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Zhou LP, Zhang RJ, Zhang HQ, Jiang ZF, Shang J, Shen CL. Effect of High-Riding Vertebral Artery on the Accuracy and Safety of C2 Pedicle Screw Placement in Basilar Invagination and Related Risk Factors. Global Spine J 2024; 14:458-469. [PMID: 35719094 PMCID: PMC10802529 DOI: 10.1177/21925682221110180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To investigate the effect of HRVA on the intrapedicular accuracy of C2PS placement through the freehand method in patients with BI and analyse the possible risk factors for C2PS malpositioning. METHOD A total of 91 consecutive patients with BI who received 174 unilateral C2PS placements through the freehand method were retrospectively included. The unilateral pedicles were assigned to the HRVA and non-HRVA groups. The primary outcome was the intrapedicular accuracy of C2PS placement in accordance with the Gertzbein-Robbins scale. Moreover, the risk factors that possibly affected intrapedicular accuracy were assessed. RESULTS The rate of intrapedicular accuracy in C2PS placement in patients with BI was 23.6%. Results showed that the non-HRVA group had remarkably higher rates of optimal and clinically acceptable C2PS placement than the HRVA group. Nevertheless, the HRVA group exhibited similar results for grade B classification as the non-HRVA group. Moreover, in the HRVA and non-HRVA groups, the most common direction of screw deviations was the lateral direction. Furthermore, the multivariate analyses showed that the obliquity of the lateral atlantoaxial joint in the sagittal plane ≥15°, and that in the coronal plane ≥ 20°, isthmus height < 4.3 mm, and distance from the skin to the spinous process ≥ 2.8 cm independently contributed to a high rate of screw malpositioning in BI patients. CONCLUSION The presence of HRVA in BI patients contributed to the high rate of malpositioning in C2PS placement via the freehand method. However, the rates of intrapedicular accuracy in patients with BI with and without HRVA were considerably low.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ren-Jie Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hua-Qing Zhang
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhen-Fei Jiang
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Jin Shang
- Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Cai-Liang Shen
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Zhou LP, Zhao CH, Zhang ZG, Shang J, Zhang HQ, Ma F, Jia CY, Zhang RJ, Shen CL. Characteristics and evaluation of C1 posterior arch variation for transpedicular screw placement between patients with and without basilar invagination. 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 2023; 32:3547-3560. [PMID: 37530951 DOI: 10.1007/s00586-023-07873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/24/2023] [Accepted: 07/22/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND C1 transpedicular screw (C1TS) placement provided satisfactory pullout resistance and 3D stability, but its application might be limited in patients with basilar invagination (BI) due to the high incidences of the atlas anomaly and vertebral artery (VA) variation. However, no study has explored the classifications of C1 posterior arch variations and investigated their indications and ideal insertion trajectories for C1TS in BI. PURPOSE To investigate the bony and surrounding arterial characteristics of the atlas, classify posterior arch variations, identify indications for C1TS, evaluate ideal insertion trajectories for C1TS in BI patients without atlas occipitalization (AO), and compare them with those without BI and AO as control. METHODS A total of 130 non-AO patients with and without BI (52 patients and 78 patients, respectively) from two medical centers were included at a 1:1.5 ratio. The posterior arch variations were assessed using a modified C1 morphological classification. Comparisons regarding the bony and surrounding arterial characteristics, morphological classification distributions, and ideal insertion trajectories between BI and control groups were performed. The subgroup analyses based on different morphological classifications were also conducted. In addition, the factors possibly affecting the insertion parameters were investigated using multiple linear regression analyses. RESULTS The BI group was associated with significantly smaller lateral mass height and width, sagittal length of posterior arch, pedicle height, vertical height of posterior arch, and distance between VA and VA groove (VAG) than control group. Four types of posterior arch variations with indications for different screw placement techniques were classified; Classifications I and II were suitable for C1TS. The BI cohort showed a significantly lower rate of Classification I than the control cohort. In the BI group, the subgroup of Classification I had significantly larger distance between the insertion point (IP) and inferior aspect of the posterior arch. In addition, it had the narrowest width along ideal screw trajectory, but a significantly more lateral ideal mediolateral angle than the subgroup of Classification II. Multiple linear regression indicated that the cephalad angle was significantly associated with the diagnosis of BI (B = 3.708, P < 0.001) and sagittal diameter of C1 (B = 3.417, P = 0.027); the ideal mediolateral angle was significantly associated with BMI (B = 0.264, P = 0.031), sagittal diameter of C1 (B = - 4.559, P = 0.002), and pedicle height (B = - 2.317, P < 0.001); the distance between the IP and inferior aspects of posterior arch was significantly associated with age (B = - 0.002, P = 0.035), BMI (B = - 0.007, P = 0.028), sagittal length of posterior arch (B = - 0.187, P = 0.032), pedicle height (B = - 0.392, P < 0.001), and middle and lower parts of posterior arch (B = 0.862, P < 0.001). CONCLUSION The incidence of posterior arch variation in BI patients without AO was remarkably higher than that in control patients. The insertion parameters of posterior screws were different between the morphological classification types in BI and control groups. The distance between VA V3 segments and VAG in BI cohort was substantially smaller than that in control cohort. Preoperative individual 3D computed tomography (CT), CT angiography and intraoperative navigation are recommended for BI patients receiving posterior screw placement.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Chen-Hao Zhao
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Zhi-Gang Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Jin Shang
- Department of Radiology, The First Affiliated Hospital of University of Science and Technology of China, 107 Huanhudong Road, Hefei, 230031, Anhui, China
| | - Hua-Qing Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Fang Ma
- Center for Scientific Research, Anhui Medical University, 81 Meishan Road, Hefei, 230032, Anhui, China
| | - Chong-Yu Jia
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China.
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China.
| | - Cai-Liang Shen
- Department of Orthopedics and Spine Surgery, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, Anhui, China.
- Laboratory of Spinal and Spinal Cord Injury Regeneration and Repair, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui, China.
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Zhou LP, Shang J, Zhang ZG, Jiang ZF, Zhang HQ, Jia CY, Zhang RJ, Shen CL. Characteristics and Comparisons of Morphometric Measurements and Computed Tomography Hounsfield Unit Values of C2 Laminae for Translaminar Screw Placement Between Patients With and Without Basilar Invagination. Neurospine 2022; 19:899-911. [PMID: 36597627 PMCID: PMC9816593 DOI: 10.14245/ns.2244730.365] [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: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Patients with basilar invagination (BI) had high incidences of vertebral variations and high-riding vertebral artery (HRVA) that might restrict the use of pedicle or pars screw and increase the use of translaminar screw on axis. Here, we conducted a radiographic study to investigate the feasibility of translaminar screws and the bone quality of C2 laminae in patients with BI, which were compared with those without BI as control to provide guidelines for safe placement. METHODS In this study, a total of 410 patients (205 consecutive patients with BI and 205 matched patients without BI) and 820 unilateral laminae of the axis were included at a 1:1 ratio. Comparisons with regard to insertion parameters (laminar length, thickness, angle, and height) for C2 translaminar screw placement and Hounsfield unit (HU) values for the assessment of the appropriate bone mineral density of C2 laminae between BI and control groups were performed. Besides, the subgroup analyses based on the Goel A and B classification of BI, HRVA, atlas occipitalization, and C2/3 assimilation were also carried out. Furthermore, the factors that might affect the insertion parameters and HU values were explored through multiple linear regression analyses. RESULTS The BI group showed a significantly smaller laminar length, thickness, height, and HU value than the control group, whereas no significant difference was observed regarding the laminar angle. By contrast, the control group showed significantly higher rates of acceptability for unilateral and bilateral translaminar screw fixations than the BI group. Subgroup analyses showed that the classification of Goel A and B, HRVA, atlas occipitalization, and C2/3 assimilation affected the insertion parameters except the HU values. Multiple linear regression indicated that the laminar length was significantly associated with the male gender (B = 0.190, p < 0.001), diagnoses of HRVA (B = -0.109, p < 0.001), Goel A (B = -0.167, p < 0.001), and C2/3 assimilation (B = -0.079, p = 0.029); the laminar thickness was significantly associated with the male gender (B = 0.353, p < 0.001), diagnoses of HRVA (B = -0.430, p < 0.001), Goel B (B = -0.249, p = 0.026), and distance from the top of odontoid to the Chamberlain line (B = -0.025, p = 0.003); laminar HU values were significantly associated with age (B = -2.517, p < 0.001), Goel A (B = -44.205, p < 0.001), Goel B (B = -25.704, p = 0.014), and laminar thickness (B = -11.706, p = 0.001). CONCLUSION Patients with BI had narrower and smaller laminae with lower HU values and lower unilateral and bilateral acceptability for translaminar screws than patients without BI. Preoperative 3-dimensional computed tomography (CT) and CT angiography were needed for BI patients.
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Affiliation(s)
- Lu-Ping Zhou
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jin Shang
- Department of Radiology, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Zhi-Gang Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Zhen-Fei Jiang
- Department of Orthopedics, the First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | - Hua-Qing Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chong-Yu Jia
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Ren-Jie Zhang
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China,Co-corresponding Author Ren-Jie Zhang Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230022, China
| | - Cai-Liang Shen
- Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China,Corresponding Author Cai-Liang Shen Department of Orthopedics, the First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, Anhui 230022, China
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