat vascular lesions by endovascular means related to the posterior circulation. Given its complex anatomy, which is subject to numerous variations, and its role in supplying vital brain regions, a thorough understanding of the VA's anatomy is paramount for any related procedure. OBJECTIVE To provide a comprehensive overview of vertebral artery anatomy and its relevance in contemporary clinical practice. METHODS Dissection of the entire vertebral artery length using cadaveric specimen, combined with a comprehensive literature review. RESULTS The vertebral artery can be subdivided into four segments. Each of these segments has its own unique topographic anatomy with its variations, anastomoses, and significance in surgery. CONCLUSION As surgical and endovascular techniques continue to evolve with technological improvements, we are now more equipped than ever to manage complex lesions involving the VA. However, with its increasingly complexity comes the necessity for a deeper and more comprehensive understanding of the VA. Possessing the detailed knowledge of the VA is vital for the successful execution of any procedure involving it.
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Affiliation(s)
- Jean-Baptiste Peeters
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada
| | - Tania Idriceanu
- Division of Neurosurgery, Department of Surgery, University of Laval Quebec Hospital Center, 11 Côte du Palais, Québec, QC G1R 2J6, Canada
| | - Gilles El Hage
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada
| | - Tristan Martin
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada
| | - Céline Salaud
- Division of Neurosurgery, Department of Surgery, University of Nantes Hospital Center, 5 All. de l'Île Gloriette, 44000 Nantes, France
| | - Pierre-Olivier Champagne
- Division of Neurosurgery, Department of Surgery, University of Laval Quebec Hospital Center, 11 Côte du Palais, Québec, QC G1R 2J6, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, University of Montreal Hospital Center, 1000, Rue St-Denis Montréal, QC H2X 0C, Canada.
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Atallah O, Almealawy YF, Badary A, Hernández-Hernández A, Andrew Awuah W, Sanker V, Chaurasia B, Umana GE. An In-Depth Analysis of the Artery of Salmon: Anatomy and Neurosurgical Implications. World Neurosurg 2024; 186:133-137. [PMID: 38531474 DOI: 10.1016/j.wneu.2024.03.105] [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: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Michel Salmon was a prominent person in the field of plastic surgery during the early 20th century. His pioneering work contributed significantly to our understanding of human anatomy, particularly with the identification of the artery of Salmon (AOS). The objective of this study is to thoroughly investigate the AOS by conducting a comprehensive literature review, providing insights into its anatomy and surgical implications. METHODS This review was undertaken after a thorough examination of literature encompassing papers about the AOS. Right up until January 2024, databases like PubMed, ScienceDirect, and Web of Science were explored. The search was conducted using specific terms such as "Artery of Salmon," "suboccipital artery," and "vertebral artery anatomy." An in-depth assessment was conducted to examine the anatomy, and surgical significance of the AOS. RESULTS The AOS is a branch of the V3 segment of the vertebral artery that supplies the suboccipital muscles. The ability, to identify it, is critical for distinguishing the origins of intraoperative hemorrhage. Through careful surgical intervention, the artery was able to devascularize tumors and vascular lesions. We also touched on the technical issues of its possible application in bypass operations for aneurysms of the posterior inferior cerebellar artery or vertebral artery. CONCLUSIONS The AOS is sometimes vital in neurosurgery, facilitating precise interventions and serving as a conduit in suboccipital bypass surgeries. Understanding its variations is essential for neurosurgeons, showcasing ongoing advancements in patient care.
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Affiliation(s)
- Oday Atallah
- Departement of Neurosurgery, Hannover Medical School, Hannover, Germany
| | | | - Amr Badary
- Departemnt of Neurosurgery, Klinikum Dessau, Dessau-Roßlau, Germany
| | - Alan Hernández-Hernández
- Department of Neurosurgery, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Vivek Sanker
- Department of Neurosurgery, Trivandrum Medical College, Kerala, India
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal.
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Dahdaleh NS, El-Tecle N, Cloney MB, Shlobin NA, Koski TR, Wolinsky JP. Functional Anatomy and Biomechanics of the Craniovertebral Junction. World Neurosurg 2023; 175:165-171. [PMID: 37365762 DOI: 10.1016/j.wneu.2023.03.084] [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: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 06/28/2023]
Abstract
The craniovertebral junction (CVJ) involves the atlas, axis, and occiput along with the atlanto-occipital and atlantoaxial joints. The anatomy and neural and vascular anatomy of the junction render the CVJ unique. Specialists treating disorders that affect the CVJ must appreciate its intricate anatomy and should be well versed in its biomechanics. This first article in a three-article series provides an overview of the functional anatomy and biomechanics of the CVJ.
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Affiliation(s)
- Nader S Dahdaleh
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Najib El-Tecle
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michael B Cloney
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tyler R Koski
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jean Paul Wolinsky
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Su H, Yu J. Treatment of high cervical arteriovenous fistulas in the craniocervical junction region. Front Neurol 2023; 14:1164548. [PMID: 37441609 PMCID: PMC10335834 DOI: 10.3389/fneur.2023.1164548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/13/2023] [Indexed: 07/15/2023] Open
Abstract
The craniocervical junction (CCJ) is a complex region. Rarely, arteriovenous fistulas (AVFs) can occur in the CCJ region. Currently, it is accepted that CCJ AVFs should only refer to AVFs at the C1-C2 levels. It is reasonable to assume that high cervical CCJ AVFs are being referred to when discussing CCJ AVFs. High cervical CCJ AVFs can be divided into the following four types: dural AVF, radicular AVF, epidural AVF and perimedullary AVF. Until now, it was difficult to understand high cervical CCJ AVFs and provide a proper treatment for them. Therefore, an updated review of high cervical CCJ AVFs is necessary. In this review, the following issues are discussed: the definition of high cervical CCJ AVFs, vessel anatomy of the CCJ region, angioarchitecture of high cervical CCJ AVFs, treatment options, prognoses and complications. Based on the review and our experience, we found that the four types of high cervical CCJ AVFs share similar clinical and imaging characteristics. Patients may present with intracranial hemorrhage or congestive myelopathy. Treatment, including open surgery and endovascular treatment (EVT), can be used for symptomatic AVFs. Most high cervical CCJ AVFs can be effectively treated with open surgery. EVT remains challenging due to a high rate of incomplete obliteration and complications, and it can only be performed in superselective AVFs with simple angioarchitecture. Appropriate treatment can lead to a good prognosis.
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Sriamornrattanakul K, Akharathammachote N, Chonhenchob A, Mongkolratnan A, Niljianskul N, Phoominaonin IS, Ariyaprakai C, Wongsuriyanan S. Course of the V3 segment of the vertebral artery relative to the suboccipital triangle as an anatomical marker for a safe far lateral approach: A retrospective clinical study. Surg Neurol Int 2022; 13:304. [PMID: 35928311 PMCID: PMC9345113 DOI: 10.25259/sni_346_2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background: The third segment of the vertebral artery (V3) is vulnerable during far lateral and retrosigmoid approaches. Although the suboccipital triangle (SOT) is a useful anatomical landmark, the relationship between V3 and the muscles forming the triangle is not well-described. We aimed to demonstrate the relationship between the V3, surrounding muscles, and SOT in clinical cases. Methods: Operative videos of patients with the vertebral artery (VA) and posterior inferior cerebellar artery (PICA) aneurysms treated with occipital artery-PICA bypass through the far lateral approach were examined. Videos from January 2015 to October 2021 were retrospectively reviewed to determine anatomy of the V3 and the SOT. Results: Fourteen patients were included in this study. The ipsilateral V3 was identified without injury in all patients using the bipolar cutting technique. The lateral 68.2% of the horizontal V3 segment, including the V3 bulge, was covered by the inferomedial part of the superior oblique muscle (SO). The medial 23.9% was covered by the inferolateral part of the rectus capitis posterior major muscle. The inferomedial part of the horizontal V3 segment is located within the SOT. Conclusion: Most of the V3, including the V3 bulge, were located beneath the SO and the inferomedial part of V3 located within the SOT. Elevation of the SO should be performed carefully using the bipolar cutting technique to avoid injury to the V3. To the best of our knowledge, this is the first description of the V3 relative to the SOT in the clinical setting.
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Affiliation(s)
| | - Nasaeng Akharathammachote
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Areeporn Chonhenchob
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Atithep Mongkolratnan
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Nattawut Niljianskul
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - I-Sorn Phoominaonin
- Department of Health Technology, Faculty of Science and Health Technology, Navamindradhiraj University, Bangkok, Thailand
| | - Chanon Ariyaprakai
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Somkiat Wongsuriyanan
- Department of Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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Braga BP, Sillero R, Pereira RM, Urgun K, Swift DM, Rollins NK, Hogge AJ, Dowling MM. Dynamic compression in vertebral artery dissection in children: apropos of a new protocol. Childs Nerv Syst 2021; 37:1285-1293. [PMID: 33155060 DOI: 10.1007/s00381-020-04956-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/28/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Our goals are (1) to report a consecutive prospective series of children who had posterior circulation stroke caused by vertebral artery dissection at the V3 segment; (2) to describe a configuration of the vertebral artery that may predispose to rotational compression; and (3) to recommend a new protocol for evaluation and treatment of vertebral artery dissection at V3. METHODS All children diagnosed with vertebral artery dissection at the V3 segment from September 2014 to July 2020 at our institution were included in the study. Demographic, clinical, surgical, and radiological data were collected. RESULTS Sixteen children were found to have dissection at a specific segment of the vertebral artery. Fourteen patients were male. Eleven were found to have compression on rotation during a provocative angiogram. All eleven underwent C1C2 posterior fusion as part of their treatment. Their mean age was 6.44 years (range 18 months-15 years). Mean blood loss was 57.7 mL. One minor complication occurred: a superficial wound infection treated with oral antibiotics only. There were no vascular or neurologic injuries. There have been no recurrent ischemic events after diagnosis and/or treatment. Mean follow-up was 33.3 months (range 2-59 months). We designed a new protocol to manage V3 dissections in children. CONCLUSION Posterior C1C2 fusion is a safe and effective option for treatment of dynamic compression in vertebral artery dissection in children. Institution of and compliance with a strict diagnostic and treatment protocol for V3 segment dissections seem to prevent recurrent stroke.
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Affiliation(s)
- Bruno P Braga
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA. .,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.
| | - Rafael Sillero
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA.,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
| | - Rosalina M Pereira
- Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kamran Urgun
- Department of Neurological Surgery, University of California Irvine, Orange, CA, USA
| | - Dale M Swift
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX, USA.,Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
| | - Nancy K Rollins
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Amy J Hogge
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Anesthesia for Children, Dallas, TX, USA
| | - Michael M Dowling
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA.,Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA.,Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
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7
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Goldstein RY, Sunde CD, Assaad P, Grimm J, Skaggs DL, Andras L. Location of the vertebral artery at C1 in children: how far out laterally can one safely dissect? J Bone Joint Surg Am 2014; 96:1552-6. [PMID: 25232079 DOI: 10.2106/jbjs.n.00025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is little information available on the anatomic location of the vertebral artery in pediatric patients undergoing a posterior cervical arthrodesis involving the first cervical vertebra (C1). The purpose of this study was to define how far laterally one can safely dissect posteriorly without risk to the vertebral artery in pediatric patients. METHODS A subset of computed tomography angiograms of the neck that had been previously obtained in patients at our institution was evaluated. The location of the vertebral artery was identified on both the right and the left side at the vertebral artery groove. RESULTS A total of 549 patients were included. The vertebral artery was an average of 13.97 mm (standard deviation, 1.89 mm) from the midline. Ninety-seven percent of the vertebral arteries were more than 1 cm lateral to the midline, and none were less than 8 mm from the midline. There was a significant difference among the age groups in the location of the vertebral artery, with the vertebral artery closer to the midline in younger patients (p < 0.001). In patients eight years of age or older, the average distance from the midline equaled the value reported for adults. CONCLUSIONS Patients under the age of eight years had vertebral arteries that were significantly closer to the midline compared with those of older patients; nonetheless, 97% of the vertebral arteries in the younger patients were more than 1 cm lateral to the midline. CLINICAL RELEVANCE Increased care must be taken when dissecting out laterally on C1 in younger patients, as the vertebral artery tends to be closer to the midline than has been described in adults.
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Affiliation(s)
- Rachel Y Goldstein
- Department of Pediatric Orthopaedics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Caleb D Sunde
- Keck School of Medicine, University of Southern California, Los Angeles, 1975 Zonal Avenue, KAM 500, CA 90089
| | - Peter Assaad
- Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 81, Los Angeles, CA 90027
| | - John Grimm
- Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 81, Los Angeles, CA 90027
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 69, Los Angeles, CA 90027. E-mail address for D.L. Skaggs:
| | - Lindsay Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 69, Los Angeles, CA 90027. E-mail address for D.L. Skaggs:
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8
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Ha W, Yang D, Gu S, Xu QW, Che X, Wu JS, Li W. Anatomical study of suboccipital vertebral arteries and surrounding bony structures using virtual reality technology. Med Sci Monit 2014; 20:802-6. [PMID: 24829084 PMCID: PMC4031225 DOI: 10.12659/msm.890840] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background This work aimed to evaluate the efficacy of virtual reality (VR) technology in neurosurgical anatomy through a comparison of the virtual 3D microanatomy of the suboccipital vertebral arteries and their bony structures as part of the resection of tumors in the craniovertebral junction (CVJ) of 20 patients compared to the actual microanatomy of the vertebral arteries of 15 cadaveric headsets. Material/Methods The study was conducted with 2 groups of data: a VR group composed of 20 clinical cases and a physical body group (PB group) composed of 15 cadaveric headsets. In the VR group, the dissection and measurements of the vertebral arteries were simulated on a Dextroscope. In the PB group, the vertebral arteries in the cadaver heads were examined under a microscope and anatomical measurements of VA and bony structures were performed. The length and course of the vertebral arteries and its surrounding bony structures in each group were compared. Results The distances from the inferior part of the transverse process foramen (TPF) of C1 to the inferior part of TPF of C2 were 17.68±2.86 mm and 18.4±1.82 mm in the PB and VR groups, respectively. The distances between the middle point of the posterior arch of the atlas and the medial intersection of VA on the groove were 17.35±2.23 mm in the PB group and 18.13±2.58 mm in the VR group. The distances between the middle line and the entrance of VA to the lower rim of TPF of Atlas were 28.64±2.67 mm in PB group and 29.23±2.89 mm in VR group. The diameters of the vertebral artery (VA) at the end of the groove and foramen of C2 transverse process were 4.02±046 mm and 4.25±0.51 mm, respectively, in the PB group and 3.54±0.44 mm and 4.47±0.62 mm, respectively, in VR group. The distances between the VA lumen center and midline of the foramen magnum at the level of dural penetration was 10.4±1.13 mm in the PB group and 11.5±1.34 mm in the VR group (P>0.05). Conclusions VR technology can accurately simulate the anatomical features of the suboccipital vertebral arteries and their bony structures, which facilitates the planning of individual surgeries in the CVJ.
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Affiliation(s)
- Wenbo Ha
- Department of Neurosurgery, 5th Hospital affiliated Harbin Medical College, Daqing, China (mainland)
| | - DeLin Yang
- Department of Neurosurgery, Huashun Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland)
| | - Shixin Gu
- Department of Neurosurgery, Huashun Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland)
| | - Qi-Wu Xu
- Department of Neurosurgery, Huashun Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland)
| | - Xiaoming Che
- Department of Neurosurgery, Huashun Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland)
| | - Jin-Song Wu
- Department of Neurosurgery, Huashun Hospital, Shanghai Medical College, Fudan University, Shanghai, China (mainland)
| | - Wensheng Li
- Department of Anatomy, Shanghai Medicine Institute, Fudan University, Shanghai, China (mainland)
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Macchi V, Porzionato A, Morra A, D’Antoni AV, Tubbs RS, De Caro R. Anatomico-radiologic study of the distribution of the suboccipital artery of Salmon. Clin Neurol Neurosurg 2014; 117:80-85. [DOI: 10.1016/j.clineuro.2013.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 11/20/2013] [Accepted: 11/29/2013] [Indexed: 11/30/2022]
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10
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D'Antoni AV, Battaglia F, Dilandro AC, Moore GD. Anatomic study of the suboccipital artery of Salmon with surgical significance. Clin Anat 2010; 23:798-802. [DOI: 10.1002/ca.21037] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 07/07/2010] [Accepted: 07/08/2010] [Indexed: 11/09/2022]
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Craniocervical fixation with occipital condyle screws: biomechanical analysis of a novel technique. Spine (Phila Pa 1976) 2010; 35:931-8. [PMID: 20375778 DOI: 10.1097/brs.0b013e3181c16f9a] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A human cadaveric biomechanical study comparing craniocervical fixation techniques. OBJECTIVE To quantitatively compare the biomechanical stability of a new technique for occipitocervical fixation using the occipital condyles with an established method for craniocervical spine fusion. SUMMARY OF BACKGROUND DATA Stabilization of the occipitocervical junction remains a challenge. The occiput does not easily accommodate instrumentation because of access and spatial constraints. In fact, the area available for the implant fixation is limited and can be restricted further when a suboccipital craniectomy has been performed, posing a challenge to current fixation techniques. Occipital screws are also associated with the potential for intracranial complications. METHODS Six fresh frozen cadaveric specimens occiput-C4 were tested intact, after destabilization and after fixation as follows: (1) occipital plate with C1 lateral mass screws and C2 pars screws and (2) occipital condyle screws with C1 lateral mass screws and C2 pars screws. Specimens were loaded in a custom spine testing apparatus and subjected to the following tests, all performed under 50-N unconstrained axial preload: flexion, extension, lateral bending, and axial rotation at 1.5 Nm. The constructs were statistically compared with a one-way analysis of variance and compared with the intact condition. RESULTS Motions were reduced by approximately 80% compared with the intact condition for both configurations under all motions. There were no statistically significant differences in the range of motion (ROM) between the 2 instrumentation conditions. The mean values indicated decreased ROM with the novel occipital condyle screw construct in comparison with the standard occipital plate and rod system. CONCLUSION Craniocervical stabilization using occipital condyle screws as the sole cephalad fixation point is biomechanically equivalent with regard to the modes tested (ROM and stiffness) to the standard occipital plate construct.
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Uribe JS, Ramos E, Baaj A, Youssef AS, Vale FL. Occipital Cervical Stabilization Using Occipital Condyles for Cranial Fixation: Technical Case Report. Neurosurgery 2009; 65:E1216-7; discussion E1217. [DOI: 10.1227/01.neu.0000349207.98394.fa] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AbstractOBJECTIVEPresentation of a successful case of craniocervical stabilization involving a novel surgical technique using the occipital condyles as the sole cranial fixation points.CLINICAL PRESENTATIONA 22-year-old man presented in a delayed fashion with neck pain after a motor vehicle accident. Evaluation revealed a type 2 odontoid fracture with pseudarthrosis and displacement of the dens superiorly and cranial settling of the dens.INTERVENTIONThe patient underwent posterior occipitocervical fixation with a polyaxial screw rod construct using the occipital condyle, C1 lateral mass, and C2 pars articularis for fixation. The patient had no immediate postoperative deficits. At the time of the 12-month follow-up examination, the patient was neurologically intact with a solid occipitocervical fusion.CONCLUSIONCraniocervical stabilization using occipital condyle screws as the sole cephalad fixation points is a feasible option and can be used safely without neurovascular complication in the treatment of craniocervical instability.
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Affiliation(s)
- Juan S. Uribe
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Edwin Ramos
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Ali Baaj
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - A. Samy Youssef
- Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Fernando L. Vale
- Department of Neurosurgery, University of South Florida, Tampa, Florida
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Tubbs RS, Shah NA, Sullivan BP, Marchase ND, Cohen-Gadol AA. Surgical anatomy and quantitation of the branches of the V2 and V3 segments of the vertebral artery. J Neurosurg Spine 2009; 11:84-7. [DOI: 10.3171/2009.3.spine08683] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The vertebral artery (VA) and its branches may be encountered during various neurosurgical procedures such as far lateral suboccipital approaches to the skull base and spinal operations. Therefore, a working knowledge of the distribution and significance of such VA branches may be advantageous to the surgeon. To date, quantitation of these branches is lacking in the literature.
Methods
The authors evaluated the branches of 20 VAs from 10 adult cadavers and assessed the distribution and surgical significance of the branches from the V2 and V3 segments.
Results
In terms of target tissues, the VA branches encountered at the C1–2 level were most likely to be muscular, branches at C2–3 osseous, and those at C3–6 radicular. No radicular or medullary branches were identified arising from any V3 segment of the VA or C1–2 level of the V2 segment. The greatest concentration of branches per level was found arising from the V2 segment at C2–3. Posterior branches of the VA tended to be radicular or muscular, whereas anterior branches tended to be radicular or osseous. Lateral branches were most commonly radicular and medial branches tended to be osseous or muscular in nature. The largest branches of the VA originated from its V3 segment or the C2–3 part of its V2 segment. Rarely, branches to the extracranial glossopharyngeal and spinal accessory nerves were identified originating from the V3 and V2 segments of the VA, respectively.
Conclusions
Although seemingly diverse in their distribution, the branches of the V2 and V3 segments of the VA may follow a certain consistent arrangement. The potential for injury to neural branches of the VA is minimal at its V3 segment and the C1–2 portion of its V2 segment. Such knowledge may be of use to the neurosurgeon who operates in the neck and at the craniocervical junction.
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Affiliation(s)
- R. Shane Tubbs
- 2University of Alabama at Birmingham School of Medicine, Birmingham, Alabama and
| | - Nemil A. Shah
- 1Section of Pediatric Neurosurgery, Children's Hospital, Birmingham
| | - Brian P. Sullivan
- 2University of Alabama at Birmingham School of Medicine, Birmingham, Alabama and
| | - Nicholas D. Marchase
- 2University of Alabama at Birmingham School of Medicine, Birmingham, Alabama and
| | - Aaron A. Cohen-Gadol
- 3Clarian Neuroscience Institute, Indianapolis Neurosurgical Group and Indiana University Department of Neurosurgery, Indianapolis, Indiana
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Kiresi D, Gumus S, Cengiz SL, Cicekcibasi A. The morphometric analysis of the V2 and V3 segments of the vertebral artery: Normal values on MDCT. Comput Med Imaging Graph 2009; 33:399-407. [DOI: 10.1016/j.compmedimag.2009.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2008] [Revised: 03/19/2009] [Accepted: 03/24/2009] [Indexed: 11/29/2022]
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Feasibility of occipital condyle screw placement for occipitocervical fixation: a cadaveric study and description of a novel technique. ACTA ACUST UNITED AC 2009; 21:540-6. [PMID: 19057245 DOI: 10.1097/bsd.0b013e31816d655e] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Occipital-cervical (OC) stabilization using occipital condyle fixation with a polyaxial screw-rod construct is described. OBJECTIVES To describe a novel technique and initial radiographic results for posterior OC fixation using the occipital condyles for cranial fixation. SUMMARY OF BACKGROUND DATA Stabilization of the OC junction remains a challenge. Owing to the regional anatomy and the poor occipital bone purchase, multiple attachment points to the occipital bone are required to increase construct rigidity. To address these issues, we propose a novel OC fixation technique using polyaxial occipital condyle screws for cranial purchase. METHODS The OC junction was exposed posteriorly in silicone-injected cadaver heads. Polyaxial titanium screws (3.5 mm) were inserted bicortically solely into the occipital condyles; C1 lateral masses and C2 pedicles, or transarticularly through C1-C2, followed by fixation to a 3-mm rod. Drilling was guided by anatomic landmarks and fluoroscopy. Computerized tomography scans were obtained. Condylar screw angles and lengths were analyzed with respect to historical morphometric condyle measurements and with respect to neurovascular structures. RESULTS The condylar entry point was 4 to 5-mm lateral to the foramen magnum on the axial plane, and 1 to 2-mm rostral to the atlantooccipital joint. The mean angle of medialization was 17 degrees (range: 12 to 22 degrees). In the sagittal plane, the maximal superior screw angulation was 5 degrees. The mean screw length to obtain bicortical purchase was 22 mm (range: 20 to 24 mm). The hypoglossal canal was uninterrupted during its full course. The jugular bulb, carotid, and vertebral arteries were not injured by condyle screw placement. No fractures were identified. CONCLUSION Condyle screws can be placed without injury to neurovascular structures. OC junction fixation using polyaxial occipital condyle screws is feasible and can be considered a salvage technique or an alternative where other fixation techniques are not available.
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Rocha R, Safavi-Abbasi S, Reis C, Theodore N, Bambakidis N, de Oliveira E, Sonntag VKH, Crawford NR. 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 2007; 6:247-54. [PMID: 17355024 DOI: 10.3171/spi.2007.6.3.247] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The authors measured relevant quantitative anatomical parameters to define safety zones for the placement of C-1 posterior screws.
Methods
Nineteen linear, two angular, and four surface parameters of 20 dried atlantal specimens were evaluated. The Optotrak 3020 system was used to define the working area. Ideal angles for screw positioning were measured using digital radiographs and a free image-processing program. Six silicone-injected cadaveric heads were dissected bilaterally to study related neurovascular anatomy.
The depth (range 5.2–9.4 mm, mean 7.2 ± 1.1 mm) and width (range 5.2–8.1 mm, mean 6.5 ± 0.9 mm) of the transverse foramen varied considerably among specimens. The mean posterior working area was 43.3 mm2. All specimens accommodated 3.5-mm-diameter screws, and 93% accepted 4-mm-diameter screws. In 10 specimens (50%), partial removal of the posterior arch was necessary to accommodate a 4-mm screw. The mean maximum angle of medialization was 16.7 ± 1.3°; the mean maximum superior angulation was 21.7 ± 4.7°.
Conclusions
The anatomical configuration of the atlas and vertebral artery (VA) varied considerably among the cadaveric specimens. The heights of the C-1 pedicle, posterior arch, and posterior lamina determine the posterior working area available for screw placement. The inferior insertion of the posterior arch may have to be drilled to increase this working area, but doing so risks injury to the VA. A dense venous plexus with multiple anastomoses may cover the screw entry site, potentially obscuring the operative view and increasing the risk of hemorrhage.
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Affiliation(s)
- Rogerio Rocha
- Department of Neurosurgery, Institute of Neurological Sciences, São Paulo, Brazil
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Passacantilli E, Santoro A, Pichierri A, Delfini R, Cantore G. Anterolateral approach to the craniocervical junction. J Neurosurg Spine 2005; 3:123-8. [PMID: 16370301 DOI: 10.3171/spi.2005.3.2.0123] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors present the surgical results obtained using the anterolateral approach to the craniocervical junction (CCJ) to resect a lesion with an extradural component located anterolateral to the foramen magnum and upper cervical spine. METHODS The anterolateral approach, which is a presternomastoid retrojugular route to the CCJ, was performed in 14 patients. The skin incision follows the anterior edge of the sternomastoid muscle. The vertebral artery (VA) was exposed at C-1. This approach was extended either down to the cervical spine or anteriorly to the jugular foramen, according to specific requirements. Two patients had previously undergone other surgical procedures. The follow-up period ranged from 4 months to 6.2 years. The tumor resection was complete in 11 cases and subtotal in two. In a case of vertebral coiling, a vein graft was interposed between the V1 and the V3 segments of the VA, and the bypass was still patent at the 2-year follow-up examination. In two cases involving a glomus tumor, there was a transitory postoperative seventh cranial nerve deficit. CONCLUSIONS The aforementioned technique allows for sufficient access to lesions located anterolateral to the CCJ. It is indicated in cases in which lesions exhibit a significant extradural component, and it provides good control of the VA, the cervical portion of the internal carotid artery, sigmoid-jugular complex, and lower cranial nerves. This approach can easily be combined with a posterolateral approach and can be extended anteriorly toward the jugular foramen and inferiorly toward the lower cervical spine.
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Affiliation(s)
- Emiliano Passacantilli
- Department of Neuroscience, Division of Neurosurgery, University of Rome, La Sapienza, Rome, Italy
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Ito K, Tanaka Y, Kakizawa Y, Hongo K, Kobayashi S. Aneurysm at the posterior inferior cerebellar artery of extradural origin for preoperative evaluation of safe clipping: case report and review of the literature. ACTA ACUST UNITED AC 2003; 60:329-33; discussion 333. [PMID: 14505854 DOI: 10.1016/s0090-3019(03)00188-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As far as we know, 6 cases of extracranial (including craniocervical junction) intradural aneurysms of the posterior inferior cerebellar artery have been previously reported. However, preoperative detailed evaluation of the origin site and a course of the posterior inferior cerebellar artery by means of angiography were not reported in previous papers. CASE DESCRIPTION We report a rare case of aneurysm of the posterior inferior cerebellar artery, which originated extradurally from the right vertebral artery. A 69-year-old woman experienced a sudden headache 16 years ago and a computed tomography scan showed a subarachnoid hemorrhage around the midbrain. Four-vessel cerebral angiography, however, failed to disclose a source of the hemorrhage. Magnetic resonance angiography incidentally revealed an aneurysm at the craniocervical junction 16 years after the subarachnoid hemorrhage. The aneurysm was exposed and clipped via a suboccipital route. At surgery, it was of no use to apply a temporary clip on the intradural segment of the vertebral artery, because the posterior inferior cerebellar artery was found to enter the intradural space separately from the vertebral artery. The blood flow to such an aneurysm cannot be stopped with this procedure. CONCLUSIONS Careful neuroimaging study is essential for the accurate diagnosis and successful treatment of such a rare aneurysm.
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Affiliation(s)
- Kiyoshi Ito
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
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